Transforming Surgical Subspecialty Care Through Clinical Integration

Background: Access to specialty care challenges all healthcare systems. The Los Angeles County Department of Health Services (LAC-DHS), the second-largest public healthcare system in the United States, attempted to improve access through clinical integration, which was pursued through empanelment, deployment of eConsult, and the development of Expected Practices. We assessed the impact of clinical integration on access to surgical subspecialty care.   Methods: In a pre-post cohort analysis, of the 3669 eConsults placed for urology review from July 2012 to November 2016, 8% from each calendar year were randomly selected for granular review and cross-referenced from three data sources. We assessed the rates of non face-to-face specialty care touches (patients who were cared for with specialty input, but without a face-to-face visit), inefficient care, and intensity of touch (iterative dialogue between primary care and specialty care provider), as well as wait times for clinic visits.   Findings: Thirty-nine percent of all patients for whom an eConsult was placed were cared for with the input of a specialist without a face-to-face clinic visit. Of the patients seen in clinic, 73% received inefficient care prior to eConsult implementation, compared with 22% during the eConsult timeframe. Wait times were reduced from 22 weeks to 4 weeks, and over 90% of patients were seen in clinic within the intended timeframe. Average intensity of touch via eConsult was 3.1, and this iterative dialogue was completed in an average of 5 days.   Interpretation: Clinical integration is an innovative approach that may improve access to surgical specialty care.   Funding Statement: The authors state: "None." Declaration of Interests: The author states: "There are no financial disclosures from any of the authors." Ethics Approval Statement: The OVMC Institutional Review Board approved the study.