Patient Waiting Time at Primary Healthcare Centers in Riyadh Region, Saudi Arabia: A Cross-sectional Study

Patient waiting time can adversely affect health services utilization and continuity of care, impacting patient satisfaction. In Saudi Arabia, there is limited information about the average waiting time at primary healthcare centers. Therefore, this study quantifies patient waiting time for services offered in Ministry of Health primary healthcare centers in Saudi Arabia. A cross-sectional study utilizing secondary data from the Health Information System at primary healthcare centers in Riyadh was conducted in December 2020. Ten primary healthcare centers were selected. All patients visiting the selected centers during the study period were included, except those who needed emergency care or came for services without seeing the physician. Data regarding patient waiting time in minutes for different stages of primary healthcare services were collected. The median total waiting time was 23 min. The median waiting time for pre-consultation and consultation were 6.00 and 6.78 min, respectively. The waiting time for pharmacies in rural primary healthcare centers was 22.1 min, while there was no recorded information regarding pharmacy waiting time in urban primary healthcare centers. The total waiting time at urban primary healthcare centers was longer than at rural primary healthcare centers, with a significant difference between both groups (t =  − 15.5, P < 0.001). Patient age, marital status, educational level, occupation, and weekdays were significant factors influencing waiting time (P < 0.05). This study reveals positive outcomes regarding the average waiting time in primary healthcare centers in the Riyadh region. Further primary research is recommended.


Introduction
Patient waiting time is a challenge for most countries aiming to achieve universal health care access and coverage for all patients as many patients still encounter delays in accessing specialized care [1]. It is "The time the patient waits before being seen by one of the clinic medical staff" [2]. Bergenmar et al. stated that waiting time objectively evaluates the quality of service received against the individual's expectations [3].
Waiting time can adversely affect health services utilization, continuity of care, and patient satisfaction [4]. According to the Institute of Medicine, at least 90% of patients should receive medical care within 30 min of their scheduled appointment [5].
Several studies have categorized patient waiting time according to each stage of care at the healthcare facility [6][7][8][9]. For example, this may include time for patient registration, appointment booking, treatment, diagnostic tests, receiving test results, or other time spent on medical care [8]. Anderson et al. reported an inverse relationship between waiting time and patient satisfaction, whereas consultation time with a physician (≥ 5 min) was directly proportionate to patient satisfaction [4]. Ba et al. assessed the waiting time for each healthcare stage at a primary health clinic. They found the average time for registration was 15 min, from registration to seeing the physician was 41 min, while the average consultation time was 18.21 min. In addition, the average waiting time to acquire medications was < 30 min [7].
Many factors influence the length of patient waiting time, including; the number of healthcare workers [10], the number of patients per shift, the distance between units, and patient/staff communication [11].
In Saudi Arabia, the average acceptable waiting time at primary health care (PHC) centers is 20-30 min [12]. However, more information is needed about the actual waiting time and the factors affecting the time of patient flow at each healthcare stage at PHC centers. Therefore, this study aimed to quantify the waiting time for services offered at PHC centers and investigate its associated factors.

Objectives
• To quantify patient waiting time at each stage of healthcare services in PHC centers. • To investigate factors influencing patient waiting time at each stage of healthcare services in PHC centers.

Study Questions
• What is the average patient waiting time at each stage of healthcare services at PHC centers? • What are the factors influencing it?

Study Design
A cross-sectional study was conducted utilizing secondary data from the Health Information System (HIS) for 1 month in December 2020 at PHC centers in the Riyadh Region.

Study Population and Sampling Technique
Ten out of 105 Ministry of Health (MOH) PHC centers with functioning HIS in the Riyadh Region were selected for the study using a systematic random sampling technique. All patients visiting the selected PHC centers during the study period were included.

Exclusion Criteria
• Patients in need of emergency care. • Patients who visited the PHC center for procedures without needing to be seen by a physician, namely repeat medications or dressing changes.

Data Collection
The data were extracted from the HIS, which was launched in 2016 at PHC centers in Saudi Arabia by the Assisting Deputyship for PHC in collaboration with Elm Information Security Company. The data included demographic data of patients, namely, age, gender, marital status, nationality, educational level, and occupation. The collected data regarding patient waiting time in minutes for each stage of healthcare services included registration, pre-consultation, consultation, and pharmacy. Data regarding the patient visit, e.g., type of appointment and name of the clinic, as well as PHC data including the name of PHC centers, type of PHC centers, number of staff, number of patients visiting per day, and number of clinics, were also assessed.

Registration time:
The time between patient arrival at the PHC and registration at the registration counter. 2. Pre-consultation time: The time between patient registration at the registration counter and entering the consultation room.

Consultation time:
The time between the patient entering the consultation room and the end of the consultation by the physician (e.g., requesting medications, diagnostic tests either laboratory or radiographic or both, or discharging the patient). 4. Pharmacy waiting time: The time between the physician entering the medication prescription to the time of dispensing medication. 5. Total waiting time: The time the patient spends at the PHC from arrival until dispensing medication or discharge.

Statistical Analysis
Data were analyzed using Jamovi software version 2. The continuous variables (patient age and waiting time) were expressed by mean with standard deviation and median with interquartile range (IQR). Welch's t-test and ANOVA were used, with a set significance level of 5%, to test the differences between the length of time spent by patients and other variables.

Results
A total of 16,221 patients who attended the studied 10 PHC clinics during December 2020 in the Riyadh Region were received. After data cleaning, 9211 patients from 9 PHC centers were included because > 50% from the data for baseline characteristics needed to be included.  (Table 1). Table 2 shows the median waiting time for patients during their visits at the PHC centers. The overall median waiting time in urban and rural PHC centers was 30.4 (IQR = 41.0) and 6.00 (IQR = 60.1) min. The median of pre-consultation and consultation times at urban PHC centers were 6.00 (IQR = 12.0) and 7.00 (IQR = 15.00) min, respectively, while in rural PHC centers, they were 7.23 (IQR = 28) and 4.05 (IQR = 5.00) min. The pharmacy waiting time in rural PHC centers was 22.1 min, while there was no record of the pharmacy waiting time in   urban PHC centers. Patients' visits to PHC centers were more or less equally distributed during weekdays and between morning and afternoon shifts (Table 3). Significant factors affecting the total waiting time of patient visits to PHC centers included region (urban versus rural, t = − 15.5, P < 0.001), age group (F = 168, P < 0.001), marital status (F = 17.9, P < 0.001), educational level (F = 25.1, P < 0.001), occupation, F = 15.2, P < 0.001, and days of the week (F = 3.67, P = 0.005; Table 4).

Discussion
This study reveals positive outcomes regarding the average waiting time in PHC centers in Riyadh. The overall median waiting times in urban and rural PHC centers were 30.4 and 6.00 min, respectively. This finding is within the acceptable average waiting time for PHC centers in Saudi Arabia (20-30 min) [12] and in Britain (30 min) [13].
Additionally, we reported a pre-consultation time of about 6 min for both urban and rural PHC centers. This finding is much shorter than that reported in previous studies. For example, in Malaysia, Ahmad et al. found that the average waiting time from registration to seeing a physician in healthcare clinics was 41 min [7]. Also, Aburayya et al. reported that the pre-consultation time in Dubai was 34.2 min [14]. Finally, Alrasheedi et al. reported that 75.48% of patients waited < 30 min to see a physician [15].
The present study recorded a short duration of 6.78 min for the consultation time. This finding was more or less in harmony with Oche et al., who stated that 36.1% of the patients spent less than 5 min in the consultation room [10]. On the other hand, a very long consultation time (18.21 min) was recorded by Ahmad et al. in Malaysia [7]. The discrepancy in consultation time between different studies could be attributed to the variation in the study setting, duration, sample size, and data collection method.
The present study could not determine the pharmacy waiting time at urban PHC centers as it needed to be recorded in the PHC HIS. In comparison, that of the rural PHC centers was 22.1 min. This figure is close to that of Afolabi and Erhun (17.09 min) [16]. Likewise, Ahmad et al. reported that 99% of patients waited < 30 min to receive their medications [7].
The present study recorded the predictable factors affecting the duration of patient waiting time. These factors included the setting of the health facility, urban or rural, and the date of the visit.
This was in agreement with Mariolis et al. when they reported that one of the most important reasons for choosing urban PHC centers is a shorter waiting time compared to that of the rural PHC centers [17]. In addition, Biya et al. 2022 found that patients who arrived in the morning had longer waiting times than those who attended in the afternoon [18]. They also found that the visit date can affect the patients' waiting time. For example, patients who attended on Monday were 2.64 times (AOR = 2.64; 95% CI 1.45, 4.79) more likely to wait longer than those who attended on Friday [18].
Regarding patients' demographic factors, this study found that patient age, marital status, educational level, and occupation can affect the duration of patient waiting time. For example, a study done by Li et al. reported that a patient's age could affect the duration of waiting time; they found that middle-aged patients (41-65 years) had the longest average waiting time [19]. Furthermore, another study found that low educational level for patients was associated with longer waiting times [18].
Other studies found different factors that can affect the duration of patients' waiting time. A study by Oche et al. found that gender, high patient load, and the number of staff were significant factors influencing the duration of waiting time [10]. Other significant factors associated with the waiting time were documented by Hemmati et al., including a large number of patients, long distance between units, insurance coverage, working shifts, and poor staff communication [11].

Limitations
The current study utilized secondary data from the HIS at PHC centers to estimate the waiting time. Despite the ease of access to data from the HIS, some limitations could affect and underestimate the results. For example, this system does not record patient arrival time at the PHC. Consequently, we could not calculate the registration time. In addition, information on requesting and dispensing medications at urban PHC centers must be linked to the system. Therefore, we could not estimate the pharmacy waiting time at urban PHC centers. Finally, the quality of data obtained from HIS was poor (inaccurate and incomplete).

Conclusion
In conclusion, this study provided insight into the average waiting time in PHC centers and some associated factors. It revealed positive outcomes regarding the average waiting time in PHC centers in Riyadh. Further primary research is recommended to investigate other factors that could affect patient waiting time and the role of these factors on patients' satisfaction.
Author Contributions MAA wrote the manuscript and analyzed and interpreted the data results. NMR and NEM modified and reviewed the manuscript. AMH reviewed the manuscript. All authors read and approved the final manuscript.

Funding
The study was not funded.

Availability of Data
The data supporting this study's findings are available upon request from the Saudi Ministry of Health. The data are not publicly available because it contains information that could compromise the privacy of the included participants and settings.

Conflict of Interest
The authors declare that they have no conflicts of interest.
Ethical Approval and Consent to Participate Ethical approval from the Internal Review Board, Ministry of Health, Riyadh, was sought to conduct the research (Number 21-13 M). The data were kept confidential and are not to be used for purposes other than the study. Patients' personal information was not indicated during the publication process.
Consent to Publication Consent to publication was obtained from the Internal Review Board, Ministry of Health, Riyadh, on 21/07/2022.
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