Patient waiting time in the outpatient clinic at a central surgical hospital of Vietnam: Implications for resource allocation

Background: Patient waiting time is considered as a crucial parameter in the assessment of healthcare quality and patients’ satisfaction towards healthcare services. Data concerning this has remained limited in Vietnam. Thus, this study aims to assess patient waiting time in the outpatient clinic in Viet Duc Hospital (Hanoi, Vietnam) in order to enable stakeholders to inform evidence-based interventions to improve the quality of healthcare services. Methods: A cross-sectional study was conducted from June 2014 to June 2015 in the outpatient clinic at Viet Duc Hospital. Waiting time stratified by years (2014 and 2015), months of the year, weekdays, and hours of the day were extracted from Hospital Management software and carefully calculated. Stata 12.0 was employed to analyze data, including the average time (M± SD), frequencies and percentage (%). Results: There was a total of 137,881 patients involved in the study. The average waiting time from registration to preliminary diagnosis in 2014 was 50.41 minutes, and in 2015 was 42.05 minutes. A longer waiting time was recorded in the morning and in those having health insurance. Conclusions: Our results provided evidence that despite the decrease of waiting time from 2014 to 2015, waiting time was much higher among patients having health insurance compared to their counterparts. The findings suggest that human resources promotion and distribution should be emphasized in outpatient clinics and health insurance-related administrative procedures should be simplified.

Patient waiting time is defined as the time patients have to wait before meeting clinical staffs or using health service needed [1][2][3] . Although patient waiting time has been defined as an important indicator in the assessment of healthcare quality 1 and patients' satisfaction towards healthcare services 2,3 , lengthy outpatient waiting time has posed a great challenge to maximize healthcare quality 4 . The patient waiting time varies across settings. In Ireland, a study conducted in an outpatient clinic showed that 50% of patients waited 60% for their appointment 4 . In Nigeria, 60% patients had to wait 90-180 minutes for receiving examination 5 . Even in the USA, the average patient waiting time was from 60 minutes in Atlanta to 188 minutes in Michigan 6 . This issue is worse among countries with low provider-patient ratios 7 .
Vietnam is among highly populated countries that are fueled by patient overload, especially in the central hospitals 8

Study design and settings
A cross-sectional study was conducted from June 2014 to June 2015 in the outpatient clinic of Viet Duc Hospital (Hanoi, Vietnam). It is the largest surgical center of Vietnam, with approximately 1300 beds and approximately 150,000 patients using outpatient services annually.

Participants
All patients that underwent a medical examination during this time were eligible for the research. There were no specific exclusion criteria used in this study. Data from a total of 137881 patients were extracted for final analysis.

Data collection and measurements
Time data was collected via Hospital Management Software, which was developed to support hospital management in Viet Duc Hospital. Data concerning the waiting time for utilizing service was computed as the time that patients met the physicians minus the time that the patient registered. These data were automatically recorded when the patients registered and when they met the physicians. We used secondary data instead of primary data in order to get the accurate data for the analysis. By using time record function from the software, we could identify exactly when the patients used their services needed. Due to using secondary data, we did not collect and report the demographic characteristics of patients.
In this study, variables of interest included health insurance status, the waiting time for health service use, year (2014 and 2015), months of the year, weekdays and hours of the day.

Statistical analysis
Data was extracted in Microsoft Excel form and Stata 12.0 was employed to analyze data: the average time (M±SD), frequencies and percentage (%). Mann-whitney test was used to test the differences of waiting time among variables. P-value < 0.05 was considered statistical significance. Since we extracted data from the software, there was no bias in this study.

Ethical approval
The study was approved by the IRB of Viet Duc Hospital, Hanoi, Vietnam. Data collection procedures and the use of data for analysis were also approved by the directors of Viet Duc Hospital. No personal data concerning patients was collected in this study. Table 1 illustrates the average waiting time of patients in the outpatient clinic of Viet Duc Hospital. There was a total of 137881 patients who had a medical examination during the time of conducting the research, in which 38298 patients had health insurance, accounting for approximately 27.8%. The average waiting time from registration to preliminary diagnosis in 2014 was 50.41 minutes and in 2015 was 42.05 minutes.

Amendments from Version 2
This version contains some major changes in the introduction section, that we have added the definition of patient waiting time and the patient waiting time across countries. In the method section, we have clarified how we used secondary data instead of collecting primary data. We have also mentioned how we collected these data in the software. In the result section, we have added standard deviation for each measure in tables. Finally, we have rewritten the discussion and conclusion to fit the research question and results. We have also modified the conclusion in Abstract to be appropriate with the conclusion of the revised manuscript.

REVISED
Patient waiting time regarding the hours of the day are presented in Table 2. The largest number of patients having a medical examination were in the hours 7:00-8:00 and 8:00-9:00. The lowest number of patients having medical examination were in the hours 11:00-12:00, 15:00-16:00 and 16:00-16:30 (because the hospital was closed at 16:30). The longest patient waiting time was at 6:30 to 7:00, and the time among those having health insurance was 81.54 minutes, while the longest patient waiting time among those who did not have health insurance was 70.63 minutes.

Discussion
The purpose of this study was to assess the patient waiting time in an outpatient clinic, Viet Duc Hospital, Hanoi, Vietnam. Our findings indicate that the average waiting time from registration to preliminary diagnosis was decreased in a period of two years from 2014 to 2015. Findings also suggest the difference regarding waiting time between the morning and the afternoon, those having health insurance compared to those that did not have health insurance. Noticeably, those having health insurance had to wait for their turn longer than those that did not have health insurance. This may potentially reflect shortcomings regarding complicated administrative procedures that could extend waiting time 9 . In fact, cumbersome administrative procedures related to health insurance remain the pressing issue in Vietnamese healthcare system 17 . Since this strategy may be hampered by health insurance-related procedures, stakeholders should pay attention on simplifying administrative procedures for insured patients.

Conclusions
Our results provided evidence that despite the decrease of waiting time from 2014 to 2015, waiting time was much higher among patients having health insurance compared to their counterparts. The findings suggest that human resources promotion and distribution should be emphasized in outpatient clinics and health insurance-related administrative procedures should be simplified.

Data availability
Dataset 1: Raw data used in the construction of Table 1- Author contributions TDT, UVN, BXT conceived, designed and conducted the experiments; TDT, UVN, VMN collected the data; TDT, UVN, BXT, VMN analyzed and interpreted the data; TDT, UVN, BXT, VMN wrote the paper. All authors read and revised the manuscript.

Competing interests
No competing interests were disclosed.

Grant information
The author(s) declared that no grants were involved in supporting this work. Thank you for providing me the opportunity to review the article. An important topic indeed. However, I think that the introduction is very superficial without adequately contextualising the waiting time problem.

Open Peer Review
Methodology is very superficial indeed. There is no indication of what additional parameters were added to the hospital management system. What parameters were used to obtain the data? Who enters the data? When is patient waiting time measured from? Why did the authors do a secondary data analysis and did not conduct primary data collection?
Results -There is no general profile of the patients provided. There is no standard deviation or confidence intervals provided. The results could be better presented using histograms for times of the day.
Discussion -This is highly superficial. There is no mention of queuing theory or application thereof. The study does not provide any human resource data and therefore cannot link the discussion on human resources requirements. The findings were not disaggregated by health insurance and therefore the last paragraph of the discussion cannot be linked to relevant data.
Conclusion -Are tailored to suit the authors agenda but not based on the findings of the study or the aims.

If applicable, is the statistical analysis and its interpretation appropriate? Partly
Are all the source data underlying the results available to ensure full reproducibility? Yes Thank you very much for your comments. We have carefully clarified and added more details in the updated manuscript. We believe that this version is sufficient for your acceptance.
Thank you very much for your comments. We have carefully clarified and added more details in the updated manuscript. We believe that this version is sufficient for your acceptance. 1) However, I think that the introduction is very superficial without adequately contextualising the waiting time problem.
Response: We have added more literatures in this section 2) Methodology is very superficial indeed. There is no indication of what additional parameters were added to the hospital management system. What parameters were used to obtain the data? Who enters the data? When is patient waiting time measured from? Why did the authors do a secondary data analysis and did not conduct primary data collection?
No competing interests were disclosed.

Competing Interests:
I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Author Response 11 May 2017 , Institute for Global Health Innovations, Duy Tan University, Vietnam Vuong Nong Minh Dear Mr Duc, Thank you very much for your comments. We would very carefully consider your feedback and revise our manuscript. We hope that our newest version makes you satisfy. Sincerely,

Authors
No competing interests were disclosed. Competing Interests: