-
Quality & Safety in Health Care Jun 2010To assess effectiveness of guidelines for referral for elective surgical assessment. (Review)
Review
AIM
To assess effectiveness of guidelines for referral for elective surgical assessment.
METHOD
Systematic review with descriptive synthesis.
DATA SOURCES
Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites.
SELECTION OF STUDIES
Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults.
OUTCOME MEASURES
Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs.
RESULTS
24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex ("one-stop shops") to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change.
CONCLUSIONS
Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.
Topics: Adult; Costs and Cost Analysis; Databases, Factual; Elective Surgical Procedures; Female; Guideline Adherence; Humans; Practice Guidelines as Topic; Primary Health Care; Referral and Consultation; Specialties, Surgical
PubMed: 20211956
DOI: 10.1136/qshc.2008.029918 -
The American Journal of Managed Care Aug 2019Referrals from primary to specialty care are a critical first step in coordination of specialty care, but shortcomings in the appropriateness, clarity, or completeness...
OBJECTIVES
Referrals from primary to specialty care are a critical first step in coordination of specialty care, but shortcomings in the appropriateness, clarity, or completeness of referrals are common. We examined (1) whether 3 tools to coordinate specialty care are associated with better referral characteristics and (2) whether greater perceived helpfulness of these tools is associated with better referral characteristics among specialists who use all 3 of them.
STUDY DESIGN
National online survey about care coordination among medical specialists receiving referrals in the Veterans Health Administration.
METHODS
Adjusted odds ratios (ORs) for associations between use and helpfulness of 3 coordination tools (service agreements, referral templates, and e-consults) and perceived frequency of 3 referral characteristics (appropriateness, clarity, and completeness).
RESULTS
Among specialists (N = 497), use of referral templates was associated with perceptions that referrals were more frequently appropriate (adjusted OR, 1.5; 95% CI, 1.0-2.4), clear (adjusted OR, 1.6; 95% CI, 1.0-2.5), and complete (adjusted OR, 1.9; 95% CI, 1.1-3.2). Use of e-consults was associated with more frequent referral clarity (adjusted OR, 1.7; 95% CI, 1.0-3.0). Among specialists using all 3 tools, those reporting that templates were very helpful also perceived more frequent referral clarity (adjusted OR, 3.1; 95% CI, 1.1-8.5) and completeness (adjusted OR, 3.6; 95% CI, 1.5-8.7). Service agreements were not associated with any referral characteristic.
CONCLUSIONS
Well-designed referral templates may help improve the clarity and completeness of primary care-specialty care referrals. Existing templates may provide models that can be adapted in collaboration with primary care and broadly applied to improve referrals. Work is needed to improve the impact of service agreements and e-consults on referrals.
Topics: Adult; Continuity of Patient Care; Female; Humans; Male; Middle Aged; Primary Health Care; Quality Improvement; Referral and Consultation; Specialization; Telemedicine; United States; United States Department of Veterans Affairs
PubMed: 31419100
DOI: No ID Found -
JAMA Network Open Jul 2020Specialist gender clinics worldwide have witnessed an increase in referrals of transgender and gender diverse (TGD) children and adolescents, but the underlying factors...
Association of Media Coverage of Transgender and Gender Diverse Issues With Rates of Referral of Transgender Children and Adolescents to Specialist Gender Clinics in the UK and Australia.
IMPORTANCE
Specialist gender clinics worldwide have witnessed an increase in referrals of transgender and gender diverse (TGD) children and adolescents, but the underlying factors associated with this increase are unknown.
OBJECTIVE
To determine whether increases in TGD young people presenting to specialist gender clinics are associated with related media coverage.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional study was conducted at 2 publicly funded, pediatric specialist gender services, one located in the UK and the other in Australia. Participants were all children and adolescents aged 0 to 18 years, referred between January 1, 2009, and December 31, 2016, to their respective gender services in the UK and Australia. Data analysis was performed in April 2019.
EXPOSURES
Media coverage of TGD issues.
MAIN OUTCOMES AND MEASURES
Referral rates from each gender service were compared with local TGD-related media coverage during the study period.
RESULTS
Referral data for 5242 TGD young people were obtained (4684 in the UK, of whom 1847 [39.4%] were assigned male at birth and 2837 [60.6%] were assigned female at birth; 558 in Australia, of whom 250 [44.8%] were assigned male at birth and 308 [55.2%] were assigned female at birth), and a total of 2614 news items were identified (UK, 2194; Australia, 420). The annual number of TGD young people referred to both specialist gender clinics was positively correlated with the number of TGD-related local media stories appearing each year (Spearman r = 1.0; P < .001). Moreover, weekly referral rates in both the UK for week 1 (β̂ = 0.16; 95% CI, 0.03-0.29; P = .01) and Australia for week 2 (β̂ = 0.12; 95% CI, 0.04-0.20; P = .003) showed evidence of association with the number of TGD-related media items appearing within the local media. There was no evidence of association between referrals and media items appearing 3 weeks beforehand. Media predominantly focused on TGD issues showed some association with increased referral rates. Specifically, TGD-focused stories showed evidence of association with referral numbers at week 1 (β̂ = 0.16; 95% CI, 0.04-0.28; P = .007) and week 2 (β̂ = 0.23; 95% CI, 0.11-0.35; P < .001) in Australia and with referral numbers at week 1 (β̂ = 0.22; 95% CI, 0.01-0.44; P = .04) in the UK. No evidence of association was found between media peripherally related to TGD issues and referral rates.
CONCLUSIONS AND RELEVANCE
This study found evidence of an association between increasing media coverage of TGD-related topics and increasing numbers of young people presenting to gender clinics. It is possible that media coverage acts as a precipitant for young people to seek treatment at specialist gender services, which is consistent with clinical experiences in which TGD young people commonly identify the media as a helpful source of information and a trigger to seek assistance.
Topics: Adolescent; Ambulatory Care Facilities; Australia; Child; Child, Preschool; Cross-Sectional Studies; Female; Humans; Interpersonal Relations; Male; Mass Media; Referral and Consultation; Transgender Persons; United Kingdom
PubMed: 32721030
DOI: 10.1001/jamanetworkopen.2020.11161 -
Family Medicine Feb 2017Specialty physician visits account for a significant portion of ambulatory visits nationally, contribute significantly to cost of care, and are increasing over the past...
BACKGROUND AND OBJECTIVES
Specialty physician visits account for a significant portion of ambulatory visits nationally, contribute significantly to cost of care, and are increasing over the past decade. Marked variability in referral rates exists among primary care practices without obvious causality. We present data describing the referral process and specialty referral curriculum within the I3 collaborative.
METHODS
Residency directors were surveyed about residency characteristics related to referrals. Specialty physician referral rates were obtained from each program and then correlated to program characteristics referral rates in four domains: presence and type of referral curriculum, process of referral review, faculty preceptor characteristics, and use of referral data for administrative processes.
RESULTS
The survey response rate was 87%; 10 programs submitted complete referral data. Three programs (23%) reported a formal curriculum addressing the process of making a referral, and four programs (31%) reported a curriculum on appropriateness of subspecialty referrals. Specialty referral rates varied from 7%-31% of active residency patients, with no relationship to age, payor status, or race.
DISCUSSION
Marked variability in referral rates and patterns exist within primary care residency training programs. Specialty referral practices are a key driver of total cost of care yet few curricula exist that address appropriateness, quantity, or process of specialty referrals. Practice patterns often develop during residency training, therefore an opportunity exists to improve training and practice around referrals.
Topics: Curriculum; Family Practice; Humans; Internship and Residency; Practice Patterns, Physicians'; Primary Health Care; Referral and Consultation; Surveys and Questionnaires; United States
PubMed: 28218933
DOI: No ID Found -
BMC Psychiatry Nov 2016Consultation-Liaison Psychiatry (CLP) is a subspecialty of psychiatry that provides care to inpatients under non-psychiatric care. Despite evidence of benefits of CLP... (Review)
Review
BACKGROUND
Consultation-Liaison Psychiatry (CLP) is a subspecialty of psychiatry that provides care to inpatients under non-psychiatric care. Despite evidence of benefits of CLP for inpatients with psychiatric comorbidities, referral rates from hospital doctors remain low. This review aims to understand barriers to CLP inpatient referral as described in the literature.
METHODS
We searched on Medline, PsychINFO, CINAHL and SCOPUS, using MESH and the following keywords: 1) Consultation-Liaison Psychiatry, Consultation Liaison Psychiatry, Consultation Psychiatry, Liaison Psychiatry, Hospital Psychiatry, Psychosomatic Medicine, the 2) Referral, Consultation, Consultancy and 3) Inpatient, Hospitalized patient, Hospitalized patient. We considered papers published between 1 Jan 1965 and 30 Sep 2015 and all articles written in English that contribute to understanding of barriers to CLP referral were included.
RESULTS
Thirty-five eligible articles were found and they were grouped thematically into three categories: (1) Systemic factors; (2) Referrer factors; (3) Patient factors. Systemic factors that improves referrals include a dedicated CLP service, active CLP consultant and collaborative screening of patients. Referrer factors that increases referrals include doctors of internal medicine specialty and comfortable with CLP. Patients more likely to be referred tend to be young, has psychiatric history, live in an urban setting or has functional psychosis.
CONCLUSION
This is the first systematic review that examines factors that influence CLP inpatient referrals. Although there is research in this area, it is of limited quality. Education could be provided to hospital doctors to better recognise mental illness. Collaborative screening of vulnerable groups could prevent inpatients from missing out on psychiatric care. CLP clinicians should use the knowledge gained in this review to provide quality engagement with referrers.
Topics: Health Services Accessibility; Hospitals; Humans; Inpatients; Mental Health Services; Physicians; Psychiatry; Referral and Consultation
PubMed: 27829386
DOI: 10.1186/s12888-016-1100-6 -
Journal of the American College of... Apr 2004
Topics: Cardiology; Conflict of Interest; Diagnostic Imaging; Humans; Referral and Consultation
PubMed: 15093890
DOI: 10.1016/j.jacc.2004.03.022 -
World Journal of Gastroenterology Jan 2019Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and... (Review)
Review
Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and puts pressure on endoscopy services. Dyspepsia is one of the most common inappropriate indications for upper GI endoscopy as diagnostic yield is low. Reasons for untimely referral are: unfamiliarity with dyspepsia guidelines, uncertainty about etiology of symptoms, and therapy failure. Unfiltered open-access referrals feed upper GI endoscopy overuse. This review highlights strategies applied to diminish use of upper GI endoscopies for dyspepsia. First, we describe the impact of active guideline implementation. We found improved guideline adherence, but resistance was encountered in the process. Secondly, we show several forms of clinical assessment. While algorithm use reduced upper GI endoscopy volume, effects of referral assessment of individual patients were minor. A third strategy proposed test and treat for all dyspeptic patients. Many upper GI endoscopies can be avoided using this strategy, but outcomes may be prevalence dependent. Lastly, empirical treatment with Proton pump inhibitors achieved symptom relief for dyspepsia and avoided upper GI endoscopies in about two thirds of patients. Changing referral behavior is complex as contributing factors are manifold. A collaboration of multiple strategies is most likely to succeed.
Topics: Dyspepsia; Endoscopy, Gastrointestinal; Guideline Adherence; Helicobacter Infections; Helicobacter pylori; Humans; Intersectoral Collaboration; Medical Overuse; Practice Guidelines as Topic; Prevalence; Referral and Consultation
PubMed: 30670908
DOI: 10.3748/wjg.v25.i2.178 -
BMC Primary Care Sep 2023In care substitution services, medical specialists offer brief consultations to provide general practitioners (GPs) with advice on diagnosis, treatment, or hospital...
BACKGROUND
In care substitution services, medical specialists offer brief consultations to provide general practitioners (GPs) with advice on diagnosis, treatment, or hospital referral. When GPs serve as gatekeepers to secondary care, these regional services could reduce pressures on healthcare systems. The aim is to determine the impact of implementing a care substitution service for dermatology, orthopaedics, and cardiology on the hospital referral rate, health care costs, and patient satisfaction.
METHODS
A before-after study was used to evaluate hospital referral rates and health care costs during a follow-up period of 1 year. The study population comprised patients with eligible International Classification of Primary Care codes for referral to the care substitution service (only dermatology, orthopaedic, cardiology indications), as pre-defined by GPs and medical specialists. We compared referral rates before and after implementation by χ tests and evaluated patient preference by qualitative analysis.
RESULTS
In total, 4,930 patients were included, 2,408 before and 2,522 after implementation. The care substitution service decreased hospital referrals during the follow-up period from 15 to 11%. The referral rate decreased most for dermatology (from 15 to 9%), resulting in a cost reduction of €10.59 per patient, while the other two specialisms experienced smaller reductions in referral rates. Patients reported being satisfied, mainly because of the null cost, improved organisation, improved care, and positive experience of the consultation.
CONCLUSIONS
The care substitution service showed promise for specialisms that require fewer hospital facilities, as exemplified by dermatology.
Topics: Humans; Patient Satisfaction; Netherlands; Referral and Consultation; Patient Preference; Secondary Care
PubMed: 37658285
DOI: 10.1186/s12875-023-02137-y -
Value in Health Regional Issues Sep 2022This study aimed to assess the cost-effectiveness of a remotely operated referral management system (RORMS) compared with a conventional referral management system...
OBJECTIVES
This study aimed to assess the cost-effectiveness of a remotely operated referral management system (RORMS) compared with a conventional referral management system (CRMS) in Brazil.
METHODS
This is a model-based cost-effectiveness analysis under the perspective of the Unified Healthcare System (Sistema Único de Saúde [SUS]) in Brazil. A Markov microsimulation model was developed to compare costs and referral outcomes of the RORMS and the CRMS. Model consisted of 4 states representative of sequential stepwise assessments of referral suitability, 3 states representative of referral outcomes, and 1 exit model state. Target population represented cases being referred from primary healthcare units to specialized care in SUS. Model inputs related to costs and effectiveness in the RORMS arm were obtained from the data set of a RORMS between July and December 2019. Model inputs for the CRMS model arm were obtained from administrative data sets of 2 Brazilian localities for the year 2019. Relative effect size of RORMS in comparison with CRMS in SUS was obtained from published studies. Effectiveness outcome was unnecessary referrals averted. The incremental cost-effectiveness ratio was calculated for the base case. Probabilistic sensitivity analysis was conducted.
RESULTS
In the base-case analyses, RORMS dominated CRMS, with expected cost-savings from $50.42 to $80.62 per unnecessary referral averted. RORMS was the dominant strategy in 83.7% of 100 000 simulations in the probabilistic sensitivity analysis. In 16.2% of simulations, incremental cost-effectiveness ratio was between $0 and $222 per unnecessary referral averted.
CONCLUSIONS
Model-based simulations indicate that the RORMS is likely to be cost saving in comparison with the CRMS.
Topics: Brazil; Cost-Benefit Analysis; Humans; Referral and Consultation; Secondary Care; Telemedicine
PubMed: 35568011
DOI: 10.1016/j.vhri.2022.03.003 -
The Cochrane Database of Systematic... Oct 2008The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.
OBJECTIVES
To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.
SEARCH STRATEGY
We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.
SELECTION CRITERIA
Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.
DATA COLLECTION AND ANALYSIS
A minimum of two reviewers independently extracted data and assessed study quality.
MAIN RESULTS
Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.
AUTHORS' CONCLUSIONS
There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
Topics: Controlled Clinical Trials as Topic; Economics, Medical; Family Practice; Humans; Information Dissemination; Medicine; Outpatients; Practice Guidelines as Topic; Primary Health Care; Referral and Consultation; Specialization
PubMed: 18843691
DOI: 10.1002/14651858.CD005471.pub2