Original Title: Estrategias para la gestión eficiente de las listas de espera y mejora de la optimización de recursos

Authors' objectives: The aim of this report is to identify strategies for waiting list management applicable in the Spanish context and to review their effectiveness in reducing waiting times and/or the number of people on waiting lists, as well as to analyze their applicability, acceptability, and sustainability from an organizational and health system planning perspective.

Authors' results and conclusions: --- RESULTS --- EFFECTIVENESS A total of five systematic reviews and 52 primary studies evaluating different waiting list management strategies were included. SYSTEMATIC REVIEWS In primary care, open-access models were the most frequently evaluated strategy and were consistently associated with substantial reductions in waiting times, with relative decreases often exceeding 60%, along with additional reductions in missed appointments. Combined strategies (triage, workload reorganization, telephone follow-up, or non-face-to-face consultations) also showed relevant reductions. The STAT model, evaluated through a cluster randomized controlled trial, demonstrated a significant reduction in waiting times of close to 30%. However, some structural reforms, such as free choice of physician, were associated with modest increases in waiting times in primary care. In specialized care, a wide range of supply-side, demand-side, and mixed strategies was identified. In most studies that conducted statistical analyses, significant reductions in waiting times were observed, generally exceeding 30%. Strategies with stronger empirical support included teleconsultations, rapid-access cancer clinics, and combined interventions in mental health. Evidence from Spain was limited but suggested relevant reductions, particularly with one-stop diagnostic models. Regarding sustainability, studies with follow-up periods longer than one year indicated that changes in referral processes, open-access models, and combined strategies could maintain waiting time reductions for up to two years or more, although the quality of the evidence was low or very low. Substitution strategies involving non-physician health professionals also showed sustained effects over time. Telemedicine has a broad and heterogeneous evidence base. Results showed significant reductions in waiting times. Teleconsultations were associated with relevant mean reductions across both medical and surgical specialties, with similarly favorable results in studies conducted in Spain. Beyond reducing waiting times, some studies reported additional benefits such as improved case resolution and reduced unnecessary testing, and one Spanish study showed improvements in clinical outcomes such as hospitalization and mortality. In pediatric rehabilitation services, evidence indicated that rapid-response strategies, process efficiency improvements, and professional substitution were associated with marked reductions in waiting times, frequently exceeding 60–70%. In this area, the quality of evidence was rated as moderate in the included systematic review. PRIMARY STUDIES Interventions based on targeted increases in funding showed significant short-term reductions in waiting times. In Norway, increased funding for individuals on sick leave significantly reduced waiting times, particularly among surgical patients, with a positive impact on the duration of sick leave. In Australia, additional funding for dental care produced a marked initial decrease in waiting lists, although this effect partially reversed in subsequent years. Referral to private providers did not show consistent benefits in reducing waiting times. A population-based study in England found that greater outsourcing of arthroplasties was associated with an overall increase in waiting times and greater socioeconomic inequalities, despite shorter waits in private centers. In diagnostic testing (CT scans), outsourcing did not significantly reduce total waiting times and was associated with an increased need for reinterpretation of results. Changes in referral systems, such as centralized referral, direct scheduling of follow-up appointments, or clinical pathways with guaranteed maximum waiting times, showed substantial and, in several cases, statistically significant reductions in waiting times to consultation, surgery, or treatment. These strategies were also associated with fewer rescheduled appointments, lower non-attendance rates, and fewer complaints, although results varied across services. Comprehensive diagnostic centers and fast-track pathways demonstrated high effectiveness, particularly in breast cancer, with substantial reductions in waiting times to diagnosis, assessment, and surgery. Similar positive results were observed in other clinical areas, with reductions exceeding 80% in some studies. Triage strategies were among the most widely evaluated interventions. In most studies, significant reductions in waiting times to first consultation and to treatment initiation were observed. Models incorporating triage performed by trained non-physician health professionals generally achieved reductions equal to or greater than those obtained with traditional models. Telemedicine, the most extensively evaluated strategy across both systematic reviews and primary studies, showed significant reductions in waiting times to therapeutic decision-making or treatment initiation. Combined quality improvement strategies, based on systematic process analysis and iterative service reorganization and evaluation, achieved consistent and often large reductions in waiting times, along with substantial decreases in the number of patients on waiting lists EXPERT OPINION STUDY Telemedicine in the form of teleconsultations was rated as the highest strategy in terms of perceived effectiveness and applicability, particularly for follow-up care, improved patient convenience, and reduced non-attendance, provided that it is implemented under clear protocols to minimize clinical, equity, and efficiency risks. Digital communication between primary and specialized care was also highly valued, being perceived as an effective tool to improve coordination and avoid unnecessary referrals, contingent upon adequate protocolization, training, and time allocation. Optimization of surgical activity and complex reorganization interventions were positively evaluated, especially when supported by clear leadership, technological infrastructure, and continuous monitoring. However, their implementation was constrained by workforce availability and organizational resistance to change. Strategies receiving lower overall ratings in terms of perceived applicability or effectiveness included task substitution/delegation to non-physician professionals, the establishment of maximum waiting times, funding increases as a stand-alone measure, free choice of physician or hospital, and referral to private providers. These were limited by legal barriers, equity and quality risks, perverse organizational effects, and sustainability challenges. Finally, participants proposed a multifactorial approach combining organizational, technological, and patient-centered measures, with particular emphasis on coordination across care levels, demand- and capacity-based planning, the use of advanced digital tools, and the humanization of the waiting experience. --- CONCLUSIONS --- EFFECTIVENESS The available empirical evidence on strategies to reduce waiting lists is extensive in terms of the number of studies (predominantly in specialized care, with fewer in primary care) but limited in methodological quality. The scarcity of randomized controlled trials, the predominance of uncontrolled observational designs, and the high heterogeneity of interventions and contexts preclude firm causal conclusions and robust comparisons of relative effectiveness. Overall, evidence quality ranges from low to moderate according to systematic reviews. Nevertheless, despite methodological weaknesses, the consistency and magnitude of favorable results suggest that many strategies may be effective when appropriately adapted to local contexts. In primary care, open-access strategies and the STAT model show relevant reductions in waiting times. In specialized care, most studies report significant reductions (>25%) in waiting times. The most extensively evaluated interventions include telemedicine, patient triage, and complex quality improvement interventions based on combined strategies, systematic analysis of demand and processes, and iterative organizational change. These interventions were also among the most highly rated by consulted experts. Delegation of triage or initial assessment tasks to trained non-physician professionals may be effective but raises regulatory, professional, and social acceptability barriers within the Spanish National Health System. In cancer care, the most evaluated strategy was integration of diagnostic processes through comprehensive diagnostic centers, fast-track pathways, or case manager nurses, although applicability depends on a high level of coordination and service integration. Other organizational strategies, such as centralized referral, open access, free choice of center, or direct scheduling of follow-up appointments, have smaller evidence base but show promising results in reducing waiting times and improving patient experience. Targeted increases in funding can reduce waiting times in the short to medium term but do not represent a sustainable stand-alone solution and should be applied selectively and in combination with organizational changes. A high-quality interrupted time series study conducted in England shows that referral of patients to private providers does not guarantee waiting list reduction and may even be associated with increased waiting times and greater socioeconomic inequalities. Sustainable reduction of waiting lists requires, at micro- and meso-levels, rigorous analysis of the causes of delays, selection of feasible and acceptable interventions, anticipation and monitoring of unintended effects, and coordinated planning across care levels, with active involvement of all system stakeholders. ETHICAL, LEGAL, ORGANIZATIONAL, SOCIAL, AND ENVIRONMENTAL ASPECTS Waiting list management strategies are complex organizational interventions whose success depends not only on technical design but also on acceptance by professionals and patients. Perceived usefulness, role clarity, and integration into clinical workflows are key determinants of adoption, whereas solutions perceived as external, rigid, or administratively burdensome tend to face resistance and fragile implementation. Strategies that reduce uncertainty improve perceived access and may reduce abandonment, particularly among more vulnerable populations, while abrupt changes in care pace without adequate communication can generate anxiety and mistrust. Although patient prioritization is widely accepted as necessary in resource-constrained contexts, current approaches present significant equity limitations. The lack of explicit criteria, sociodemographic data, and clear management frameworks hampers identification and correction of inequalities, underscoring the need to address waiting list management through systemic approaches integrating organizational, ethical, social, and distributive justice considerations.

Authors' methods: First, a systematic search of reviews in tertiary sources and reports published since 2015 was conducted, together with a systematic review of primary studies and a review of ethical, legal, organizational, and social aspects. In parallel, a structured search of information in official sources and websites of the Spanish Autonomous Communities was carried out to identify waiting list management strategies implemented in practice. In addition, an expert opinion study was conducted to assess the applicability and expected effectiveness of the identified strategies. Given the heterogeneity of the studies and strategies evaluated, the evidence was synthesized narratively.

Project Status: Completed

Year Published: 2026

URL for published report: https://sescs.es/en/sescs-report-efficient-management-waiting-lists-2025/

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Canary Health Service

Contact Address: Dirección del Servicio. Servicio Canario de la Salud, Camino Candelaria 44, 1ª planta, 38109 El Rosario, Santa Cruz de Tenerife

Contact Name: sescs@sescs.es

Contact Email: sescs@sescs.es