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PloS One 2019Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist... (Review)
Review
BACKGROUND
Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions.
METHODS
MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach.
RESULTS
Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities.
DISCUSSION
The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.
Topics: Developing Countries; Economics, Hospital; Health Resources; Hospital Administration; Hospitals; Humans; Poverty; Program Evaluation; Quality Improvement; Referral and Consultation; Surgical Procedures, Operative
PubMed: 31560716
DOI: 10.1371/journal.pone.0223328 -
Journal of Medical Imaging and... Jun 2017Referral to a clinical radiologist is the prime means of communication between the referrer and the radiologist. Current Australian and New Zealand government... (Review)
Review
Referral to a clinical radiologist is the prime means of communication between the referrer and the radiologist. Current Australian and New Zealand government regulations do not prescribe what clinical information should be included in a referral. This work presents a qualitative compilation of clinical radiologist opinion, relevant professional recommendations, governmental regulatory positions and prior work on diagnostic error to synthesise recommendations on what clinical information should be included in a referral. Recommended requirements on what clinical information should be included in a referral to a clinical radiologist are as follows: an unambiguous referral; identity of the patient; identity of the referrer; and sufficient clinical detail to justify performance of the diagnostic imaging examination and to confirm appropriate choice of the examination and modality. Recommended guideline on the content of clinical detail clarifies when the information provided in a referral meets these requirements. High-quality information provided in a referral allows the clinical radiologist to ensure that exposure of patients to medical radiation is justified. It also minimises the incidence of perceptual and interpretational diagnostic error. Recommended requirements and guideline on the clinical detail to be provided in a referral to a clinical radiologist have been formulated for professional debate and adoption.
Topics: Australia; Diagnostic Imaging; Guidelines as Topic; Humans; Interprofessional Relations; New Zealand; Radiologists; Referral and Consultation
PubMed: 28139044
DOI: 10.1111/1754-9485.12577 -
Social Science & Medicine (1982) May 2006A functioning referral system is generally considered to be a necessary element of successful Safe Motherhood programmes. This paper draws on a scoping review of... (Review)
Review
A functioning referral system is generally considered to be a necessary element of successful Safe Motherhood programmes. This paper draws on a scoping review of available literature to identify key requisites for successful maternity referral systems in developing countries, to highlight knowledge gaps, and to suggest items for a future research agenda. Key online social science, medical and health system bibliographic databases, and websites were searched in July 2004 for evidence relating to referral systems for maternity care. Documentary evidence on implementation is scarce, but it suggests that many healthcare systems in developing countries are failing to optimise women's rapid access to emergency obstetric care, and that the poor and marginalised are affected disproportionately. Likely requisites for successful maternity referral systems include: a referral strategy informed by the assessment of population needs and health system capabilities; an adequately resourced referral centre; active collaboration between referral levels and across sectors; formalised communication and transport arrangements; agreed setting-specific protocols for referrer and receiver; supervision and accountability for providers' performance; affordable service costs; the capacity to monitor effectiveness; and underpinning all of these, policy support. Theoretically informed social and organisational research is required on the referral care needs of the poor and marginalised, on the maternity workforce and organisation, and on the implications of the mixed economy of healthcare for referral networks. Clinical research is required to determine how maternity referral fits within newborn health priorities and where the needs are different. Finally, research is required to determine how and whether a more integrated approach to emergency care systems may benefit women and their communities.
Topics: Developing Countries; Female; Health Knowledge, Attitudes, Practice; Humans; Maternal Health Services; Referral and Consultation; Research
PubMed: 16330139
DOI: 10.1016/j.socscimed.2005.10.025 -
Family Practice Dec 2000Variations in referral rates exist, at GP and practice level. Although the National Institute for Clinical Excellence is to produce referral guidelines, it is unclear if... (Review)
Review
BACKGROUND
Variations in referral rates exist, at GP and practice level. Although the National Institute for Clinical Excellence is to produce referral guidelines, it is unclear if this variation requires regulation. A critical review of the literature on variation in referral rates was undertaken to see if existing evidence could inform the debate.
OBJECTIVES
The aim of this study was to describe the variation in referral rates; to identify likely explanatory variables; and to describe the effect of GPs' decision making on the referral process.
METHODS
Six bibliographic databases, the Cochrane Library, the NHS Centre for Reviews and Dissemination, and the National Research Register were searched.
RESULTS
Patient characteristics explain <40% of the observed variation; practice and GP characteristics <10%. The availability of specialist care does affect referral rates, but its influence on the observed variation of referral rates is not known. Intrinsic psychological variables are important. GPs who are less tolerant of uncertainty or who perceive serious disease to be a more frequent event may refer more patients. There is a lack of consensus about what constitutes an appropriate referral, and the use of guidelines has had only limited success in altering referral behaviour.
CONCLUSIONS
Variation in referral rates remains largely unexplained. Targeting high or low referrers through clinical guidelines may not be the issue. Rather, activity should concentrate on increasing the number of appropriate referrals, regardless of the referral rate. Pressure on GPs to review their referral behaviour through the use of guidelines may reduce their willingness to tolerate uncertainty and manage problems in primary care, resulting in an increase in referrals to secondary care. The use of referral rates to stimulate dialogue and joint working between primary and secondary care may be more appropriate.
Topics: Decision Making; Family Practice; Female; Humans; Male; Practice Patterns, Physicians'; Referral and Consultation; Social Class; United Kingdom
PubMed: 11120716
DOI: 10.1093/fampra/17.6.462 -
Medical Decision Making : An... Jan 2019Signal detection theory (SDT) describes how respondents categorize ambiguous stimuli over repeated trials. It measures separately "discrimination" (ability to recognize...
BACKGROUND
Signal detection theory (SDT) describes how respondents categorize ambiguous stimuli over repeated trials. It measures separately "discrimination" (ability to recognize a signal amid noise) and "criterion" (inclination to respond "signal" v. "noise"). This is important because respondents may produce the same accuracy rate for different reasons. We employed SDT to measure the referral decision making of general practitioners (GPs) in cases of possible lung cancer.
METHODS
We constructed 44 vignettes of patients for whom lung cancer could be considered and estimated their 1-year risk. Under UK risk-based guidelines, half of the vignettes required urgent referral. We recruited 216 GPs from practices across England. Practices differed in the positive predictive value (PPV) of their urgent referrals (chance of referrals identifying cancer) and the sensitivity (chance of cancer patients being picked up via urgent referral from their practice). Participants saw the vignettes online and indicated whether they would refer each patient urgently or not. We calculated each GP's discrimination ( d ') and criterion ( c) and regressed these on practice PPV and sensitivity, as well as on GP experience and gender.
RESULTS
Criterion was associated with practice PPV: as PPV increased, GPs' c also increased, indicating lower inclination to refer ( b = 0.06 [0.02-0.09]; P = 0.001). Female GPs were more inclined to refer than male GPs ( b = -0.20 [-0.40 to -0.001]; P = 0.049). Average discrimination was modest ( d' = 0.77), highly variable (range, -0.28 to 1.91), and not associated with practice referral performance.
CONCLUSIONS
High referral PPV at the organizational level indicates GPs' inclination to avoid false positives, not better discrimination. Rather than bluntly mandating increases in practice PPV via more referrals, it is necessary to increase discrimination by improving the evidence base for cancer referral decisions.
Topics: Adult; Decision Making; Diagnostic Errors; Female; General Practitioners; Humans; Lung Neoplasms; Male; Middle Aged; Practice Patterns, Physicians'; Psychological Theory; Referral and Consultation; Sex Factors; United Kingdom
PubMed: 30799690
DOI: 10.1177/0272989X18813357 -
Primary Health Care Research &... May 2018Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for... (Review)
Review
BACKGROUND
Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality.
METHODS
A search strategy designed following a Problem, Intervention, Comparator, Outcome model was used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources.
RESULTS
A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease 'inappropriate referrals' by up to 50%; templates increase documentation and awareness of risk factors; mixed interventions combining different intervention types provide tangible improvements in content and appropriateness.
CONCLUSION
Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve.
Topics: Documentation; Health Services Research; Humans; Primary Health Care; Quality Improvement; Referral and Consultation; Secondary Care
PubMed: 29212565
DOI: 10.1017/S1463423617000755 -
Nursing Standard (Royal College of...Criteria for referral to the district nursing service need to be drawn up in response to the Audit Commission Report (1999), with the aim of reducing the number of...
Criteria for referral to the district nursing service need to be drawn up in response to the Audit Commission Report (1999), with the aim of reducing the number of inappropriate referrals and providing patients with a more efficient service.
Topics: Algorithms; Decision Trees; Efficiency, Organizational; Health Services Misuse; Humans; Nursing Assessment; Nursing Audit; Patient Selection; Practice Guidelines as Topic; Public Health Nursing; Referral and Consultation; Workload
PubMed: 11974205
DOI: 10.7748/ns2000.07.14.45.39.c2890 -
BMJ (Clinical Research Ed.) Apr 2006Referral management centres are intended to improve referrals between primary and secondary care. The aim is good but so far we have little evidence that they can deliver (Review)
Review
Referral management centres are intended to improve referrals between primary and secondary care. The aim is good but so far we have little evidence that they can deliver
Topics: Health Care Rationing; Health Policy; Humans; Quality of Health Care; Referral and Consultation; United Kingdom
PubMed: 16601048
DOI: 10.1136/bmj.332.7545.844 -
Rapid Access Cardiology (RAC) Services Within a Large Tertiary Referral Centre-First Year in Review.Heart, Lung & Circulation Nov 2018Rapid Access Cardiology (RAC) services are hospital co-located cardiologist-led outpatient clinics providing prompt assessment and management of chest pain. This service... (Review)
Review
BACKGROUND
Rapid Access Cardiology (RAC) services are hospital co-located cardiologist-led outpatient clinics providing prompt assessment and management of chest pain. This service model is part of chest pain management in the United Kingdom. However, little data exists on RAC services in Australia. Our aim was to describe the introduction of RAC services to an Australian tertiary centre (utility, safety, and acceptability).
METHODS
Referrals were accepted for low-intermediate risk chest pain. Referrer and patient clinical data was collected prospectively in the first year of RAC - 4 February 2015 to 4 February 2016. Data was linked to hospital presentations/admissions to identify readmissions/mortality data.
RESULTS
Among 520 patients (55.0% male, mean age 55.2 years), 87.6% were referred from emergency and 68.4% assessed within 5 days. The final diagnosis was new coronary artery disease (CAD) in 7.9%, and 81.3% had ≥2 cardiovascular risk factors (diabetes, hyperlipidaemia, hypertension, overweight/obesity, smoker, pre-existing CAD, and chronic renal failure). On average, 0.8 cardiac tests were ordered per person. In total, 35 (6.7%) had invasive coronary angiograms, with 51.4% having obstructive CAD. Patients reported in surveys (82.8% response rate) that 93.0% "strongly agreed" RAC services were useful to the community. Referrers were also "very satisfied" with RAC (7/17) or "satisfied" (9/17). Furthermore, of 336 referrals, referrers reported without RAC they would admit the patient in 11.3% of cases. There were 4.8% (25/520) unplanned cardiovascular readmissions and 0.6% (3/520) of these were for acute coronary syndromes and no deaths.
CONCLUSIONS
Outpatient RAC services are an accepted, effective and safe pathway for management of low-intermediate risk chest pain.
Topics: Coronary Artery Disease; Humans; Referral and Consultation; Tertiary Care Centers
PubMed: 30278913
DOI: 10.1016/j.hlc.2018.05.201 -
BMJ Health & Care Informatics Jun 2024Referring providers are often critiqued for writing poor-quality referrals. This study characterised clinical referral guidelines and forms to understand which data... (Observational Study)
Observational Study
BACKGROUND
Referring providers are often critiqued for writing poor-quality referrals. This study characterised clinical referral guidelines and forms to understand which data consultant providers require. These data were then used to codesign an evidence-based, high-quality referral form.
METHODS
This study used both observational and quality improvement approaches. Canadian referral guidelines were reviewed and summarised. Referral data fields from 150 randomly selected Ontario referral forms were categorised and counted. The referral guideline summary and referral data were then used by referring providers, consultant providers and administrators to codesign a referral form.
RESULTS
Referral guidelines recommended 42 types of referral data be included in referrals. Referral data were categorised as patient demographics, provider demographics, reason for referral, clinical information and administrative information. The percentage of referral guidelines recommending inclusion of each type of referral data varied from 8% to 77%. Ontario referral forms requested 264 different types of referral data. Digital referral forms requested more referral data types than paper-based referral forms (55.0±10.6 vs 30.5±8.1; 95% CI p<0.01). A codesigned referral form was created across two sessions with 29 and 21 participants in each.
DISCUSSION
Referral guidelines lack consistency and specificity, which makes writing high-quality referrals challenging. Digital referral forms tend to request more referral data than paper-based referrals, which creates administrative burdens for referring and consultant providers. We created the first codesigned referral form with referring providers, consultant providers and administrators. We recommend clinical adoption of this form to improve referral quality and minimise administrative burdens.
Topics: Referral and Consultation; Humans; Ontario; Quality Improvement
PubMed: 38901862
DOI: 10.1136/bmjhci-2023-100926