Waiting Time for Outpatient Specialty Appointments Through the Standard Versus Non-standard Referral Pathway in Public Hospitals in Ecuador

Background: Waiting time is a key dimension of effective access to health- care. We assessed whether waiting time to outpatient specialist appointments differs between standard (system-based) and non-standard (non-system-based) referral pathways in Ecuador and whether differences vary by specialty referral requirement. We further stratified analyses by referral requirement among different specialties.&nbsp; <div> <br> </div> <div> Methods: We analysed hospital-based survey data from Ecuadorian public hospitals restricted to respondents attending for a specialist appointment (n=4436). Waiting time (days) was compared by access type using the Mann–Whitney U test. Sociodemographic correlates of non-standard access were examined using adjusted logistic regression. Adjusted differences in waiting time were estimated using median (quantile) regression (τ=0·50). Analyses were stratified into direct-access specialties (Dentistry, General Medicine, Psychology) versus referral-required specialties (all other specialties).&nbsp; </div> <div> <br> </div> <div> Findings: Non-standard access was associated with shorter waiting time than standard access. In adjusted median regression, non-standard access remained associated with a 3·2-day shorter median waiting time (adjusted median difference −3·2 days, 95% CI −4·6 to −1·8). The waiting-time gap was larger for direct-access specialties (standard: 30 days [IQR 15–30], n=130; non-standard: 15 [5–30], n=281; median difference −15·0 days, 95% CI −15·0 to −6·0) than for referral-required specialties (standard: 30 [15–45], n=1301; non-standard: 25 [15–45], n=2724; median difference −5·0 days, 95% CI −5·0 to 0·0).&nbsp; </div> <div> <br> </div> <div> Interpretation: In Ecuadorian public hospitals, non-standard access to specialist appointments was associated with shorter waiting times than standard access, particularly in specialties that do not require referral in practice. Strengthening equitable timeliness may require improved transparency and governance of appointment allocation and referral coordination. </div>