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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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2
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Diagnostic Agreement Among General Practitioners, Residents, and Senior Rheumatologists for Rheumatic Diseases. J Clin Rheumatol 2022; 28:293-299. [PMID: 35660703 DOI: 10.1097/rhu.0000000000001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the concordance of the diagnoses made by senior rheumatologists and those made by residents in rheumatology and by general practitioners (GPs). METHODS In this cohort, 497 patients referred by GPs from August 1, 2018 to December 16, 2019 were evaluated first by a second-year resident in rheumatology. After clinical rounds, the diagnoses by senior rheumatologists were assumed as the criterion standard and defined the prevalence of the rheumatic diseases, divided into 5 groups: rheumatoid arthritis, spondyloarthritis, other connective tissue diseases and vasculitis, nonautoimmune rheumatic diseases, and nonrheumatic diseases. The follow-up ended on November 30, 2020. We calculated sensibility, specificity, positive predictive value, negative predictive value, and κ coefficient of the diagnosis by GPs and residents. RESULTS The diagnoses were changed for 58% of the referral letters. Diseases of low complexity, such as fibromyalgia and osteoarthritis, accounted for 50% of the diagnoses. Compared with senior rheumatologists, residents in rheumatology had κ > 0.6 for all the groups, whereas GPs had κ < 0.5, with the worst performance for nonautoimmune rheumatic disease (κ = -0.18) and nonrheumatic disease (κ = 0.15). In terms of level of complexity, 46% of the letters were inappropriate. CONCLUSIONS We found a poor level of diagnostic agreement between GPs and the rheumatology team. General practitioners had difficulties diagnosing and treating rheumatic diseases, referring patients that should be treated in the primary level of health care. One year of training in rheumatology made residents' skills comparable to those of senior rheumatologists.
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3
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Widdifield J. Preventing Rheumatoid Arthritis: A Global Challenge. Clin Ther 2019; 41:1355-1365. [DOI: 10.1016/j.clinthera.2019.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/08/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023]
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Wong J, Tu K, Bernatsky S, Jaakkimainen L, Thorne JC, Ahluwalia V, Paterson JM, Widdifield J. Quality and continuity of information between primary care physicians and rheumatologists. BMC Rheumatol 2019; 3:1. [PMID: 31149655 PMCID: PMC6533707 DOI: 10.1186/s41927-019-0067-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/25/2019] [Indexed: 12/12/2022] Open
Abstract
Background Good communication is central to a high-quality consultation process. We assessed the quality of referral information from primary care physicians (PCPs) to rheumatologists and the quality and timeliness of consultation letters from rheumatologists back to PCPs. Methods We sampled referral letters between 2000 and 2013 from 168 PCPs and performed a retrospective chart review of 2430 patients referred to 146 rheumatologists. We assessed the completeness and timeliness of referral and consultation letters. Results Osteoarthritis (n = 787, 32%) and systemic inflammatory rheumatic diseases (n = 745, 31%) comprised the top reasons for referral. Only 55% of referral letters summarized the patients’ medical history. Referral letters provided some details of diagnostic tests (51% labs, 34% imaging) but there was underreporting of this information on referral letters. Almost all referral letters (92%) contained details of at least one patient symptom, with the most common complaint being joint pain (54%). Only half of all referral letters provided symptom duration. The PCP only stressed an urgent consultation among 211 patients (9%). Overall, 69% of consultation letters were returned to PCPs within 30 days of consultation visit. Conclusion We found that basic items necessary for appropriate triage, including a description of symptoms or other relevant history and results of investigations were often lacking in referral letters. The delay of receipt of consultation letters may further represent a lost opportunity for coordination and continuity of care, and may affect the quality of care patients receive.
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Affiliation(s)
- Jenna Wong
- 1Sunnybrook Research Institute, Holland Bone and Joint Research Program, Toronto, Ontario Canada
| | - Karen Tu
- 2Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Sasha Bernatsky
- 3McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Liisa Jaakkimainen
- 4Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, ICES, University of Toronto, Toronto, Ontario Canada
| | - J Carter Thorne
- 5Southlake Regional Health Centre, Newmarket, Ontario Canada
| | - Vandana Ahluwalia
- 6William Olser Health System, Brampton Civic Hospital, Brampton, Ontario Canada
| | - J Michael Paterson
- 7Department of Family Medicine, McMaster University, Hamilton, Ontario Canada.,8Chronic Disease & Pharmacotherapy Program, ICES, Toronto, Ontario Canada.,9University of Toronto Institute of Health Policy, Management and Evaluation, MG 352 - 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
| | - Jessica Widdifield
- 1Sunnybrook Research Institute, Holland Bone and Joint Research Program, Toronto, Ontario Canada.,8Chronic Disease & Pharmacotherapy Program, ICES, Toronto, Ontario Canada.,9University of Toronto Institute of Health Policy, Management and Evaluation, MG 352 - 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
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5
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Burgers LE, Raza K, van der Helm-van Mil AH. Window of opportunity in rheumatoid arthritis - definitions and supporting evidence: from old to new perspectives. RMD Open 2019; 5:e000870. [PMID: 31168406 PMCID: PMC6525606 DOI: 10.1136/rmdopen-2018-000870] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/11/2022] Open
Abstract
The therapeutic window of opportunity in rheumatoid arthritis (RA) is often referred to. However, some have questioned whether such a period, in which the disease is more susceptible to disease-modifying treatment, really exists. Observational studies are most frequently referenced as supporting evidence, but results of such studies are subject to confounding. In addition formal consensus on the definition of the term has never been reached. We first reviewed the literature to establish if there is agreement on the concept of the window of opportunity in terms of its time period and the outcomes influenced. Second, a systemic literature search was performed on the evidence of the benefit of early versus delayed treatment as provided by randomised clinical trials. We observed that the concept of the window of opportunity has changed with respect to timing and outcome since its first description 25 years ago. There is an ‘old definition’ pointing to the first 2 years after diagnosis with increased potential for disease-modifying treatment to prevent severe radiographic damage and disability. Strong evidence supports this concept. A ‘new definition’ presumes a therapeutic window in a pre-RA phase in which the biologic processes could be halted and RA development prevented by very early treatment. This definition is not supported by evidence, although is less well studied in trials. Some suggestions for future research in this area are made.
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Affiliation(s)
- Leonie E Burgers
- Department of Rheumatology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Karim Raza
- Immunity and Infection, University of Birmingham, Birmingham, UK.,Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Annette H van der Helm-van Mil
- Department of Rheumatology, Leids Universitair Medisch Centrum, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Greenwood-Lee J, Jewett L, Woodhouse L, Marshall DA. A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC Health Serv Res 2018; 18:986. [PMID: 30572898 PMCID: PMC6302393 DOI: 10.1186/s12913-018-3745-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated. METHODS We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes. RESULTS We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies. CONCLUSION The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.
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Affiliation(s)
- James Greenwood-Lee
- Centre for Science, Athabasca University, 6th Floor, 345 6 Avenue SE, Calgary, Alberta, T2G 4V1, Canada
| | - Lauren Jewett
- Geography & Planning, University of Toronto, Sidney Smith Hall, Rm 594, 100 St George St., Toronto, Ontario, M5S 3G3, Canada
| | - Linda Woodhouse
- Faculty of Rehabilitation Medicine, University of Alberta, 3-10 Corbett Hall, 8205 114 Street, Edmonton, Alberta, T6G 2G4, Canada
| | - Deborah A Marshall
- Canada Research Chair, Health Services and Systems Research, Arthur J.E. Child Chair in Rheumatology Outcomes Research, Department of Community Health Sciences, University of Calgary, Calgary, Canada.
- 3C56 Health Research Innovation Centre (HRIC), 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.
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Eskeland SL, Rueegg CS, Brunborg C, Aabakken L, de Lange T. Electronic checklists improve referral letters in gastroenterology: a randomized vignette survey. Int J Qual Health Care 2018; 30:450-456. [PMID: 29635304 PMCID: PMC6047431 DOI: 10.1093/intqhc/mzy057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/16/2018] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Sigrun Losada Eskeland
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, PO Box 800, Drammen, Norway.,Institute of Clinical Medicine, University of Oslo, PO Box 1171 Blindern, Oslo, Norway
| | - Corina Silvia Rueegg
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, PO Box 1122 Blindern, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, PO Box 1122 Blindern, Oslo, Norway
| | - Lars Aabakken
- Institute of Clinical Medicine, University of Oslo, PO Box 1171 Blindern, Oslo, Norway.,Section of GI Endoscopy, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, PO Box 4950 Nydalen, Oslo, Norway
| | - Thomas de Lange
- Institute of Clinical Medicine, University of Oslo, PO Box 1171 Blindern, Oslo, Norway.,Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Bowel Cancer Screening, Cancer Registry of Norway, Majorstuen, Oslo, Norway
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8
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Referral characteristics and wait times for uveitis consultation at academic tertiary care centres in Toronto. Can J Ophthalmol 2018; 53:639-645. [PMID: 30502992 DOI: 10.1016/j.jcjo.2018.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/11/2018] [Accepted: 03/13/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the characteristics of referrals to academic uveitis tertiary care centres in Toronto and identify determinants of wait time for consultation. DESIGN Retrospective case series. METHODS Consecutive new uveitis referrals received at 5 University of Toronto-affiliated uveitis tertiary care centres, between February 2016 and November 2016, were included. RESULTS A total of 159 new uveitis referrals were received from academic (69%) and community (31%) providers. A large proportion of referrals were sent by comprehensive ophthalmologists (33%) and retina specialists (38%). Disease was bilateral in 46% of cases, had an acute onset in 43% of cases, and was classified as posterior uveitis in 38% of cases. Disease etiology at the time of referral was unknown in 55% of cases. Only 43% of all referrals included a basic uveitis workup, and patients who had undergone diagnostic testing had a shorter wait time for consultation (41 ± 43 vs. 59 ± 54 days, p = 0.033). Acute uveitis had a shorter wait time compared with recurrent and chronic uveitis (33 ± 42 vs. 66 ± 44 and 59 ± 58 days, p < 0.001). Referrals triaged as urgent had significantly shorter wait times compared with referrals triaged as semiurgent or elective (7 ± 10 vs. 54 ± 43 and 88 ± 59, p < 0.001). CONCLUSIONS Referrals to academic uveitis tertiary care centres in Toronto are often acute, bilateral cases affecting the posterior segment without a known etiology. Approximately half of referrals include no diagnostic workup, which may delay diagnosis for patients and lengthen wait times for consultation. We provide a set of recommendations for investigations that should be included in uveitis referrals.
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Eskeland SL, Brunborg C, Rueegg CS, Aabakken L, de Lange T. Assessment of the effect of an Interactive Dynamic Referral Interface (IDRI) on the quality of referral letters from general practitioners to gastroenterologists: a randomised cross-over vignette trial. BMJ Open 2017; 7:e014636. [PMID: 28667208 PMCID: PMC5734248 DOI: 10.1136/bmjopen-2016-014636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES We evaluated whether interactive, electronic, dynamic, diagnose-specific checklists improve the quality of referral letters in gastroenterology and assessed the general practitioners' (GPs') acceptance of the checklists. DESIGN Randomised cross-over vignette trial. SETTING Primary care in Norway. PARTICIPANTS 25 GPs. INTERVENTION The GPs participated in the trial and were asked to refer eight clinical vignettes in an internet-based electronic health record simulator. A referral support, consisting of dynamic diagnose-specific checklists, was created for the generation of referral letters to gastroenterologists. The GPs were randomised to refer the eight vignettes with or without the checklists. After a minimum of 3 months, they repeated the referral process with the alternative method. MAIN OUTCOME MEASURES Difference in quality of the referral letters between referrals with and without checklists, measured with an objective Thirty Point Score (TPS).Difference in variance in the quality of the referral letters and GPs' acceptance of the electronic dynamic user interface. RESULTS The mean TPS was 15.2 (95% CI 13.2 to 16.3) and 22.0 (95% CI 20.6 to 22.8) comparing referrals without and with checklist assistance (p<0.001), respectively. The coefficient of variance was 23.3% for the checklist group and 39.6% for the non-checklist group. Two-thirds (16/24) of the GPs thought they had included more relevant information in the referrals with checklists, and considered implementing this type of checklists in their clinical practices, if available. CONCLUSIONS Dynamic, diagnose-specific checklists improved the quality of referral letters significantly and reduced the variance of the TPS, indicating a more uniform quality when checklists were used. The GPs were generally positive to the checklists.
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Affiliation(s)
- Sigrun Losada Eskeland
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Cathrine Brunborg
- Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Corina Silvia Rueegg
- Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Lars Aabakken
- Department of Transplantation Medicine, Section of GI Endoscopy, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Thomas de Lange
- Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
- Departement of Bowel Cancer Screening, Cancer Registry of Norway, Majorstuen, Oslo, Norway
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Hendrickson CD, Saini S, Pothuloori A, Mecchella JN. ASSESSING REFERRALS AND IMPROVING INFORMATION AVAILABILITY FOR CONSULTATIONS IN AN ACADEMIC ENDOCRINOLOGY CLINIC. Endocr Pract 2016; 23:190-198. [PMID: 27849384 DOI: 10.4158/ep161514.or] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Outpatient specialty consultations rely on the timeliness and completeness of referral information to facilitate a valuable patient-specialist interaction. This project aimed to increase essential diagnostic information availability at the initial consultation for patients referred for common endocrine conditions frequently lacking such data-diabetes mellitus, thyroid nodule, thyrotoxicosis, and hypercalcemia. METHODS At an endocrinology clinic at an academic medical center in rural New England, providers see several thousand new patients annually, the majority of whom are referred by providers external to the clinic's healthcare system. Through consensus, endocrinology clinic providers agreed on the two or three data elements essential for a meaningful initial consultation for each. A quality improvement team employed a planned series of interventions based on previously published methods and an innovative approach: dissemination of a referral guideline, an assessment of referral adequacy in the endocrinology clinic workflow, coupled with focused requests for missing items, and a pre-visit lab appointment. RESULTS Between April 2015 and March 2016, 762 referrals were reviewed. At baseline for the four conditions, referrals contained all essential elements only 27.5% (22 of 80) of the time. Over a 7-month period, the team implemented the interventions, with subsequent referrals containing all essential elements increasing to 75.5% (P<.0001), largely attributable to the pre-visit lab appointment. CONCLUSION Incoming referrals that lack essential information are a significant problem in specialty care and may adversely affect patient experience, provider satisfaction, and clinic efficiency. Improvement may require innovative approaches, such as the potentially transferable and generalizable ones employed here. ABBREVIATIONS DHMC = Dartmouth-Hitchcock Medical Center EHR = electronic health record PDSA = Plan-Do-Study-Act.
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Eskeland SL, Brunborg C, Seip B, Wiencke K, Hovde Ø, Owen T, Skogestad E, Huppertz-Hauss G, Halvorsen FA, Garborg K, Aabakken L, de Lange T. First quality score for referral letters in gastroenterology-a validation study. BMJ Open 2016; 6:e012835. [PMID: 27855107 PMCID: PMC5073635 DOI: 10.1136/bmjopen-2016-012835] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To create and validate an objective and reliable score to assess referral quality in gastroenterology. DESIGN An observational multicentre study. SETTING AND PARTICIPANTS 25 gastroenterologists participated in selecting variables for a Thirty Point Score (TPS) for quality assessment of referrals to gastroenterology specialist healthcare for 9 common indications. From May to September 2014, 7 hospitals from the South-Eastern Norway Regional Health Authority participated in collecting and scoring 327 referrals to a gastroenterologist. MAIN OUTCOME MEASURE Correlation between the TPS and a visual analogue scale (VAS) for referral quality. RESULTS The 327 referrals had an average TPS of 13.2 (range 1-25) and an average VAS of 4.7 (range 0.2-9.5). The reliability of the score was excellent, with an intra-rater intraclass correlation coefficient (ICC) of 0.87 and inter-rater ICC of 0.91. The overall correlation between the TPS and the VAS was moderate (r=0.42), and ranged from fair to substantial for the various indications. Mean agreement was good (ICC=0.47, 95% CI (0.34 to 0.57)), ranging from poor to good. CONCLUSIONS The TPS is reliable, objective and shows good agreement with the subjective VAS. The score may be a useful tool for assessing referral quality in gastroenterology, particularly important when evaluating the effect of interventions to improve referral quality.
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Affiliation(s)
| | - Cathrine Brunborg
- Research Support Services, Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Birgitte Seip
- Department of Medicine, Vestfold Hospital Trust Tønsberg, Tønsberg, Norway
| | - Kristine Wiencke
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Drammen, Norway
| | - Øistein Hovde
- Department of Gastroenterology, Innlandet Hospital Trust Gjøvik, Gjøvik, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tanja Owen
- Department of Gastroenterology, Østfold Hospital Kalnes, Kalnes, Norway
| | - Erik Skogestad
- Department of Medicine, Innlandet Hospital Trust Lillehammer, Lillehammer, Norway
| | - Gert Huppertz-Hauss
- Department of Gastroenterology, Telemark Hospital Trust Skien, Skien, Norway
| | - Fred-Arne Halvorsen
- Department of Medicine, Vestre Viken Hospital Trust Drammen, Drammen, Norway
| | - Kjetil Garborg
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Department of Health Economics and Health Management, University of Oslo, Oslo, Norway
| | - Lars Aabakken
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Thomas de Lange
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Drammen, Norway
- Cancer Registry of Norway, Oslo University Hospital, Oslo, Norway
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Hendrickson CD, Lacourciere SL, Zanetti CA, Donaldson PC, Larson RJ. Interventions to Improve the Quality of Outpatient Specialty Referral Requests. Am J Med Qual 2016; 31:454-62. [DOI: 10.1177/1062860615587741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Chase D. Hendrickson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Stacy L. Lacourciere
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Cole A. Zanetti
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Concord Hospital, Concord, NH
| | - Patrick C. Donaldson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Tuck School of Business at Dartmouth, Hanover, NH
| | - Robin J. Larson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Veteran’s Affairs Medical Center, White River Junction, VT
- Geisel School of Medicine at Dartmouth, Hanover, NH
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13
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Cummins LL, Vangaveti V, Roberts LJ. Rheumatoid Arthritis Referrals and Rheumatologist Scarcity: A Prioritization Tool. Arthritis Care Res (Hoboken) 2015; 67:326-31. [DOI: 10.1002/acr.22449] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 08/12/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Lisa L. Cummins
- Princess Alexandra Hospital and University of Queensland; Brisbane Australia
| | | | - Lynden J. Roberts
- Townsville Hospital and James Cook University, Townsville; Queensland Australia
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Thompson AE, Haig SL, LeRiche NGH, Rohekar G, Rohekar S, Pope JE. Comprehensive arthritis referral study -- phase 2: analysis of the comprehensive arthritis referral tool. J Rheumatol 2014; 41:1980-9. [PMID: 25179851 DOI: 10.3899/jrheum.140167] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Rheumatologists triage referrals to assess those patients who may benefit from early intervention. We describe a referral tool and formally evaluate its sensitivity for urgent and early inflammatory arthritis (EIA) referrals. METHODS All referrals received on a standardized referral tool were reviewed by a rheumatologist and, based on the information conferred, assigned a triage grade using a previously described triage system. Each referral was also dichotomized as suspected EIA or not. After the initial rheumatologic assessment, the diagnosis was recorded and a consultation grade, blinded to referral grade, was assigned to each case. Agreement between referral and consultation grades was assessed. A regression analysis was performed to determine factors that predicted truly urgent referrals including EIA. RESULTS We evaluated 696 referrals. A total of 210 (30.2%) were categorized as urgent at the time of consultation. The referral tool was able to successfully detect 169 of these referrals (sensitivity 80.5%, specificity 79.4%). EIA occurred in 95 (13.6%); of those referrals, 86 were correctly classified as urgent at the time of triage (sensitivity 90.5%, specificity 69.6%). Items that helped correctly discriminate urgent or EIA referrals included patient age < 60, duration of disease, morning stiffness, patient-reported joint swelling, a personal or family history of psoriasis, urgency as rated by referring physician, prior assessment by a rheumatologist, elevated C-reactive protein, and a positive rheumatoid factor. CONCLUSION A 1-page referral tool that includes parts completed by the referring physician and patient has good sensitivity to detect urgent referrals including EIA.
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Affiliation(s)
- Andrew E Thompson
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University.
| | - Sara L Haig
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Nicole G H LeRiche
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Gina Rohekar
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Sherry Rohekar
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Janet E Pope
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
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Tay SH, Lim AYN, Lee TL, Low BPL, Cheung PP. The value of referral letter information in predicting inflammatory arthritis—factors important for effective triaging. Clin Rheumatol 2014; 33:409-13. [DOI: 10.1007/s10067-014-2503-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 12/28/2013] [Accepted: 01/16/2014] [Indexed: 11/29/2022]
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To screen or not to screen: How to find and identify very early arthritis. Best Pract Res Clin Rheumatol 2013; 27:487-97. [DOI: 10.1016/j.berh.2013.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Briggs AM, Fary RE, Slater H, Ranelli S, Chan M. Physiotherapy co-management of rheumatoid arthritis: identification of red flags, significance to clinical practice and management pathways. ACTA ACUST UNITED AC 2013; 18:583-7. [PMID: 23414962 DOI: 10.1016/j.math.2013.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 01/17/2013] [Accepted: 01/19/2013] [Indexed: 10/27/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease. Physiotherapy interventions for people with RA are predominantly targeted at ameliorating disability resulting from articular and peri-articular manifestations of the disease and providing advice and education to improve functional capacity and quality of life. To ensure safe and effective care, it is critical that physiotherapists are able to identify potentially serious articular and peri-articular manifestations of RA, such as instability of the cervical spine. Additionally, as primary contact professionals, it is essential that physiotherapists are aware of the potentially serious extra-articular manifestations of RA. This paper provides an overview of the practice-relevant manifestations associated with RA that might warrant further investigation by a medical practitioner (red flags), their relevance to physiotherapy practice, and recommended management pathways.
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Affiliation(s)
- Andrew M Briggs
- Curtin Health Innovation Research Institute (CHIRI), Curtin University, GPO Box U 1987, Perth, WA 6845, Australia.
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