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Wait watchers: the application of a waiting list active management program in ambulatory care

Antonio Giulio De Belvis, Marta Marino, Maria Avolio, Ferruccio Pelone, Danila Basso, Gian Antonio Dei Tos, Sandro Cinquetti, Walter Ricciardi
DOI: http://dx.doi.org/10.1093/intqhc/mzt015 205-212 First published online: 13 February 2013


Objective This study describes and evaluates the application of a waiting list management program in ambulatory care.

Design Waiting list active management survey (telephone call and further contact); before and after controlled trial.

Setting Local Health Trust in Veneto Region (North-East of Italy) in 2008–09.

Participants Five hundred and one people on a 554 waiting list for C Class ambulatory care diagnostic and/or clinical investigations (electrocardiography plus cardiology ambulatory consultation, eye ambulatory consultation, carotid vessels Eco-color-Doppler, legs Eco-color-Doppler or colonoscopy, respectively).

Intervention Active list management program consisting of a telephonic interview on 21 items to evaluate socioeconomic features, self-perceived health status, social support, referral physician, accessibility and patients' satisfaction. A controlled before-and-after study was performed to evaluate anonymously the overall impact on patients' self-perceived quality of care.

Main outcome measures The rate of patients with deteriorating healthcare conditions; rate of dropout; interviewed degree of satisfaction about the initiative; overall impact on citizens' perceived quality of care.

Results 95.4% patients evaluated the initiative as useful. After the intervention, patients more likely to have been targeted with the program showed a statistically significant increase in self-reported quality of care.

Conclusions Positive impact of the program on some dimensions of ambulatory care quality (health status, satisfaction, willingness to remain in the queue), thus confirming the outstanding value of ‘not to leave people alone’ and ‘not to leave them feeling themselves alone’ in healthcare delivery.

  • patient satisfaction
  • quality measurement
  • waiting lists
  • ambulatory care


Waiting lists are a matter of public concern as a consequence of the mismatch between demand, supply and capacity of healthcare services. A long wait for assistance could result in poorer health status and reduced ability to benefit when care is provided, causing increasing pain, stress and anxiety in patients and even eroding public confidence in healthcare organizations and professionals [1]. Some countries developed prioritization policies and active management interventions for patient groups expected to spend a long time in a queue, i.e. in a waiting list. Waiting list active management is more than a simple waiting list review [2]: it aims at monitoring patients' health status, stress and anxiety conditions, assessing their need for immediate and/or additional healthcare interventions and verifying their willingness to remain in the queue. These communications may have an impact on waiting list efficiency and also citizens' views of the healthcare system [3], as patients and care-givers appreciate contact with trained healthcare professionals even by telephone.

In Italy, waiting lists became a ‘structural issue’ within essential package benefits of care in 2002, because fair, appropriate and timely healthcare has to meet population's needs [4]. A priority scoring system, based on General Practitioner's (GP) anamnesis and clinical assessment at primary care level, have been taken place since 2002. Four top priority categories have been identified: (i) Class A, requesting specialist consultation or diagnostic test to be performed within 10 days; (ii) Class B, requesting specialist consultation to be performed within 30 days and diagnostic test within 60 days; (iii) Class C, requesting specialist consultation or diagnostic test to be performed within 180 days; (iv) Class 0, all not postponable emergency services to be delivered within a few hours. In addition, each Local Health Trust (LHT) has to define an implementation plan for such priority classification system, monitoring and measuring waiting lists and waiting times.

Despite widespread interest in citizen rights to timely healthcare and a large literature on patient satisfaction with waiting times [5], few studies have examined the impact of waiting lists on patients in ambulatory care. Unlike Italy [68], New Zealand, Sweden and Denmark applied and measured the impact of management systems aimed at monitoring health status, accessibility and willingness to remain in the queue of citizens included in long-time waiting list. When available, these systems referred to elective surgery or in-patient visit [3]. Our study describes and evaluates the application of a waiting list active management program in an Italian LHT among a sample of citizens on waiting lists for ambulatory care diagnostic and/or clinical investigations.


The study was conducted in an Italian LHT in Veneto Region from October 2008 to April 2009 (Fig. 1), with the LHT Ethic Committee's approval. In cooperation with the LHT Quality Service and the Customer Relations Office, the authors conducted a waiting list active management program and survey among patients in C class. On February 2008, patients waiting for more than 180 days were only 4.1% of the total patients in ‘C’ Class, as this would represent a major cause of concern and disappointment in public opinion and media releases.

Figure 1

The study design, time sequence and findings.

The active management program consisted of:

  • a telephone call targeted at patients in their waiting list midterm (90 days left), with repeated attempts to contact non-respondents;

  • a further contact step—if needed—with either the patient's GP or the LHT centralized waiting lists register to reassess patient priority class.

The program was managed by two female retained nurses previously working in ambulatory care areas. Their curricula had been selected as they demonstrated to have nursing profession core competency skills like behavioral attributes (i.e. willingness to serve, gentleness, efficiency, keen observation and judgment) as well as advanced practice skills (i.e. management, skills in general care, collaboration and communication) [9], and they were most likely to encounter the issue of patient quality of life and their satisfaction with healthcare professionals and system [10]. According to the study program, they underwent a training course on waiting list management including techniques for survey interviewing, recommended by Bowling [11].

Four main outcomes were defined to evaluate the impact of the waiting list active management system:

  1. patients with deteriorating healthcare conditions so as to reassess their priority status. Such an outcome was investigated by a specific question on the progression of the health status as the referral and by questions on access to Emergency and Acceptance services, ambulatory care visits, hospital admissions in the meanwhile for causes related to the referrals [3];

  2. dropouts, i.e. appointments that, unexpectedly, are not attended by the scheduled patients, thus causing disturbances to the regular ambulatory workflow, waste of resources and, eventually, longer waiting lists for ambulatory care;

  3. satisfaction about the initiative: such an indicator was self-declared by the interviewed at the end of the telephone survey [12], by answering the following question: ‘With respect to waiting list management, do you consider the interview as: useful, not useful, I don't care?’;

  4. citizens' perceived quality of care: such an indicator has been chosen as an overall measure of the waiting list active management program and exactly reproduced the question taken from the National Survey on Healthcare [13] so as to compare the patient-perceived quality of healthcare service with Veneto regional data.

Survey instrument and sample

The survey consisted of 21 items evaluated socioeconomic characteristics, social support, accessibility, referral physician, self-perceived health status and patients' satisfaction. Eighteen items over 21 (86%) derived from National Survey on Healthcare [13]; the other three questions, dealing with different types of access to healthcare, were taken from a consultation carried on during the training course.

We surveyed all the 554 people of the LHT centralized waiting list electronic register in Priority class ‘C’ (within 3 months), exactly in the middle of the waiting time (90 days left). Patients being surveyed were extracted among those awaiting interventions generally considered at high risk of dropout by the LHT staff: electrocardiography (ECG) plus cardiology ambulatory consultation (42.7%), eye ambulatory consultation (18%), carotid vessels Eco-color-Doppler (20.9%), legs Eco-color-Doppler (3.4%) or colonoscopy (15%). A cross-sectional study of the stratum of those exactly in the middle of the list (i.e. visit scheduled exactly 83–90 days after) was performed (Fig. 1).

Before-and-after controlled trial

A controlled before-and-after study was performed to evaluate the overall impact on citizens' perceived quality of care among those patients referred for cardiology (intervention) and physiatry (control) ambulatory visits. Physiatric patients were chosen as the ‘control group’ for being delivered in the four accredited ambulatory centers, as they were likely to match with cardiology patients characteristics (age, gender, delivery setting), except for the ‘exposition’ [14].

The authors computed the sample size of the before-and-after controlled trial using EpiInfo Version 3.6. The significance level was set at 0.05 and the power at 0.80, the worst accepted result at ±3%, considering as the expected difference, the frequency of the worst rate of patients' perceived quality of healthcare services in Veneto Region according to the National Health Survey in 2005, 14.1% [13]. The ideal difference would have been 0.17.

The ‘pre-intervention’ stage was performed before the implementation of the waiting list active management program (Fig. 1) and involved an age and gender representative sample of 160 patients attending cardiology ambulatory visits and 187 patients attending a physiatry ambulatory visit. An anonymous questionnaire (see below) was administered, and consisted of 10 items extracted from the previous 21, dealing with socio-demographic characteristics, health status, satisfaction with the national healthcare system as well as with local public services (i.e. education, mail delivery service, water supply and local healthcare). The impact of the active management interview on citizens' self-reported quality of healthcare was measured through a question taken from the National Health Survey: ‘What is your opinion on quality of care offered by the Italian National Health Service over the last 12 months?’; the available answers were: ‘It's getting improved; It's the same; It's getting worse; I don't know’ [13].

The ‘post-intervention’ stage involved both patients who were likely to have been included in the waiting list management program (ECG plus cardiology ambulatory consultation), and patients in the control group (physiatry). An age and gender representative sample of 207 patients attending a cardiology ambulatory visit and 192 patients attending a physiatry ambulatory visit, distributed in the four ambulatory centers, were given the same anonymous questionnaire (Fig. 1).


Descriptive and inference statistical analysis were performed by using SPSS 14.

A multiple logistic regression analysis was carried out in the controlled before-and-after trial to verify the influence of socio-demographic characteristics, health status and satisfaction with other public local services, chosen as independent variables [13] on the patients' satisfaction (‘get improved/it's the same’ and ‘get worst/I don't know.’) with the Italian National Health Service (NHS).


Active waiting list management

Of the 554 people selected, 501 were interviewed with an average response rate of 90.4% (Table 1). Among those who did not answer, 82% were not available over phone or the telephone number was wrong, the others refused as they were not interested in the initiative. Thirteen percent of patients required more than one telephone call to obtain a response. Two people (0.4% of the sample) reported that they were getting worse (Fig. 1) and referred to their GP. Five patients (1%) no longer planned to attend the scheduled intervention.

View this table:
Table 1

Sample classification according to age, classes and gender (n, %)

Colonoscopy [n (%)]ECG cardiological evaluation [n (%)]Carotid vessels Eco Doppler [n (%)]Lower extremity venous Doppler [n (%)]Oculistic visit [n (%)]Total [n (%)]
Age group
 0–1703 (1.6)0010 (11.1)15 (2.9)
 18–395 (6.7)10 (4.8)02 (13.3)15 (16.7)33 (6.5)
 40–6433 (44.0)52 (24.2)29 (27.6)10 (60.0)32 (35.6)153 (30.5)
 65+37 (49.3)149 (69.4)76 (72.4)5 (26.7)33 (36.7)301 (60.1)
Total75 (100)214 (100)105 (100)17 (100)90 (100)501 (100)
 Male47 (62.7)109 (50.8)59 (56.2)9 (53.3)37 (41.0)258 (51.4)
 Female28 (37.3)105 (49.2)46 (43.8)8 (46.7)53 (59.0)243 (48.6)
Total75 (100)214 (100)105 (100)17 (100)90 (100)501 (100)

In each age class, 95.4% patients reported that the interview was useful to them, with values ranging from 100% in the younger age group to 90.6% in the 18–39 and the 40–64 age groups.

Before-and-after controlled trial

At baseline, 51.9% of patients referred for ECG plus cardiology consultation and 40.6% of those referred for physiatry consultation reported a positive judgment about perceived quality of the National Health Service. After the active management intervention, 53.1% of patients referred for ECG plus cardiology consultation reported a positive judgment, while only 33.9% of patients referred for physiatry consultation reported a positive judgment (Table 2).

View this table:
Table 2

Analysis of the healthcare perceived quality at cardiology and physiatry clinics (LHU TV 7) in January–March 2009

Pre (160 subjects)Post (207 subjects)Difference on positive opinion between pre and post (%)P-valuePre (187 subjects)Post (192 subjects)Difference on positive opinion between pre and post (%)P-value
Number of intervewed subjects1602071.2<0.05187192−6.7<0.0005
Positive Opinion on NHS over the last 12 monthsa (%)51.953.140.633.9
  • Partition between pre- and post-intervention (absolute value, relative frequency, and difference between frequencies).

  • a‘What is your opinion on quality of care offered by the Italian National Health Service over the last 12 months?’ [Available answers: ‘It's getting improved’, ‘It's the same’ = positive opinion; ‘It's getting worse’; ‘I don't know’: negative or irrelevant].

This pre–post differences within each of the two cardiology and physiatry groups were statistically significant (difference on positive opinion in cardiology between pre and post: 1.2%, P < 0.05; difference on positive opinion in physiatry between pre and post: −6.7%, P < 0.0005).

In the logistic regression model, people who reported a score on the Regional health services below the median value were likely to negatively evaluate the NHS. In addition, we reported a positive influence of the satisfaction with school services and a negative of worsening in self-reported health status and of water local supply, respectively (Table 3).

View this table:
Table 3

Logistic regression model relating groups of variables and positive opinion on national health system over the last 12 months

VariablesP-valueOdds ratio95% CI
Age class
Place of residence
 Inside the LHUT1
 Outside the LHUT0.7901.1180.4912.546
 Out of Veneto region0.5811.5340.3367.000
Educational level
 Primary school0.6470.8310.3771.834
 Middle school0.7381.1430.5222.502
 Professional school0.5200.7630.3341.742
 Secondary school0.5841.2450.5692.724
Health status satisfaction
 Highly satisfied1
 Enough satisfied0.2580.6650.3281.348
 Poor satisfied0.6291.2030.5692.544
Compared to 1 year ago, how do you consider your health status?
 Worse-I don't care0.3611.1920.8181.735
Do you ask to someone for important decision on own health?
 I ask my private physician1
 I take final decision myself0.6401.1510.6372.081
 I ask my GP0.5100.8500.5251.377
 I ask a specialist0.1310.5820.2891.175
Postal services’ opinion
Railway services’ opinion
School system’ opinion
Telecommunication group services’ opinion
Regional health services’ opinion
Electricity and gas services' opinion
Water services' opinion
Television services' opinion
  • *P < 0.05. **P < 0.001.

Moreover, we performed the Hosmer–Lemeshow goodness-of-fit test that confirmed that the models fit the data set quite satisfactorily [χ2 = 4735, degrees of freedom (df) = 8, P = 0.786].


This study described and evaluated the application of a waiting list active management program in an ambulatory care setting, by surveying people in the middle of their waiting time and by assessing the rate of those with deteriorating healthcare conditions, the rate of dropouts and the satisfaction with the program. In addition, by using a before-and-after trial with a comparison group, the authors evaluated the impact of the active management interview on citizens' self-reported quality of NHS system.

Only two patients (0.4% of the whole sample) declared worsening health status, suggesting that the regional healthcare standards governing whether and when a patient ought to be placed on an expected long-time waiting list were not having an adverse impact on most patients' health conditions. Only 1% of patients reported intent to drop out of the list. These results are similar to those of two local waiting list management experiences [15, 16], although much lower than the rate in ambulatory care dropout observed by the Italian Ministry of Health, and ranging up from 20 to 50% [17].

Self-reported satisfaction with the healthcare system based on the question used in the National Health Survey [13] was increased among patients referred for ECG plus cardiology consultation (and expected to have been reached by the active waiting list management system), compared with the control group of physiatry patients who were not included in the active waiting list management program.

Patients' satisfaction is increasingly investigated as an indicator of health system performance [18] and varies systematically with certain characteristics such as age, sex, educational level, socioeconomic status and ethnicity of the patient [19]. The use of a logistic regression model to control the effects of some of these factors (except ethnicity) may have minimized but not eliminated the confounding effects of these factors on patients' expectations, differences in the other services provided or differences in the way patients report their experiences [20].

We observed a negative influence of self-reported health status on satisfaction with the Italian National healthcare system. Such associations are not unexpected and may account for the lower satisfaction among physiatry patients.

On the other hand, satisfaction with healthcare delivery system was associated with the reported quality of other local public services, rather than information on quality of healthcare systems gathered by mass media.

This is particularly relevant in countries like Italy were the regional government is accountable for the overall quality of Welfare as well other public services governance, although not directly delivered [4, 13].

We acknowledge some limitations of the research. First of all, the high rate of satisfaction with the telephone survey could be biased by the combination of uncertainty, powerlessness and consequent psychological distress and subjection [21]. The survey methods were derived from the 2005 National Health Survey which had been previously validated [13]. In addition, phone interviews appear to have equal accuracy rates both to face-to-face interviews [11] and mail [22] in relation to the collection of data on general health status. The role of nurses in identifying situations that affect healthcare choices was quite well recognized [23].

The authors are aware of the impact on the detection of health status conditions, dropouts and patients' satisfaction on the initiative due to the decision to survey a cross-section exactly in the middle of the long expected waiting times (90th day on a maximum of 180 days).

In addition, the authors decided to perform a controlled before-and-after study to split the contribution of waiting list management on the whole self-perceived quality of care from other determinants mostly linked to the overall service quality during the ambulatory visit deliveries (i.e. technical quality, reliability, responsiveness and assurance) [24].

A limitation in such a study design would depend on the decision to perform an anonymous questionnaire in the ‘pre’ and ‘post’ phase; hence, to represent most of the people already surveyed during the active waiting list management system, the authors even tried to schedule appropriately the survey submission days.

There is a complex set of factors that affect the quality of waiting lists management systems (i.e. health status, satisfaction, willingness to remain in the queue), thus confirming the outstanding value of ‘not to leave people alone’ and ‘not to leave them feeling themselves alone’ in healthcare.

In conclusion, the application of a waiting lists management program on our sample was likely to be successful in terms of its capability to monitor health status and accessibility to healthcare services and in terms of satisfaction with the program and the health system itself.

It must be pointed out that, as some studies have investigated such an impact on elective surgery [25], our study is one of the first to investigate it in ambulatory care [26].

Implications for policy deal with the need to improve such programs on a wider scale, so as to integrate other prioritization policies aimed at managing waiting lists in ambulatory or other outpatient settings, such as for patients queuing for a while. This issue represents a challenge for researchers, considering the scarcity of assessment studies registered on these topics.

Future research should put much more emphasis on the evaluation on the appropriateness of the prescription and the inclusion in waiting lists, in order to perform concordance analysis of prioritization and diagnosis between referral and ambulatory visits. On the other hand, in public-funded healthcare systems, patients in waiting lists do not hesitate to switch to another healthcare provider if they do not obtain satisfaction [27]: as a result, provision of quality service and improvement of patient satisfaction are key strategies, crucial to the long-term success and reduction of dropouts.

At the moment, our study findings may be considered as a proxy of trust and satisfaction with quality of healthcare services, as well as of a good level of citizens' empowerment.

Indeed, data concerning the relatively high satisfaction should be read together with the high proportion of interviewing subjects who wanted to remain in the queue, as well as the relatively high telephone survey response rate. There is, in fact, a high level of empowerment and civic accountability of all the users toward both the health system and the other citizens in a waiting list: this indicates the ‘trust’ of citizens in the organization's ability to meet their own health needs, including the demand management.


This research was supported by a grant from the Local Health Trust TV/7 of Veneto Region.


The authors acknowledge Dr Amalia Biasco, Dr Agnese Lazzari and Dr Roberto Falvo for their useful collaboration in the draft preparation. They also acknowledge the SPi Journals—Professional Editing Services for their assistance.


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