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International Journal For Quality in... Jul 2018Investigate whether gastroenterologists rate the quality of referral letters higher if electronic dynamic checklist items are added to a standard free-text referral... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Investigate whether gastroenterologists rate the quality of referral letters higher if electronic dynamic checklist items are added to a standard free-text referral letter. Assess how this affects the gastroenterologists' assessment of the patient's need for healthcare and the agreement between their assessments.
DESIGN
Randomized vignette study.
SETTING
Norwegian primary gastroenterology services.
PARTICIPANTS
Thirty-two Norwegian gastroenterologists.
INTERVENTION
Between June 2015 and January 2016, participants were recruited through an open invitation to all members of the Norwegian Society of Gastroenterology. They were asked to rate 16 referral letters (vignettes) in a web interface: eight letters in free text following a general template and eight letters based on a general referral template combined with diagnosis-specific checklist items. The study was completed in two subsequent rounds ≥3 months apart.
MAIN OUTCOME MEASURES
Quality of referral letters assessed on a rating scale from 0 to 10. Agreement in the referral assessment and accuracy of the selection of correct preliminary diagnosis and appropriate work-up.
RESULTS
The mean quality assesses on the rating scale was 7.0 (95% confidence interval [CI] 6.8-7.2) for all letters combined (n = 511), 6.5(CI 6.2-6.8) for the free-text referrals (n = 256) and 7.5(CI 7.3-7.7) for the checklist referrals (n = 255) (P < 0.001, paired t-test). No difference was observed in the triage of the patients, but fewer gastroenterologists felt the need to collect additional information about the patients in the checklist group.
CONCLUSION
Checklist items may ease the assessment of the referrals for gastroenterologists. We were not able to show that checklists significantly influence the management of patients.
Topics: Adult; Aged; Checklist; Cross-Over Studies; Female; Gastroenterologists; Gastrointestinal Diseases; Humans; Male; Middle Aged; Norway; Quality Improvement; Referral and Consultation; Surveys and Questionnaires
PubMed: 29635304
DOI: 10.1093/intqhc/mzy057 -
BMC Family Practice Mar 2020The communication of relevant patient information between general practitioners (GPs) and medical specialists is important in order to avoid fragmentation of care thus...
BACKGROUND
The communication of relevant patient information between general practitioners (GPs) and medical specialists is important in order to avoid fragmentation of care thus achieving a higher quality of care and ensuring physicians' and patients' satisfaction. However, this communication is often not carried out properly. The objective of this study is to assess whether communication between GPs and medical specialists in the referral process is associated with the organisation of primary care within a country, the characteristics of the GPs, and the characteristics of the primary care practices themselves.
METHODS
An analysis of a cross-sectional survey among GPs in 34 countries was conducted. The odds ratios of the features that were expected to relate to higher rates of referral letters sent and communications fed back to GPs were calculated using ordered logistic multilevel models.
RESULTS
A total of 7183 GPs from 34 countries were surveyed. Variations between countries in referral letters sent and feedback communication received did occur. Little of the variance between countries could be explained. GPs stated that they send more referral letters, and receive more feedback communications from medical specialists, in countries where they act as gatekeepers, and when, in general, they interact more with specialists. GPs reported higher use of referral letters when they had a secretary and/or a nurse in their practice, used health information technologies, and had greater job satisfaction.
CONCLUSIONS
There are large differences in communication between GPs and medical specialists. These differences can partly be explained by characteristics of the country, the GP and the primary care practice. Further studies should also take the organisation of secondary care into account.
Topics: Continuity of Patient Care; Cross-Sectional Studies; Female; General Practitioners; Humans; Information Dissemination; Interdisciplinary Communication; Internationality; Interprofessional Relations; Male; Middle Aged; Needs Assessment; Patient Satisfaction; Primary Health Care; Quality of Health Care; Referral and Consultation; Secondary Care; Specialization
PubMed: 32183771
DOI: 10.1186/s12875-020-01124-x -
The Ulster Medical Journal May 2011Current NHS guidelines require patients with suspected breast cancer to be seen urgently at a specialist breast clinic. The aim of this study was to assess referral...
INTRODUCTION
Current NHS guidelines require patients with suspected breast cancer to be seen urgently at a specialist breast clinic. The aim of this study was to assess referral patterns and clinical findings of patients referred to a specialist breast clinic.
MATERIALS AND METHODS
A prospective database was maintained for consecutive patients referred. Symptoms and clinical findings in primary and secondary care were recorded. Correlation with final diagnoses was made. Tertiary referral patients were excluded.
RESULTS
1098 patients attended a specialist breast clinic over six months. 588 (54%) were referred as urgent, 285 (26%) routinely and 225 (20%) were unspecified. 492 (45%) patients were referred with the incorrect referral priority. 42 patients were unexamined in primary care. Examination findings in primary and secondary care correlated in only 487 (46%) patients. Examination in primary care when compared with secondary care was highly sensitive for detecting breast lumps, but specificity was low. 86 patients (8%) were diagnosed with breast cancer, 72 (84%) were referred urgently, 6 (7%) routinely and 8 (9%) as unspecified priority. Regardless of the clinical expertise of the referrer, sensitivity and specificity of the two-week guidelines for cancer are low.
CONCLUSIONS
Examination findings in primary and secondary care correlate in only 46% of referrals. Additionally, 55% of referrals were of the correct priority. The two-week rule guidelines have poor sensitivity and specificity for cancer. The safest and fairest policy would be to abandon the concept of urgent referral criteria and see all patients in a timely fashion. Alternatively, simplifying the referral criteria would improve sensitivity and specificity for cancer without leading to increased waiting times.
Topics: Aged; Breast Neoplasms; Chi-Square Distribution; Cohort Studies; Female; Health Services Accessibility; Humans; Ireland; Middle Aged; Practice Guidelines as Topic; Primary Health Care; Prospective Studies; Referral and Consultation; Sensitivity and Specificity; Statistics, Nonparametric; Waiting Lists
PubMed: 22347745
DOI: No ID Found -
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 -
Journal of Adolescent and Young Adult... Apr 2019To assess the fertility preservation (FP) referral rates and patterns of newly diagnosed breast cancer in female adolescent and young adult (AYA) patients.
PURPOSE
To assess the fertility preservation (FP) referral rates and patterns of newly diagnosed breast cancer in female adolescent and young adult (AYA) patients.
METHODS
Women aged 15-39 years with newly diagnosed breast cancer in Ontario from 2000 to 2017 were identified using the Ontario Cancer Registry. Exclusion criteria included prior sterilizing procedure, health insurance ineligibility, and prior infertility or cancer diagnosis. Women with a gynecology consult between cancer diagnosis and chemotherapy commencement with the billed infertility diagnostic code (ICD-9 628) were used as a surrogate for FP referral. The effect of age, parity, year of cancer diagnosis, staging, income, region, neighborhood marginalization, and rurality on referral status was investigated.
RESULTS
A total of 4452 patients aged 15-39 with newly diagnosed breast cancer met the inclusion criteria. Of these women, 178 (4.0%) were referred to a gynecologist with a billing code of infertility between cancer diagnosis and initiation of chemotherapy. Older patients, prior parity, and advanced disease were inversely correlated with referrals. Referral rates also varied regionally: patients treated in the south-east and south-west Local Health Integration Networks (LHINs) had the highest probability of referral, and patients covered by north LHINs had the lowest (central LHIN as reference). General surgeons accounted for 36.5% of all referrals, the highest percentage of all specialists. Referral rates significantly increased over time from 0.4% in 2000 to 10.7% in 2016.
CONCLUSION
FP referral rates remain low and continue to be influenced by patient demographics and prognosis. These findings highlight the need for further interdisciplinary coordination in addressing the fertility concerns of AYA with newly diagnosed breast cancers.
Topics: Adolescent; Adult; Breast Neoplasms; Canada; Female; Fertility Preservation; Follow-Up Studies; Humans; Infertility; Practice Patterns, Physicians'; Prognosis; Referral and Consultation; Retrospective Studies; Young Adult
PubMed: 30676852
DOI: 10.1089/jayao.2018.0102 -
Canadian Family Physician Medecin de... Aug 2017To identify the proportion and evaluate the content of eConsults (electronic consultations) in which the Champlain BASE (Building Access to Specialists through...
OBJECTIVE
To identify the proportion and evaluate the content of eConsults (electronic consultations) in which the Champlain BASE (Building Access to Specialists through eConsultation) eConsult process prompted a referral to a specialist that was not originally contemplated by the primary care provider (PCP).
DESIGN
Cross-sectional study of all eConsults submitted between April 15, 2011, and January 31, 2015.
SETTING
Champlain Local Health Integration Network, a large health region in eastern Ontario.
PARTICIPANTS
Primary care providers registered to use the Champlain BASE eConsult service.
MAIN OUTCOME MEASURES
Answers from a close-out survey-completed by PCPs at the conclusion of each eConsult-stating that specialist referral was not originally contemplated but that the eConsult process had prompted referral. The logs containing the communication exchanged between the PCPs and the specialists were reviewed, and each prompted referral case was categorized by the type of question asked, if pharmaceutical advice was given, if the referral was redirected to a different specialty group, and if the referral was urgent.
RESULTS
A total of 188 (3.4%) of 5601 eConsults completed during the study period were cases in which PCPs stated that they had originally not contemplated referring the patient to a specialist but that the Champlain BASE eConsult process had prompted referral. Prompted referrals were most often directed to cardiologists (10.6%), dermatologists (10.6%), infectious disease specialists (9.0%), hematologists (9.0%), and urologists (8.5%). The most common questions were about diagnosis (34.0%), drug treatment (18.0%), and management (15.0%). Pharmaceutical advice was given in 28.0% of prompted referral cases, and in 26.0% of cases, the face-to-face referral was redirected to another specialty group. In 5.0% of cases, the specialist stated the referral was urgent. The median specialist response time was 0.96 days (interquartile range 0.17 to 3.80 days).
CONCLUSION
By providing PCPs with increased access to specialists, the Champlain BASE eConsult service serves an important role in identifying and preventing the potential detrimental consequences of delayed medical referrals across specialty groups.
Topics: Adolescent; Adult; Aged; Child; Child, Preschool; Cross-Sectional Studies; Female; Health Services Accessibility; Humans; Infant; Infant, Newborn; Interprofessional Relations; Male; Middle Aged; Ontario; Outcome and Process Assessment, Health Care; Practice Patterns, Physicians'; Primary Health Care; Referral and Consultation; Surveys and Questionnaires; Young Adult
PubMed: 28807973
DOI: No ID Found -
Journal of the American Medical... Jun 2018To evaluate the impact of a referral manager tool on primary care practices.
OBJECTIVE
To evaluate the impact of a referral manager tool on primary care practices.
MATERIALS AND METHODS
We evaluated a referral manager module in a locally developed electronic health record (EHR) that was enhanced to improve the referral management process in primary care practices. Baseline (n = 61) and follow-up (n = 35) provider and staff surveys focused on the ease of performing various steps in the referral process, confidence in completing those steps, and user satisfaction. Additional metrics were calculated that focused on completed specialist visits, acknowledged notes, and patient communication.
RESULTS
Of 1341 referrals that were initiated during the course of the study, 76.8% were completed. All the steps of the referral process were easier to accomplish following implementation of the enhanced referral manager module in the EHR. Specifically, tracking the status of an in-network referral became much easier (+1.43 [3.91-2.48] on a 5-point scale, P < .0001). Although we found improvement in the ease of performing out-of-network referrals, there was a greater impact on in-network referrals.
DISCUSSION
Implementation of an electronic tool developed using user-centered design principles along with adequate staff to monitor and intervene when necessary made it easier for primary care practices to track referrals and to identify if a breakdown in the process occurred. This is especially important for high-priority referrals. Out-of-network referrals continue to present challenges, which may eventually be helped by improving interoperability among EHRs and scheduling systems.
CONCLUSION
An enhanced referral manager system can improve referral workflows, leading to enhanced efficiency and patient safety and reduced malpractice risk.
Topics: Attitude of Health Personnel; Data Display; Electronic Health Records; Humans; Medical Records Systems, Computerized; Primary Health Care; Quality of Health Care; Referral and Consultation; Surveys and Questionnaires; User-Computer Interface
PubMed: 29471355
DOI: 10.1093/jamia/ocy004 -
BMJ Open Feb 2019To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice. (Meta-Analysis)
Meta-Analysis
Improving the management of musculoskeletal conditions: can an alternative approach to referral management underpinned by quality improvement and behavioural change theories offer a solution and a better patient experience? A mixed-methods study.
OBJECTIVES
To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice.
DESIGN
Prospective cohort study using mixed methodology including random-effects meta-analysis and interrupted time series.
SETTING AND PARTICIPANTS
36 general practices in East London.
INTERVENTION
Informed by the results of a Cochrane review on educational interventions to improve general practitioners' (GPs) musculoskeletal care, we developed a multifaceted intervention, underpinned by quality improvement and behavioural change theories. It combined locally agreed clinical pathways, feedback on referral rates, clinical audit and peer review.
MAIN OUTCOME MEASURES
Referral letter content, pathway adherence, referral rates, inter-practice variability and patient experience were evaluated before and after the intervention.
RESULTS
Referral letter content on suspected diagnosis and prior management improved from a pooled preintervention proportion of 59% (95% CI 53% to 65%) and 67% (95% CI 61% to 73%), respectively, to 77% (95% CI 70% to 84%) and 81% (95% CI 74% to 88%). Pathway adherence improved from a pooled preintervention percentage of 42% (95% CI 35% to 48%) to 66% (95% CI 57% to 76%). The effect was greater across all quality outcomes for practices with baseline performance below or equal to the pooled baseline performance. There were reductions in the variability and rates of orthopaedic referrals at 6, 12 and 18 months (referral rate relative effect 32% (95% CI 14% to 48%), 30% (95% CI 7% to 53%) and 30% (95% CI 0% to 59%), respectively). Patient rating of how well GPs explained the musculoskeletal condition improved by 29% (95% CI 14% to 43%) and patient perception on the usefulness of the GP appointment improved by 24% (95% CI 9% to 38%).
CONCLUSIONS
A quality improvement-based approach to referral management which values GPs' professionalism can result in improvements across a range of outcomes including referral quality, patient experience, referral rates and variability.
Topics: General Practice; Guideline Adherence; Humans; Interrupted Time Series Analysis; London; Musculoskeletal Diseases; Patient Participation; Practice Guidelines as Topic; Primary Health Care; Prospective Studies; Quality Improvement; Referral and Consultation
PubMed: 30782916
DOI: 10.1136/bmjopen-2018-024710 -
The British Journal of General Practice... Dec 2014Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to... (Review)
Review
BACKGROUND
Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure.
AIM
To review the international evidence on interventions to manage referral from primary to specialist care.
DESIGN AND SETTING
Systematic review.
METHOD
Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions.
RESULTS
The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts.
CONCLUSIONS
To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.
Topics: Evidence-Based Medicine; Health Services Needs and Demand; Humans; Outcome and Process Assessment, Health Care; Practice Guidelines as Topic; Primary Health Care; Referral and Consultation; Secondary Care; United Kingdom
PubMed: 25452541
DOI: 10.3399/bjgp14X682837 -
Primary Care Respiratory Journal :... Mar 2011The UK National Health Service (NHS) is essentially publicly funded through general taxation. Challenges facing the NHS include the rise in prevalence of long-term... (Review)
Review
INTRODUCTION
The UK National Health Service (NHS) is essentially publicly funded through general taxation. Challenges facing the NHS include the rise in prevalence of long-term conditions and financial pressures. NATIONAL POLICY TRENDS: Political devolution within the UK has led to variations in the way services are organised and delivered between the four nations. PRIMARY CARE RESPIRATORY SERVICES IN THE UK: Primary care is the first point of contact with services. Most respiratory conditions are managed here, including prevention, diagnosis, treatment and palliative care.
EPIDEMIOLOGY
Respiratory disease accounts for more primary care consultations than any other type of illness, with 24 million consultations annually.
ACCESS TO CARE
Equitable access to care is an ongoing challenge: telehealthcare is being tried as a possible solution for monitoring of asthma and COPD. REFERRAL AND ACCESS TO SPECIALIST CARE: Referrals for specialist advice are usually to a secondary care respiratory physician, though respiratory General Practitioners with a Special Interest (GPwSIs) are an option in some localities.
CONCLUSIONS
Prevalence of asthma and COPD is high. Asthma services are predominantly nurse-led. Self-management strategies are widely promoted but poorly implemented. COPD is high on the policy agenda with a shift in focus to preventive lung health and longterm condition management.
Topics: Cost Savings; Delivery of Health Care; Female; Health Care Costs; Health Planning; Health Policy; Humans; Male; National Health Programs; Practice Guidelines as Topic; Primary Health Care; Program Development; Program Evaluation; Quality of Health Care; Referral and Consultation; Respiratory Tract Diseases; State Medicine; United Kingdom
PubMed: 21057735
DOI: 10.4104/pcrj.2010.00070