Emergency departments (ED) provide timely care for acute conditions and serve as a vital safety net. Longer ED wait times are associated with worse health outcomes, but differences in ED wait times by patient language remain understudied. Examine differences in ED wait times between English and non-English language patients and its association with ED crowding. Retrospective cohort study of ED visits at an academic medical center in 2023 and 2024. 73,420 ED visits among adult patients not triaged to the highest acuity categories. Wait times from triage to provider assignment by patient primary language were assessed via unadjusted analyses and generalized linear models adjusting for demographic, temporal, and system factors as well as patient comorbidities and chief complaint. Language was then interacted with ED census to assess for effect modification from ED crowding. Secondary outcomes were time from provider assignment to ED disposition and rates of left without being seen (LWBS). Patients with a primary non-English language waited on average 6.5 min (p < 0.001) or 8.4% longer than English-primary patients for an ED provider-a difference that persisted after statistical adjustment (6.6 min, p < 0.001). Cantonese, Spanish, Russian, and Toishanese language patients experienced statistically longer wait times than English language patients. With ED census, each 10 additional patients in the ED were associated with an adjusted 2.3 min (p = 0.02) longer differential wait time for non-English language patients. Despite these differences, rates of LWBS were significantly lower for non-English language patients in both unadjusted and adjusted analyses (p < 0.001). Longer ED wait times for patients with a primary non-English language reflect a health inequity affecting a disadvantaged population. The degree of disparity widened as ED census increased. Health system and policy attention is needed to address ED crowding and other factors that could contribute to this disparity.
Access to dermatologic care varies by visit type and urgency. Academic programs serve as important referral centers, yet appointment wait times remain understudied. Using a cross-sectional secret shopper study, we evaluated wait times for new patient dermatology appointments. Calls were made to accredited residency-affiliated clinics requesting appointments for three standardized scenarios: (1) urgent lesion (changing/bleeding mole), (2) routine total body skin exam (TBSE), and (3) new-onset rash. All inquiries assumed cash-pay status. Median wait times for the first, second, and third available appointments across 113 U.S. academic medical dermatology clinics were evaluated. Median wait times differed across visit types. While urgent lesion appointments were scheduled most quickly (median 71.5 days, IQR: 26.8-109.8), compared to rashes (median 92.0 days, IQR: 66.0-138.0) and TBSEs (median 88.0 days, IQR: 64.0-134.0), wait times far exceeded those previously reported in community settings. Pairwise comparisons revealed urgent lesion visits were scheduled significantly sooner than either rash or TBSE visits (p < 0.0001 for both contrasts), while no difference was observed between rash and TBSE wait times. Substantial inter-program variability was noted, ranging from same-week to several-month delays. Academic dermatology clinics prioritize suspected malignancies but show little differentiation between rashes and routine visits. Even for suspected cancers, median wait times exceeded 70 days, raising concern for significant delays in diagnosis. These findings highlight the need for scheduling strategies that ensure timely access for urgent cancer concerns as well as inflammatory skin disease.
Prolonged waiting time is a ubiquitous challenge in public hospitals in low-and-middle-income countries (LMICs), significantly impacting patient satisfaction and service quality. The study's objective is to analyze the components and impact of waiting time on patient satisfaction at the National Hospital Abuja (NHA). In a cross-sectional study of 300 outpatients, time spent at different service points (records, nursing, doctor consultation, laboratory, pharmacy) and total hospital time were recorded. Satisfaction with these times was measured on a 5-point Likert scale. Data were analyzed using descriptive statistics and an independent samples t-test. The mean total time spent in the hospital was 247.5 minutes (~4 hours). The longest waiting time was to see a doctor (112.6 ± 86.6 minutes), while the shortest was with records staff (20.7 ± 29.5 minutes). Despite the long wait to see a doctor, patients were "Very Satisfied" (mean=3.60) with the consultation time itself. Overall satisfaction with waiting time (responsiveness) was the lowest among all quality domains (mean=2.99). Insured patients spent a longer total time (267.9 min) than uninsured patients (230.8 min), but satisfaction levels did not differ significantly (P-value = 0.33). Waiting time, particularly for physician consultation, is a major bottleneck and a key dissatisfier at the NHA. The discrepancy between long waits and high consultation satisfaction suggests that patients value the interaction once it occurs. To improve satisfaction, hospital administration must address the systemic failure of non-individualized appointment scheduling. Implementing a time-specific scheduling system is recommended as a crucial quality improvement intervention.
This study aimed to quantify wait times for adjuvant breast radiotherapy at Christchurch Hospital following surgery or completion of chemotherapy, with specific attention to the impact of COVID-19 lockdowns on service delivery. A retrospective review was conducted of patients with breast cancer who initiated adjuvant radiotherapy between 1 January 2018 and 31 December 2022 at Christchurch Hospital. Wait times were defined as the interval (in days) from final surgery or chemotherapy to the first fraction of radiotherapy. Median wait times were tabulated and graphed to determine trend lines accounting for the COVID-19 lockdown periods affecting Canterbury, New Zealand. The cohort included 682 patients. Median wait time to radiotherapy from surgery was 72 days and from adjuvant chemotherapy was 36 days. A statistically significant increase in wait times was observed from surgery to radiotherapy of 7.2 days per annum (95% confidence interval 6.84-7.65 days, p<0.001). An initial increase in wait times was followed by a comparative reduction during the COVID-19 lockdown period. Wait times for adjuvant breast radiotherapy have increased at Christchurch Hospital from 2018 to 2022. Although COVID-19 restrictions temporarily reduced delays, sustained increases suggest multifactorial pressures. Excessive delays to commencing radiation should be minimised to reduce the risk of locoregional recurrence.
Prolonged waiting times for eating disorder treatment are common in Australian public services and are associated with high attrition. Qualitative evidence suggests waiting may worsen symptoms and treatment credibility and expectancy beliefs; however, quantitative evidence is limited. This study examined whether waitlist duration was associated with eating disorder symptom severity, psychological distress, interpersonal problems, treatment beliefs, or treatment completion at a specialist outpatient service. Data from 168 clients (98% female; Mage 25 years) were analyzed. Mean waitlist duration was 132 days (SD = 73.4). Waitlist duration was not significantly associated with symptom severity, depression, anxiety, stress, interpersonal problems, treatment credibility, or expectancy, or treatment completion (all ρs ≤ 0.11, p > 0.05). Regardless of wait time, clients presented with substantial symptom severity and elevated distress at intake. Although longer waits were not associated with outcomes among those who reached intake, prolonged delays in the context of significant clinical need highlight the importance of rapid treatment responsiveness and closer attention to engagement and attrition processes.
To describe and compare the sociodemographic and access to care characteristics, specifically travel patterns, funding, and wait times, following the Dobbs decision among people receiving assistance from a practical support abortion fund, and examine factors associated with variation in wait times within each period. We used administrative data from a U.S. abortion fund that provides logistical support to people seeking abortions and prioritizes pregnancies of 15 weeks or greater. We included clients that received funding and with abortion appointments between July 2019 and June 2023. Bivariate analyses compared travel patterns, funding, and wait times between pre- and post-Dobbs groups. We used Wilcoxon-Mann-Whitney tests to compare median wait times between periods and Kruskal-Wallis tests to assess within-group differences. Among 3641 clients, 62.9% received support before Dobbs. More than half (56.0%) had pregnancies of 24 weeks or greater at the time of referral to the abortion fund. Compared with pre-Dobbs clients, post-Dobbs clients were more likely to originate from states with restrictive abortion policies (67.8% vs 53.1%) and from the South (69.4% vs 52.6%). Post-Dobbs clients also received more funding on average ($1732 vs $899) and experienced longer wait times (median 9 vs 6 days) for their abortion appointment. Following Dobbs, clients from a practical support abortion fund were more likely to travel from restrictive states, required more funding, and waited longer for abortion care. These findings highlight increasing barriers to abortion access and the critical role of practical support organizations in helping people obtain care.
Total Neoadjuvant Therapy (TNT) is increasingly replacing standard chemoradiotherapy (sCRT) for the treatment of locally advanced rectal cancer (LARC). Data on the use of personalized TNT (pTNT) regimens tailored to patient disease characteristics remain scarce. Accordingly, this study aimed to assess long-term outcomes of pTNT in patients with LARC. This was a secondary analysis of a multicentre retrospective cohort study. Patients treated with pTNT between 2019 and 2022 were compared to a historical cohort from the WAIT trial (2012-2014), which included extended chemotherapy during the interval period (xCRT) or sCRT followed by adjuvant chemotherapy. The main outcomes were 4-year disease-free survival (DFS) and overall survival (OS). Forty patients treated with pTNT were matched with 49 patients from the WAIT trial (25 xCRT, 24 sCRT). All WAIT trial patients underwent surgery, whereas 27 (67.5%) pTNT patients underwent surgery and 13 (32.5%) were managed non-operatively. Median follow-up was 48 months. No significant differences were observed in 4-year DFS (pTNT 70% vs. xCRT 68% vs. sCRT 75%, P = 0.764) or OS (pTNT 82.5% vs. xCRT 80% vs. sCRT 83.3%, P = 0.907). Within the pTNT group, patients with an oCR had significantly higher OS compared to those without oCR (95.2% vs. 68.4%, P = 0.021). Our findings suggest that pTNT achieves comparable survival outcomes to xCRT and sCRT in patients with LARC, despite higher rates of non-operative management. These findings should be interpreted cautiously given the exploratory nature of the analysis and limited sample size. Larger studies with longer follow-up are required to validate these early data.
Delays in care can lead to poor health outcomes and suboptimal patient and family experiences. We aimed to reduce the average wait time for gastrointestinal endoscopic procedures (procedure request to procedure completion) from 145 to 15 days (a 90% reduction) within 4 months (November 2023 to March 2024). A3 problem-solving methodology was used. The primary intervention was a multiday, multidisciplinary improvement workshop. Outcome measures included (1) procedure request date to procedure completion date, and (2) favorable patient satisfaction score for timeliness of access to care. Process measures included (1) procedure request date to date procedure scheduled by staff, and (2) date procedure scheduled by staff to procedure completion date. The balancing measure was the number of procedures scheduled per weekday. Control charts assessed the impact of interventions. Following the primary intervention (October 2023), special cause improvement was seen for all but the balancing measure. Outcome measure 1 achieved a sustained reduction in mean monthly wait time from 145 to 26.4 days (an 82% reduction), whereas outcome measure 2 achieved sustained improvement in patient satisfaction from 39.7% to 50.2% (a 26.4% relative improvement). Process measures 1 and 2 had sustained reductions from 56.5 to 14.7 days (a 74% reduction) and 89.1 to 20.7 days (a 77% reduction), respectively. The balancing measure also remained unchanged at a monthly average of 11.7 procedures scheduled per weekday. Using A3 problem-solving methodology, we achieved an 82% sustained reduction in endoscopic procedure wait times with a concurrent 26.4% improvement in patient satisfaction. Procedures are now routinely completed within 1 month of the request date.
The treatment of locally advanced rectal cancer has been transformed over the last century with nearly 40% of patients achieving complete eradication of their tumor with total neoadjuvant therapy alone. Nonoperative management with a watch-and-wait approach has now allowed a subset of patients the chance to avoid surgery altogether with 50% of watch-and-wait patients achieving long-term organ preservation. However, the other half of patients develop either local regrowth, which requires expeditious surgical intervention, or distant recurrence. Watch-and-wait is a reasonable option for select patients in a protocolized environment that can successfully deliver the recommended surveillance protocol, which ensures its safety.
Prolonged wait times for outpatient psychiatric care are a persistent problem across health systems and have been exacerbated following the COVID-19 pandemic, particularly in community hospital settings with limited specialist capacity. Purpose. To describe and evaluate a psychiatrist-led telephone consultation triage pathway designed to optimize specialist time and reduce outpatient psychiatry wait times. A quality improvement initiative was implemented in November 2022 at a Canadian community hospital. A structured triage process was applied to all outpatient psychiatry referrals, with selected lower-complexity referrals redirected to alternative pathways or addressed through psychiatrist-led telephone consultations with primary care providers. Service-level metrics were examined descriptively. Between November 2022 and May 2023, 687 outpatient psychiatry referrals were reviewed. Of these, 495 (72%) were accepted for psychiatric assessment and 192 (28%) were redirected. Following implementation, psychiatrist-led telephone consultations increased from approximately one per month to 12-15 per month. Compared with standard 90-minute psychiatric assessments, telephone consultations averaged approximately 10 min. Average outpatient wait times decreased from approximately 10 months prior to implementation to approximately 6 weeks during the post-implementation period. A structured psychiatrist-led telephone consultation triage pathway was associated with improved access to outpatient psychiatric care in a community hospital setting. This pragmatic, low-cost approach may be relevant to other services facing similar post-pandemic pressures.
People experiencing addiction often face barriers to care, including long wait times and social isolation. Peer support, delivered by people with lived experience, can address these challenges by fostering engagement and building recovery skills. This study piloted a peer intervention using the RECovery CAPital (REC-CAP) strengths assessment and planning tool for individuals on a waiting list for alcohol and other drug community treatment. Eligible participants (n = 21) were referred to peer workers for an assessment and goal setting session using REC-CAP between April and August 2024. Follow-up sessions occurred at 4- and 12-weeks to revisit goals and readminister REC-CAP, alongside brief fortnightly check-ins. At 12 weeks, qualitative interviews explored participant experiences and identified suggestions for improvement. Interviews were analysed using inductive content analysis. Changes in recovery capital (REC-CAP score) were assessed using a general linear model. Of the 21 participants (55% male, mean age 44), 72% identified alcohol as their primary drug of concern. Recovery capital significantly increased across the three time points, with the greatest gains observed between baseline and 4 weeks (n = 15). Qualitative findings highlighted the value of peer connection and structured goal setting while waiting for treatment. Peer support based on REC-CAP strengths profile and care planning shows promise in increasing recovery capital and maintaining motivation during treatment delays. Participants valued the peer relationship and the opportunity to reflect on recovery goals. These findings support further investigation in a fully powered trial to assess impact, effectiveness and scalability.
Waiting lists for an autism evaluation delay timely diagnosis and entry into autism-specific early intervention. To solve this crisis, our field must increase capacity by embracing efficient diagnostic processes. Traditional diagnostic pathways involve complex evaluations and rely on a highly trained but limited pool of specialists, which elongate wait times. Evidence suggests that emerging approaches, including telehealth assessments, primary care diagnosis, and tiered models, reduce barriers. We guide readers through five core issues critical to updating the standard of care for early autism assessment: (1) What are the consequences of maintaining the status quo? (2) What do families prioritize? (3) What evidence supports efficient diagnostic models? (4) What are the consequences of reducing accuracy? and (5) What level of assessment depth is needed to inform action? Our team contends that the critical advantages of adopting efficient service delivery models far outweigh the disadvantages. Collaboration across disciplines, and trust in families' insights, will help build capacity. We conclude with actionable recommendations for clinicians and policymakers in support of adopting these models.Lay AbstractThe growing demand for autism diagnostic services has outpaced available resources. This creates significant delays in first diagnosis and entry into early intervention services (early diagnosis and intervention improve outcomes). Expert diagnosticians in the field have debated - and tested - streamlined and flexible alternative diagnostic processes to speed up access to services; we believe that the advantages of such approaches outweigh the disadvantages, and that evidence supports updating our current standards.
Survival outcomes in patients managed nonoperatively ("watch-and-wait"; W&W) have been compared to those achieving pathological complete response after total mesorectal excision (TME). However, limited data exists on how these outcomes align across the spectrum of treatment responses in TME patients. Adult patients at Mayo Clinic (2017-2023) with clinical TNM stage II/III microsatellite-stable primary rectal adenocarcinoma treated with total neoadjuvant therapy were categorized into two cohorts: W&W and TME. The TME cohort was stratified by American Joint Committee on Cancer/College of American Pathologists tumor regression grade (TRG). Primary outcomes were 3-year distant-metastasis-free survival (3Y-DMFS) and disease-free survival (3Y-DFS). Among 385 patients, 79 were in the W&W cohort; 306 underwent TME (81 TRG0, 75 TRG1, 114 TRG2, and 36 TRG3). W&W patients had significantly shorter tumor-anorectal junction distances, smaller tumors, less tumors with extramural vascular invasion on pretreatment MRI, less threatened/involved mesorectal fascia, and lower clinical T and N stages. At a median follow-up of 26.0 months, Kaplan-Meier and Cox-Regression analyses showed that the 3Y-DMFS of W&W cohort resembled TRG1 (near-complete response) and TRG2 (partial response), the 3Y-DFS was similar to TRG2 (partial response) and TRG3 (minimal to no response). In contrast, patients with TRG0 (pathological complete response) had a 100% 3Y-DMFS and 3Y-DFS. Despite favorable baseline characteristics, W&W patients had prognoses similar to TME patients with suboptimal responses. Nonoperative management is a viable option for well-selected patients prioritizing organ preservation, but its cancer control outcomes appear not to match the well-established efficacy of definitive oncological resection.
Research has established the accuracy and reliability of emergency nursing triage. However, little is known about how emergency nurses use assigned triage scores to determine the order of emergency bed assignments. We define acuity-arrival order as the prioritization of patients first by acuity and then by time of arrival. An observational study was conducted across 6 emergency departments. Participants were emergency nurses in roles responsible for determining emergency bed assignments. Data were collected using demographic questionnaires, a structured data collection tool, and narrative field notes. Analysis included inductive content analysis and descriptive statistics. Overall, 18 observation sessions were completed, including 37 nurse participants. Among 524 patient encounters, 325 bed assignment decisions were observed, of which 57.8% deviated from acuity-arrival order. Prioritization decisions were shaped by variable institutional norms and processes. In small departments, triage scoring was completed inconsistently and did not play a significant role in determining bed assignment order. In large departments, patient prioritization was heavily impacted by the presence of patient streaming processes. Across all study sites, nurses expressed distrust in assigned triage scores and the belief that patient prioritization is a complex and holistic decision. Waiting emergency patients do not systematically receive bed assignments according to their assigned triage score or wait time. Instead, patient prioritization is determined through complex considerations of clinical acuity, waiting room safety, patient flow management logistics, and operational expectations. Patient prioritization has been found to be subjective and inconsistent, raising concerns about the quality, safety, and ethics of current emergency practice.
To evaluate the optimal management of the clinically node-negative (cN0) neck in early-stage (T1-T2) oral squamous cell carcinoma (OSCC) by comparing initial elective neck dissection (END) versus a Watch & Wait (W&W) approach with therapeutic neck dissection (TND) upon nodal relapse. Studies comparing END versus W&W/TND in T1-T2 cN0 OSCC patients were searched on PubMed till January 2026. PET imaging data were also assessed for nodal staging and surveillance. Studies comparing END versus W&W/TND in T1-T2 cN0 OSCC patients were searched on PubMed up to January 2026. This comprehensive systematic review without meta-analysis (SWiM) qualitatively synthesized data regarding key outcomes: overall survival (OS), disease-specific survival (DFS), disease-free survival (DFS), nodal recurrence rates, and treatment-related morbidity. Effect estimates from landmark clinical trials and meta-analyses were evaluated to establish a risk-stratified framework. END demonstrated improved 3-year OS (80.0% vs. 67.5%; HR 0.64, P = 0.01) and DFS (69.5% vs. 45.9%; P < 0.001) compared to TND, alongside significantly lower nodal recurrence (15.1% vs. 41.5%; OR 0.25, P < 0.00001). In low-risk patients (T1 tumors, DOI <4 mm, well-differentiated histology), a strict W&W protocol incorporating operator-dependent ultrasound, fine-needle aspiration cytology (FNAC), and PET surveillance achieved comparable DSS. END provides superior survival and regional control in higher-risk T1-T2 cN0 OSCC. Conversely, a risk-stratified W&W strategy incorporating multimodal surveillance or staging via sentinel lymph node biopsy (SLNB) is highly effective for select low-risk, compliant patients, optimizing oncologic outcomes while minimizing treatment-related morbidity.
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Despite strong evidence supporting exclusive breastfeeding (EBF) for the first six months of life, global and national rates remain suboptimal. In the critical first 48-72 hours after birth, several widespread clinical practices and beliefs, unsupported by current evidence, may inadvertently undermine breastfeeding initiation and continuation in healthy term neonates. To critically examine the available evidence on three clinical practices that may compromise early breastfeeding establishment in healthy term neonates: the perception that colostrum volumes are insufficient for the newborn's needs, the routine restriction of pacifier use, and the early introduction of electric breast pumps as a substitute for direct breastfeeding or hand expression. Narrative review of evidence from randomised controlled trials, systematic reviews, meta-analyses, and observational cohort studies, addressing three evidence-practice gaps relevant to the first 48-72 hours postpartum: (1) the physiology of colostrum production and the mismatch between normal volumes and maternal/professional expectations; (2) the effect of pacifier use on breastfeeding outcomes in term infants; and (3) the impact of breast pump use in the first days of life on breastfeeding duration and exclusivity. Colostrum volumes (2-10 mL per feed, 30-60 mL/day in the first 72 hours) are physiologically matched to neonatal gastric capacity and metabolic needs; perceived insufficient milk supply is overwhelmingly driven by unrealistic expectations rather than true lactation failure. Randomised evidence shows that small-volume, structured formula supplementation does not compromise breastfeeding duration, and that pacifier use in healthy breastfeeding term infants does not reduce breastfeeding rates. Routine introduction of electric breast pumps in the first days of life is associated with shorter breastfeeding duration; hand expression yields greater colostrum volumes and is associated with higher breastfeeding rates at two months than electric pumping. Evidence-based counselling on colostrum sufficiency, individualised pacifier counselling, and prioritisation of hand expression over routine electric pump use in the first 48-72 hours could meaningfully improve breastfeeding outcomes in healthy term neonates. Future research should prioritise pragmatic cluster-randomised trials evaluating bundled interventions in routine maternity care settings.
To evaluate the feasibility and safety of active MRI surveillance as an alternative to immediate surgical re-exploration in patients with small, asymptomatic postoperative cholesteatoma recurrence. Prospective single-arm pilot study. Secondary referral otology center. Patients with prior cholesteatoma surgery demonstrating postoperative recurrence ≤5 mm on non-echo-planar diffusion-weighted MRI without otologic symptoms, suspicious findings on otoscopy for cholesteatoma, or radiologic proximity to critical structures. Structured active surveillance with serial non-echo-planar diffusion-weighted MRI scans at 12- to 18-month intervals. Surgery-free survival (SFS) is defined as the time from baseline MRI demonstrating recurrence to surgical intervention. The secondary outcome included the annual lesion growth rate. Thirteen patients were included in the longitudinal analysis with a mean follow-up of 43±17 months. Ten patients (77%) remained surgery-free throughout the surveillance. Three patients (23%) required surgical intervention due to lesion enlargement or symptom development. The mean lesion growth rate was 0.32±1.0 mm/year. Three patients (23%) demonstrated spontaneous radiologic regression during follow-up. Kaplan-Meier analysis demonstrated cumulative SFS of 100% at 24 months and 91% (95% CI: 74-100) at 36 months. In selected patients with small, asymptomatic postoperative cholesteatoma recurrence, active MRI surveillance may safely defer surgical re-exploration. These findings support further prospective evaluation of imaging-guided surveillance strategies for the management of MRI-detected recurrence.
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The care pathway for severe aortic stenosis (AS) remains vulnerable to diagnostic delay, referral inertia, undertreatment, and procedural waiting times despite the availability of definitive intervention with surgical or transcatheter aortic valve replacement. This systematic review with narrative synthesis aimed to identify where delay and attrition occur across the contemporary severe AS pathway and to summarise evidence for digital, organisational, and workflow interventions designed to improve timely care. Randomised and non-randomised studies examining diagnostic, referral, treatment-decision, or procedural-access delays in adults with severe AS were eligible. Findings were mapped onto a four-checkpoint framework: pre-echocardiographic recognition, echocardiographic detection, post-diagnostic referral and decision-making, and procedural access. Nineteen studies met inclusion criteria. After de-duplication of overlapping registries and exclusion of studies without a verifiable unique severe-AS or severe-AS pathway denominator, the synthesis represented approximately 52,000 patients. Evidence was unevenly distributed, with no included study providing severe-AS-specific data before echocardiography. At echocardiographic detection, missed or delayed recognition was concentrated in low-gradient phenotypes and women; an artificial-intelligence-assisted alert system increased severe-AS detection from 2.4% to 4.1%. After diagnosis, undertreatment persisted despite guideline indications, and non-cardiology ordering of the diagnostic echocardiogram was associated with lower early follow-up or AVR and higher mortality. Electronic provider notification increased one-year AVR rates from 37.2% to 48.2%, with the largest observed effects in women, patients older than 80 years, and inpatient echocardiography. At procedural access, wait-list mortality was approximately 4.5%-5.8%, with deaths occurring early after referral. Risk-based triage reduced modelled wait-list mortality, while decentralised pre-procedural work-up shortened referral-to-TAVI time from 126 to 32 days. Severe AS care is characterised by measurable delay and attrition across multiple post-diagnostic transitions, while pre-echocardiographic recognition remains an important evidence gap. A four-checkpoint framework may support benchmarking and targeted pathway improvement through structured reporting, electronic referral prompts, risk-based triage, and decentralised workflows.