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Six KA, Aban IB, Daniels GM, Wolfson J, Beierle EA, Kutny MA, Lebensburger J, Xavier AC. Outcomes of Referrals in Pediatric Patients With Peripheral Lymphadenopathy. J Pediatr Hematol Oncol 2024; 46:322-326. [PMID: 38652051 DOI: 10.1097/mph.0000000000002867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024]
Abstract
Lymphadenopathy is a common reason for referral to a subspecialist, which may result in significant anxiety for parents. Understanding which patients require a subspecialty referral for lymphadenopathy is key to streamlining health care utilization for this common clinical entity. This is an IRB-approved retrospective study examining pediatric patients consecutively referred to pediatric hematology oncology, otolaryngology, or surgery for lymphadenopathy from 2012 to 2021 at a free-standing tertiary-care children's hospital. Logistic regression was fitted to examine the association between the maximum size of the lymph nodes (LN) and a diagnosis of malignancy. The odds ratio, area under the receiver operator curve, sensitivity, and specificity were estimated. We found a significant association between LN size and cancer diagnosis. For every centimeter increase in the maximal dimension of LN, there was an estimated 2.3 times increase in the odds of malignancy (OR=2.3, 95% CI: 1.65-3.11; P <0.0001). The estimated area under the curve (0.84, 95% CI: 0.78-0.90) indicated that LN size correlated well with cancer diagnosis. A LN cut-off size of 2 cm resulted in an estimated sensitivity of 1.0 (95% CI: 0.87-1.00) and specificity of 0.54 (95% CI: 0.46-0.61). Maximum LN size may be a predictor of malignancy among pediatric patients with lymphadenopathy.
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Affiliation(s)
- Kathryn A Six
- Atrium Health Levine Children's Cancer & Blood Disorders, Wake Forest University School of Medicine, Charlotte, NC
| | | | | | - Julie Wolfson
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Heersink School of Medicine
| | - Elizabeth A Beierle
- Department of Surgery, Division of Pediatric Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew A Kutny
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Heersink School of Medicine
| | - Jeffrey Lebensburger
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Heersink School of Medicine
| | - Ana C Xavier
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Heersink School of Medicine
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Wang T, Lund B, Dow M. Do Hospitals Satisfy Our Healthcare Information Needs for Rare Diseases?: Comparison of Healthcare Information Provided by Hospitals with Information Needs of Family Caregivers. HEALTH COMMUNICATION 2024; 39:1628-1637. [PMID: 37340548 DOI: 10.1080/10410236.2023.2228010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
This study uses a cross-sectional online survey approach to investigate the gap between healthcare information provided by hospitals and family caregivers' information needs and the relationship between demographic factors and information satisfaction. The results indicate that family caregivers have diverse healthcare information needs for daily care, but the information provided by hospitals could not satisfy these information needs most of the time. Family caregivers' information satisfaction was unrelated to various demographic factors, such as age, race, education level, and annual household income. Family caregivers who were male and spent less time searching for rare disease related information and whose children received a rare disease clinical diagnosis and spent more days in hospitals after birth expressed higher information satisfaction. Based on the findings, this study recommends strengthening continuing education of physicians about rare diseases to increase diagnosis and conducting information literacy assessments of family caregivers to better meet their information needs about daily care.
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Affiliation(s)
- Ting Wang
- School of Library and Information Management, Emporia State University
| | - Brady Lund
- College of Information, University of North Texas
| | - Mirah Dow
- School of Library and Information Management, Emporia State University
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Staykov E, Helmer-Smith M, Fung C, Tanuseputro P, Liddy C. Development of the electronic consultation long-term care utilization and savings estimator tool to model the potential impact of electronic consultation for residents living in long-term care. J Telemed Telecare 2024; 30:597-603. [PMID: 35073207 PMCID: PMC10988991 DOI: 10.1177/1357633x221074500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 02/21/2024]
Abstract
Ageing populations have resulted in more patients living in long-term care or nursing homes, where they face challenges to accessing prompt specialist care exacerbated in many cases by physical or cognitive decline. Electronic consultation has demonstrated an ability to improve access to specialist care for vulnerable groups and offers a potential solution to this gap in care. To support electronic consultation's uptake among long-term care homes, we created the electronic consultation long-term care utilization and savings estimator, an Excel-based tool that estimates the number of off-site appointments that patients in a long-term care home could avoid through electronic consultation, along with the consequent time and cost savings. In this brief report, we discuss the electronic consultation long-term care utilization and savings estimator's creation and function, and provide a case study using long-term care data to demonstrate its potential impact. We anticipate the electronic consultation long-term care utilization and savings estimator will be a highly impactful tool and intend to test it in real-world conditions following the relaxation of COVID-19 restrictions.
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Affiliation(s)
- Emiliyan Staykov
- Department of Biology, University of Ottawa, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Canada
- Ottawa Hospital Research Institute, Canada
| | - Mary Helmer-Smith
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Canada
- Department of Family Medicine, University of Ottawa, Canada
| | - Celeste Fung
- Department of Family Medicine, University of Ottawa, Canada
- St Patrick’s Home of Ottawa, Canada
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Canada
- Bruyère Research Institute, Bruyère Centre of Learning, Research and Innovation in Long-Term Care, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Canada
- Department of Family Medicine, University of Ottawa, Canada
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Canada
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Tennankore K, Jones J, Miller A, Adib A, Mathew S, Rasic D, Cookey J. Transforming healthcare delivery: a descriptive study of a novel provider-to-provider virtual care platform. Front Public Health 2023; 11:1284566. [PMID: 38155888 PMCID: PMC10753175 DOI: 10.3389/fpubh.2023.1284566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/16/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction Addressing challenges in access to specialty care, particularly long wait times and geographic disparities, is a pressing issue in the Canadian healthcare system. This study aimed to evaluate the impact and feasibility of provider-to-provider phone consultations between primary care providers (PCPs) and specialists using a novel virtual care platform in Nova Scotia (Virtual Hallway). Methods We conducted a cross-sectional survey over 5 months, involving 211 PCPs and 34 specialists across Nova Scotia. The survey assessed the need for formal in-person referrals as well as clinician satisfaction. Statistical methods included descriptive statistics and the one-sample t-test. Results We found that 84% of provider-to-provider phone consultations negated the need for an in-person specialist referral. It was also reported that 90% of patients that did require in-person consultation had enhanced care while they awaited an in-person appointment with a specialist. Very high levels of satisfaction were reported among both PCPs and specialists, and there was a noticeable increase in billing volumes related to these consultations as measured by provincial billing codes. Conclusion The findings indicate that provider-to-provider phone consultations are feasible, well-accepted and also effective in reducing the need for in-person specialist visits. This approach offers a promising avenue for alleviating waitlist burdens, enhancing the quality of care, and improving the overall efficiency of healthcare delivery.
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Affiliation(s)
| | - Jennifer Jones
- Division of Digestive Care and Endoscopy, QEII - Victoria Building, Halifax, NS, Canada
| | - Ashley Miller
- Division of General Internal Medicine, QEII - Bethune Building, Halifax, NS, Canada
| | - Ashfaq Adib
- Virtual Hallway Consults Inc., Halifax, NS, Canada
| | - Shan Mathew
- Pleasant Street Medical Group, Dartmouth, NS, Canada
| | - Daniel Rasic
- Virtual Hallway Consults Inc., Halifax, NS, Canada
| | - Jacob Cookey
- Virtual Hallway Consults Inc., Halifax, NS, Canada
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Use of modern information communication technology to enable real-time consultation between primary and specialty care providers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:966-967.e1. [PMID: 36410661 DOI: 10.1016/j.jaip.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/21/2022]
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Campbell E, Huston M, Collard B. The Changing Face of Head and Neck Cancer; How the Head and Neck One-Stop Clinic Has Evolved Since Conception. J Maxillofac Oral Surg 2022; 21:1074-1077. [PMID: 36896088 PMCID: PMC9989097 DOI: 10.1007/s12663-022-01786-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/05/2022] [Indexed: 10/14/2022] Open
Abstract
Purpose The purpose of this study was to compare the patient journey through the head and neck clinic across 13 years of service improvement. We aimed to compare pick-up rates of cancer; number of patients receiving tissue diagnoses at first visit; and number of patients who were discharged on their first visit. Methods In the one-stop head and neck cancer clinic, the demographic data, investigations and outcomes for 277 patients who attended in 2004 were compared to those of 205 patients who attended in 2017. The number of patients receiving ultrasonography and fine needle aspiration cytology was compared. Patient outcomes were analysed: specifically, the number discharged on first visit and the number of malignancies diagnosed. Results The pick-up rate for malignancy from 2004 to 2017 has remained stable (17.3% vs 17.1%). The number of patients receiving ultrasound has remained stable from 264 (95%) in 2004 to 191 (93%) in 2017. The number undergoing FNA has decreased from 139 (50%) to 68 (33%) (p < 0.01). The number of patient's discharged on the first visit has significantly increased from 82 (30%) in 2004 to 89 (43%) in 2017 (p < 0.01). Conclusion The one-stop clinic provides an effective and efficient means of head and neck lump assessment. Since inception of this service, the accuracy of diagnostic investigation has improved over time.
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Affiliation(s)
- Elaine Campbell
- Department of Oral and Maxillofacial Surgery, Derriford Hospital, Derriford Rd, Plymouth, PL6 8DH UK
| | - Mervyn Huston
- Department of Oral and Maxillofacial Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW Devon UK
| | - Benjamin Collard
- Department of Oral and Maxillofacial Surgery, Derriford Hospital, Derriford Rd, Plymouth, PL6 8DH UK
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Zhou AE, Adalsteinsson JA, Grant-Kels JM. Dermatologic care for patients with mobility-related disabilities. J Am Acad Dermatol 2022; 87:e181-e182. [PMID: 35809799 DOI: 10.1016/j.jaad.2022.06.1203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Albert E Zhou
- Department of Dermatology, University of Connecticut, Farmington, Connecticut
| | - Jonas A Adalsteinsson
- Department of Dermatology, University of Connecticut, Farmington, Connecticut; Department of Dermatology, University of Utah, Salt Lake City, Utah
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut, Farmington, Connecticut; Department of Dermatology, University of Florida, Gainesville, Florida.
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Slatman S, Mossink A, Jansen D, Broeks J, van der Lugt P, Prosman GJ, d'Hollosy WON. Factors used by general practitioners for referring patients with chronic musculoskeletal pain: a qualitative study. BMC PRIMARY CARE 2022; 23:126. [PMID: 35610564 PMCID: PMC9129062 DOI: 10.1186/s12875-022-01743-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/12/2022] [Indexed: 06/01/2023]
Abstract
Around 20% of the Dutch population is living with chronic musculoskeletal pain (CMP), which is a complex and multifactorial problem. This complexity makes it hard to define a classification system, which results in non-satisfactory referring from the general practitioner (GP). CMP is often explained using the biopsychosocial model in which biological, psychological and social factors cause and maintain the pain. The presented study investigated the factors related to the GPs' referral for patients with CMP to further treatment.Using convenience sampling, semi-structured interviews and a focus group were conducted among 14 GPs. The interviews were iteratively analyzed using inductive conventional content analysis.Analysis of the interviews demonstrated that there were 28 referral factors that were mentioned by more than 50% of the interviewed GPs. The results showed that the GPs were mostly focussing on the physical (e.g. pain location) and psychological (e.g. acceptation of pain) factors, indicating that they lack focus on the social factors. Furthermore, unfamiliarity of GPs with treatment options was a noteworthy finding.The referral of patients with CMP by GPs is complex and based on multiple factors. To improve referral, it is recommended to include social factors in the decision-making process and to increase the familiarity of the GPs with available treatments.
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Affiliation(s)
- Syl Slatman
- Department of Psychology Health & Technology, University of Twente, Faculty of Behavioral, Management & Social Sciences (BMS), De Zul 10, 7522NJ, Enschede, the Netherlands.
| | - Annemiek Mossink
- Department of Psychology Health & Technology, University of Twente, Faculty of Behavioral, Management & Social Sciences (BMS), De Zul 10, 7522NJ, Enschede, the Netherlands
| | - Duncan Jansen
- Department of EEMCS/BSS, University of Twente, Enschede, the Netherlands
| | - José Broeks
- Department of Rehabilitation, Zorggroep Twente, Almelo, the Netherlands
- Roessingh Rehabilitation Center (Department of Chronic Pain), Enschede, the Netherlands
| | - Peter van der Lugt
- Research Department General Practice, General Practitioner Cooperative Twente (THOON), Hengelo, the Netherlands
| | - Gert-Jan Prosman
- Department of Psychology Health & Technology, University of Twente, Faculty of Behavioral, Management & Social Sciences (BMS), De Zul 10, 7522NJ, Enschede, the Netherlands
- Roessingh Rehabilitation Center (Department of Chronic Pain), Enschede, the Netherlands
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Smyth H, Gorey S, O'Keeffe H, Beirne J, Kelly S, Clifford C, Kerr H, Mulroy M, Ahern T. Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision? Eur J Intern Med 2022; 98:47-52. [PMID: 34953654 DOI: 10.1016/j.ejim.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The discussion surrounding generalist versus specialist acute medical admissions continues to stimulate debate and patients with certain conditions benefit from specialist care. AIM To determine whether a specialty medical admission program would reduce inpatient length of stay (LOS), mortality and readmission rates. DESIGN/METHODS A prospective cohort study of inpatients admitted under a general internal medicine (GIM) service before and after introduction of a specialty-directing programme. We hypothesized that early transfer of patient care to a specialty suited to their presenting complaint would reduce LOS and a specialty-directing early redistribution of care programme was introduced. Seven of the ten clinical teams participating in the GIM roster adopted the programme. On the morning following a specialty-directing team being on call for all new GIM admissions during a 24-hour period, specialty-directing teams were allocated one patient appropriate to their specialty. RESULTS 5,144 patient-care episodes were analysed over the two-year study period. LOS increased by greater than 15%, one year after introducing the specialty-directing programme (8.5±8.4 vs 7.3±7.5 days, p < 0.001). LOS did not differ between teams that participated and those who did not (8.4±8.1 vs 8.1±7.9 days, p = 0.298). No differences were found in the proportion of patients who were discharged home, died while an inpatient or re-admitted within 30 days of discharge. The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019(p == 0.009). CONCLUSION Widespread adoption of specialist care may not be beneficial for all medical inpatients and physicians should continue to undergo dual specialist and GIM training.
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Affiliation(s)
- Hannah Smyth
- Specialist Registrar in Geriatric Medicine and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland.
| | - Sarah Gorey
- Specialist Registrar in Geriatric Medicine and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Hannah O'Keeffe
- Specialist Registrar in Nephrology and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Joanna Beirne
- Senior House Officer in General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Shaunna Kelly
- Senior House Officer in General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Cathal Clifford
- Specialist Registrar in Gastroenterology and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Hilary Kerr
- Senior House Officer in General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Martin Mulroy
- Consultant Physician in Geriatric Medicine and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Tomás Ahern
- Consultant Physician in Endocrinology and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
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Safi M, Clay-Williams R, Thude BR, Vaisman J, Brandt F. Today's referral is tomorrow's repeat patient: referrals to and between medical outpatient clinics in a hospital. BMC Health Serv Res 2022; 22:254. [PMID: 35209886 PMCID: PMC8876391 DOI: 10.1186/s12913-022-07633-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background Unnecessary referrals in Danish hospitals may be contributing to inefficient use of health services already stretched and under pressure and may lead to delayed treatment for patients. Despite a growing awareness in the literature and in practice of issues related to referrals, there has been relatively little research on referrals between specialists in hospital outpatient clinics and how it can be improved. This study aimed to describe the referral patterns to and within the Medical Department at the University Hospital of Southern Denmark. The Medical Department consists of the following medical specialist outpatient clinics; nephrology, pulmonology, endocrinology, cardiovascular, wound outpatient clinic, and a day hospital. Methods Two specialist physicians assessed all referrals to the medical specialist outpatient clinics over one month (from 01 September 2019 to 30 September 2019) using data drawn from the Danish electronic patient record system (Cosmic). Data on referral pattern, and patient age and sex, were statistically analysed to identify and characterise patterns of referral. Results Four hundred seventy-one (100%) referrals were included in the study. 49.5% (233) of the referrals were from the hospital and 50.5% (238) from general practitioners (GPs). Of the 233 referrals from the hospitals, 31% (72) were from the Medical Department. Conclusion The high rate of referrals (31%) from own Medical Department or outpatient clinics may reflect an inefficient internal referral process within the department. Improved collaboration between specialists could have the potential to improve health outcomes, timely access to care and more appropriate healthcare resource utilisation.
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Affiliation(s)
- Mariam Safi
- Internal Medicine Research Unit, University Hospital of Southern Denmark, Department for Regional Health Research, Aabenraa, Denmark. .,University of Southern Denmark, Odense, Denmark.
| | - Robyn Clay-Williams
- Australian Institute of Healthcare Innovation, Macquarie University, Sydney, Australia
| | - Bettina Ravnborg Thude
- Internal Medicine Research Unit, University Hospital of Southern Denmark, Department for Regional Health Research, Aabenraa, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Julija Vaisman
- Internal Medicine Research Unit, University Hospital of Southern Denmark, Department for Regional Health Research, Aabenraa, Denmark
| | - Frans Brandt
- Internal Medicine Research Unit, University Hospital of Southern Denmark, Department for Regional Health Research, Aabenraa, Denmark.,University of Southern Denmark, Odense, Denmark
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Miyazaki C, Ishii Y, Stelmaszuk NM. Disease burden and treatment sequence of polymyositis and dermatomyositis patients in Japan: a real-world evidence study. Clin Rheumatol 2021; 41:741-755. [PMID: 34677707 PMCID: PMC8873135 DOI: 10.1007/s10067-021-05939-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/17/2021] [Accepted: 09/22/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION/OBJECTIVES Since new consensus on polymyositis (PM) and dermatomyositis (DM) were released in Japan, an updated evidence on treatment landscape and PM/DM burden was essential. This study evaluates treatment burden and overall treatment cost of PM/DM-related inpatient and outpatient visits, treatments, and procedures/patient/year. METHOD This retrospective, observational study analyzed insurance claims from Japan Medical Data Center (JMDC) database. Patients with at least one PM/DM diagnosis/one dispensation of treatment between 1 January 2009 and 31 December 2019 were enrolled. Patient characteristics, treatment patterns and sequence, treatment choices, healthcare resource utilization (HCRU), and related costs were assessed. Chi-square test and linear regression model were used to assess impact of patient characteristics on treatment choice. RESULTS Patients (836/4,961) receiving a relevant treatment were analyzed. Heart disease (35%), interstitial lung disease (27%), and diabetes mellitus (26%) were frequently identified as comorbidities. Concomitant dispensation of immunosuppressants and systemic steroids was largely found in first and second line of treatment (LoT) while systemic steroids remained as single dominant treatment across all LoTs. HCRU was very low for inpatient visits (0.68 [1.43]) or rehabilitation (4.74 [14.57]). The mean (SD) number of inpatient visits decreased from first (1.23 [2.32]) to third year (0.11 [0.54]). Total mean (SD) healthcare cost per patients per year was ¥ 3,815,912 (7,412,241), with overall drug dispensation compounding to 80% of total cost. CONCLUSIONS High concomitant immunosuppressant and systemic steroid prescriptions in first LoT recommend early optimal treatment to manage PM/DM. Although inpatient costs are low, outpatient dispensation costs increase overall economic burden.
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Affiliation(s)
- Celine Miyazaki
- Health Economics Department, Janssen Pharmaceutical K.K., Tokyo, Japan.
| | - Yukata Ishii
- Immunology, Infectious Diseases and Vaccine Department, Medical Affairs Division, Janssen Pharmaceutical K.K., Tokyo, Japan
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Wang K, Guo X, Yu S, Gao L, Wang Z, Zhu H, Xing B, Zhang S, Dong D. Patient-Identified Problems and Influences Associated With Diagnostic Delay of Acromegaly: A Nationwide Cross-Sectional Study. Front Endocrinol (Lausanne) 2021; 12:704496. [PMID: 34744996 PMCID: PMC8566913 DOI: 10.3389/fendo.2021.704496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Insidious-onset acromegaly may easily be overlooked by non-specialists of acromegaly and cause diagnostic delay. This study aims to examine the association between diagnostic delay and advice from doctors before any confirmed diagnosis and subsequent comorbidities, and elicit patient-perceived reasons for misdiagnoses. METHODS An online nationwide cross-sectional study was conducted through China Acromegaly Patient Association. Growth Hormone (GH) and Insulin-like Growth Factor 1 (IGF-1) levels at diagnosis and cancerous, endocrine-metabolic, musculoskeletal, cardiovascular, respiratory, and psychiatric comorbidities were reported by patients. The association between diagnostic delay and pre-diagnostic advice from doctors as well as subsequent comorbidities after diagnosis were examined. RESULTS In total, 447 valid responses were collected. Overall, 58.8% patients experienced misdiagnoses, and 22.6% had diagnostic delay. Before arriving at any diagnosis, patients without treatment (adjusted odds ratio [AOR]: 3.66, 95% confidence interval [CI]: 1.30-10.33) or receiving treatment to symptoms only (AOR: 7.05, 95%CI: 4.09-12.17) had greater chance of being misdiagnosed, and hence had diagnostic delay. Patients believed insufficient specialists, limited awareness of acromegaly of non-specialists and poor doctor-patient communications were major reasons of misdiagnosis. Diagnostic delay were associated with higher GH level at diagnosis and endocrine-metabolic, musculoskeletal and cardiovascular comorbidities (all P<0.05). CONCLUSIONS Suboptimal pre-diagnostic advice for patients, reflecting limited awareness of acromegaly among non-specialists, may delay the diagnosis and increase comorbidities. Feedbacks on the patients' final diagnosis from specialists to non-specialists should be considered, and doctor-patient communication and clinical decision-making process should be improved. Comorbidities should be screened and monitored particularly for patients with diagnostic delay.
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Affiliation(s)
- Kailu Wang
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong, SAR China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China Pituitary Disease Registry Center, Beijing, China
- China Pituitary Adenoma Specialist Council, Beijing, China
| | - Siyue Yu
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong, SAR China
| | - Lu Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China Pituitary Disease Registry Center, Beijing, China
- China Pituitary Adenoma Specialist Council, Beijing, China
| | - Zihao Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China Pituitary Disease Registry Center, Beijing, China
- China Pituitary Adenoma Specialist Council, Beijing, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China Pituitary Disease Registry Center, Beijing, China
- China Pituitary Adenoma Specialist Council, Beijing, China
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China Pituitary Disease Registry Center, Beijing, China
- China Pituitary Adenoma Specialist Council, Beijing, China
- China Alliance of Rare Diseases, Beijing, China
- *Correspondence: Dong Dong, ; Bing Xing, ; Shuyang Zhang,
| | - Shuyang Zhang
- China Alliance of Rare Diseases, Beijing, China
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Dong Dong, ; Bing Xing, ; Shuyang Zhang,
| | - Dong Dong
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong, SAR China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
- *Correspondence: Dong Dong, ; Bing Xing, ; Shuyang Zhang,
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Pat JJ, Aart TVD, Steffens MG, Witte LPW, Blanker MH. Assessment and treatment of recurrent urinary tract infections in women: development of a questionnaire based on a qualitative study of patient expectations in secondary care. BMC Urol 2020; 20:190. [PMID: 33267816 PMCID: PMC7709265 DOI: 10.1186/s12894-020-00764-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/27/2020] [Indexed: 11/17/2022] Open
Abstract
Background To develop a questionnaire to facilitate the inventorying of women’s expectations for the assessment and treatment of recurrent urinary tract infection (UTI) in secondary care.
Methods Semi-structured interviews were conducted among women with recurrent UTI referred to our urology department. The interviews were conducted by one interviewer, recorded, transcribed verbatim, and analyzed thematically by two researchers. We first developed 35 questions to identify potential themes, and we then tested them among women with and without recurrent UTI. Changes were made according to the feedback received. Results Six interviews were conducted before saturation was reached. Thematic analysis identified three themes: patient pathway, personal knowledge, and social implications. All respondents had received multiple antibiotic courses but no prophylactic antibiotic therapy, and although all were aware of some preventive measures, they wanted more information about their disease. However, some women were afraid to access information for fear of what they might learn. Recurrent UTI also significantly affected the daily lives all respondents. Some women expressed fears over frequent antibiotic use, and others felt that there must be something wrong with their body to have so many UTIs. Women expected the urologist to provide an explanation and to start adequate therapy for their recurrent UTI. We created a 32-item questionnaire based on these themes Conclusion This study not only developed a questionnaire for use when assessing patient expectations of recurrent UTI management in secondary care but also provided novel insights into the thoughts, opinions, and expectations of women who are referred.
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Affiliation(s)
- J J Pat
- Department of General Practice, University of Groningen, University Medical Centre, Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - T V D Aart
- Department of General Practice, University of Groningen, University Medical Centre, Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - M G Steffens
- Department of Urology, ISALA Clinics, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - L P W Witte
- Department of Urology, ISALA Clinics, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - M H Blanker
- Department of General Practice, University of Groningen, University Medical Centre, Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Mors M, Bohr C, Fozo M, Shermetaro C. Consultation Intervention Rates for the Otolaryngology Service: A Large Metropolitan Hospital Experience. Spartan Med Res J 2020; 4:11596. [PMID: 33655167 PMCID: PMC7746046 DOI: 10.51894/001c.11596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT The purpose of this study was to evaluate the types of consultations received by an otolaryngology service at a 772-bed large metropolitan, MI-based hospital. METHODS The authors performed a retrospective review of the specific types of consultations received during calendar year 2016. RESULTS A total of 518 consultations were reviewed and analyzed by the first and second authors (MM, CB). Consultations with low intervention rates included dysphagia (difficulty swallowing) (32.3%), dysphonia (difficulty speaking) (16%), otalgia (earache) (20.8%), hearing loss (13.3%), rule out vocal cord dysfunction (0%), and vertigo/dizziness (0%). Epistaxis (nosebleed) was the most frequent reason for consultations, and angioedema (lip or airway swelling) was the most common airway-related consultation. Notably, emergent or urgent surgery was only performed on 4.6% of sample patients. Several common consultation reasons (e.g., longer-term hearing loss evaluation and cerumen (“earwax”) removal) could have been deferred for clinic-based evaluation where audiograms and microscopes are more readily available. CONCLUSIONS These findings suggest areas for continuing education for primary care provider and resident education to place more appropriate hospital consultations. Annual resident lectures to prepare junior residents for the most common call scenarios (i.e., control epistaxis and incision and drainage of peritonsillar abscesses) could be helpful in this area. In addition, didactic lectures for primary care physicians on how to evaluate patients with dysphagia may be of value as this was a common consult for otolaryngologist referrals.
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Affiliation(s)
- Matt Mors
- McLaren Oakland Regional Medical Center
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Tzartzas K, Oberhauser PN, Marion-Veyron R, Bourquin C, Senn N, Stiefel F. General practitioners referring patients to specialists in tertiary healthcare: a qualitative study. BMC FAMILY PRACTICE 2019; 20:165. [PMID: 31787078 PMCID: PMC6885318 DOI: 10.1186/s12875-019-1053-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 11/19/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center. METHODS Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results. RESULTS Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress. CONCLUSIONS General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.
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Affiliation(s)
- Konstantinos Tzartzas
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
| | | | - Régis Marion-Veyron
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - Céline Bourquin
- Psychiatry Liaison Service, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nicolas Senn
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - Friedrich Stiefel
- Psychiatry Liaison Service, University Hospital of Lausanne, Lausanne, Switzerland
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Lee L, King G, Freeman T, Eva KW. Situational cues surrounding family physicians seeking external resources while self-monitoring in practice. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:783-796. [PMID: 31123847 DOI: 10.1007/s10459-019-09898-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/17/2019] [Indexed: 06/09/2023]
Abstract
Many models of safe and effective clinical decision making in medical practice emphasize the importance of recognizing moments of uncertainty and seeking help accordingly. This is not always done effectively, but we know little about what cues prompt health professionals to call on resources beyond their own knowledge or skill set. Such information would offer guidance regarding how systems might be designed to offer better individual support. In this study, the authors explored the situational factors that are present during moments of uncertainty that lead primary care physicians to access external resources. To do so, a generic qualitative exploratory analysis was conducted on 72 narratives collected through audio recorder-based, self-observational, journaling completed by 12 purposively selected family physicians. Participants were asked to provide a detailed descriptive account of the circumstances surrounding their consultation of external resources immediately after 6 sequential patient encounters in which they felt compelled to seek such support. Thematic analysis of the transcripts was performed to better understand participants' experiences of the social, contextual, and personal features surrounding decisions to seek support. When doing so we observed that specific features of patient encounters were routinely present when physicians decided to access external sources for help. These included medical aspects of the case (e.g., complex presentations), social aspects (e.g., the presence of another individual), and personal factors (e.g., feeling a need for reassurance). External resources were seen as an opportunity for verification, a mechanism to increase patient satisfaction, and a means through which to defend decision-making. Accessing such resources appeared to influence the physician-patient relationship for various reasons. Recognition and further study of the cues that prompt use of external information will further our understanding of physicians' behavioural responses to challenging/uncertain situations, highlight mechanisms through which a culture of self-directed assessment seeking might be encouraged, and offer guidance regarding ways in which physicians can be encouraged to practice mindfully. Our results make it clear that reasons for which primary care physicians seek the support of external resources may be multifactorial and, therefore, one should be cautious when inferring reasons for the pursuit of such support.
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Affiliation(s)
- Linda Lee
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.
- Schlegel Chair in Primary Care for Elders, The Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada.
- Centre for Family Medicine Family Health Team, 10B Victoria St. South, Kitchener, ON, N2G 1C5, Canada.
| | - Gillian King
- Bloorview Research Institute, Toronto, ON, Canada
- Department of Occupational Science and Occupational Therapy, The University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Thomas Freeman
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Kevin W Eva
- Department of Medicine, Centre for Health Education Scholarship, The University of British Columbia, Vancouver, BC, Canada
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Offering eConsult to Family Physicians With Patients on a Pain Clinic Wait List: An Outreach Exercise. J Healthc Qual 2019; 40:e71-e76. [PMID: 29189436 DOI: 10.1097/jhq.0000000000000117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Wait times for many chronic pain programs in Canada range from 6 months to 2 years. This project sought to determine the interest of primary care providers (PCPs) in using an electronic consult system for patient(s) waiting for a pain consultation. This cross-sectional study was conducted at the pain clinic of a Canadian tertiary academic health sciences center. Participants were PCPs who had submitted a referral to this clinic. Referrals received between April 1, 2012, and March 31, 2014, were reviewed to determine their appropriateness for eConsult, and a letter providing information about eConsult and encouraging its use was sent to the referring PCP. Of the 585 referrals that were reviewed, 227 were appropriate for eConsult. Fifty-one (26%) of the 194 PCP responses received were positive. Technologies like eConsult may help address the growing demand for specialist advice. In addition to facilitating response to specific questions, the bidirectional nature of eConsult permits its use for educating PCPs about chronic pain treatment. Given that almost one third of responding PCPs indicated an interest in eConsult, its potential reach is vast. Additional study is needed to understand barriers to PCP acceptance and use of eConsult and the uptake of advice given.
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Rea CJ, Wenren LM, Tran KD, Zwemer E, Mallon D, Bernson-Leung M, Samuels RC, Toomey SL. Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider-Specialty Care Coordination. Acad Pediatr 2018; 18:797-804. [PMID: 29625232 DOI: 10.1016/j.acap.2018.03.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/14/2018] [Accepted: 03/24/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication. METHODS The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction. RESULTS A total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P < .001), and completion rates improved from 58% to 70% (P < .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals. CONCLUSIONS Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.
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Affiliation(s)
- Corinna J Rea
- Division of General Pediatrics, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Larissa M Wenren
- Division of General Pediatrics, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass
| | - Katherine D Tran
- Division of General Pediatrics, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass
| | - Eric Zwemer
- Division of General Pediatrics, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Daniel Mallon
- Harvard Medical School, Boston, Mass; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass; Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass
| | - Miya Bernson-Leung
- Harvard Medical School, Boston, Mass; Department of Neurology, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass
| | - Ronald C Samuels
- Division of General Pediatrics, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics, Boston Children's Hospital, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Boston, Mass; Harvard Medical School, Boston, Mass
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Transitioning Patients From Specialty Care to Primary Care: What We Know and What We Can Do. J Ambul Care Manage 2018; 41:314-322. [PMID: 29923847 DOI: 10.1097/jac.0000000000000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Growing demand for specialty care has resulted in longer wait times for appointments, particularly at US academic referral centers. A proportion of specialty visits are for routine follow-up care of stable problems, and there is evidence that primary care providers are willing and able to take responsibility for a significant proportion of these patients. However, little is known about how to transition care back to a referring primary care clinician in a manner that is acceptable to everyone involved. In this article, we describe social, legal, and financial barriers to effective care transition and propose communication strategies to overcome them.
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Koenig CJ, Wenger M, Graham GD, Asch S, Rongey C. Managing professional knowledge boundaries during ECHO telementoring consultations in two Veterans Affairs specialty care liver clinics: A theme-oriented discourse analysis. J Telemed Telecare 2018. [PMID: 29514547 DOI: 10.1177/1357633x18756454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Consultations are the traditional method of communication between generalist and specialist providers managing patients with specialty care needs. Traditional written consultations have limitations, including inadequate clinical information and inappropriate, or unclear consultation questions. Teleconsultations minimize these limitations through real-time communication between generalist and specialist providers to actively manage professional knowledge boundaries about specialty care problems. METHODS We video-recorded 37 teleconsultation sessions, resulting in 115 consultations between generalist and specialty care providers participating in Veterans Affairs (VA) Extension for Community Healthcare Outcomes (ECHO) liver clinics. Data were collected at two US sites across nine months to observe consultation communication among 33 primary care generalists and three liver specialists. Video recordings were transcribed verbatim and analysed using theme-oriented discourse analysis to characterize consultation question content and format. RESULTS Generalists' consultation question content addressed a range of topics, including treatment, diagnosis, interpreting results, patient communication, screening and surveillance, and care coordination. Some generalists relied on descriptive narratives rather than a specific question to convey complex patient cases. Consultation question format showed nearly even division between targeting general medical knowledge and specialty care knowledge domains, including specialty care, medical, organizational, and experiential knowledge. DISCUSSION Timely access to specialists through teleconsultation has the potential to transform specialty care delivery. This article examines provider-to-provider interactions to understand how the communication process contributes to knowledge management during teleconsultations. Video studies of health information technology use provide a rich opportunity for analysing real-time communication that may help improve cross-specialty collaboration and the coordinated management of patients with specialty care needs.
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Affiliation(s)
- Christopher J Koenig
- 1 San Francisco State University, San Francisco, CA, USA.,2 Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA.,3 San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Matthew Wenger
- 3 San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Glenn D Graham
- 3 San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,4 Specialty Care Services, VA Central Office, Washington, DC, USA
| | - Steven Asch
- 2 Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA.,5 Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Catherine Rongey
- 6 University of California, San Francisco, San Francisco, CA, USA.,7 Kaiser Permanente, Vallejo, CA, USA
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Lowenstein M, Bamgbose O, Gleason N, Feldman MD. Psychiatric Consultation at Your Fingertips: Descriptive Analysis of Electronic Consultation From Primary Care to Psychiatry. J Med Internet Res 2017; 19:e279. [PMID: 28778852 PMCID: PMC5562932 DOI: 10.2196/jmir.7921] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Mental health problems are commonly encountered in primary care, with primary care providers (PCPs) experiencing challenges referring patients to specialty mental health care. Electronic consultation (eConsult) is one model that has been shown to improve timely access to subspecialty care in a number of medical subspecialties. eConsults generally involve a PCP-initiated referral for specialty consultation for a clinical question that is outside their expertise but may not require an in-person evaluation. Objective Our aim was to describe the implementation of eConsults for psychiatry in a large academic health system. Methods We performed a content analysis of the first 50 eConsults to psychiatry after program implementation. For each question and response, we coded consults as pertaining to diagnosis and/or management as well as categories of medication choice, drug side effects or interactions, and queries about referrals and navigating the health care system. We also performed a chart review to evaluate the timeliness of psychiatrist responses and PCP implementation of recommendations. Results Depression was the most common consult template selected by PCPs (20/50, 40%), followed by the generic template (12/50, 24%) and anxiety (8/50, 16%). Most questions (49/50, 98%) pertained primarily to management, particularly for medications. Psychiatrists commented on both diagnosis (28/50, 56%) and management (50/50, 100%), responded in an average of 1.4 days, and recommended in-person consultation for 26% (13/50) of patients. PCPs implemented psychiatrist recommendations 76% (38/50) of the time. Conclusions For the majority of patients, psychiatrists provided strategies for ongoing management in primary care without an in-person evaluation, and PCPs implemented most psychiatrist recommendations. eConsults show promise as one means of supporting PCPs to deliver mental health care to patients with common psychiatric disorders.
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Affiliation(s)
- Margaret Lowenstein
- University of Pennsylvania Perelman School of Medicine, National Clinician Scholars Program, Philadelphia, PA, United States
| | - Olusinmi Bamgbose
- Marin General Hospital, Department of Psychiatry, Greenbrae, CA, United States
| | - Nathaniel Gleason
- University of California, San Francisco, Division of General Internal Medicine, San Francisco, CA, United States
| | - Mitchell D Feldman
- University of California, San Francisco, Division of General Internal Medicine, San Francisco, CA, United States
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Al-Natour SH. Dermatology referrals are valuable. JOURNAL OF DERMATOLOGY & DERMATOLOGIC SURGERY 2017. [DOI: 10.1016/j.jdds.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Varga Z, Sabzwari SAR, Abusaada K. Impact of Consultation on Hospital Outcomes and Resource Utilization for Patients with Acute Congestive Heart Failure. South Med J 2017; 110:452-456. [DOI: 10.14423/smj.0000000000000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Schreiner A, Simpson K. Primary care and chronic disease: the intersection of comfort and specialty involvement - a cross-sectional study. J Eval Clin Pract 2017; 23:494-497. [PMID: 27524806 DOI: 10.1111/jep.12621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/11/2016] [Accepted: 07/12/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary care referrals to specialty physicians play an integral role in patient care and health care costs. Multiple factors play into the primary care physician's decision to refer, including comfort managing particular conditions. As the burden of chronic disease climbs, the relationship between patients, primary care physicians and specialists in accurately diagnosing, managing and treating chronic conditions needs clarity. The objective of this study is to assess the relationship between specialty physician involvement and the care of three chronic conditions: diabetes mellitus (DM), chronic kidney disease (CKD) and systemic lupus erythematosus (SLE). METHODS To achieve this objective, we performed a cross-sectional study of 2013 MarketScan data (875 million billing records) for three chronic medical conditions. Participants were identified in the dataset by having received a diagnosis code for DM, CKD or SLE in an outpatient care setting during 2013. The study compared proportions of outpatient visits with specialty physicians in endocrinology, nephrology and rheumatology for patients with DM, CKD and SLE respectively. RESULTS Data included 1 615 609 visits with the diagnosis of DM, 158 424 visits with the diagnosis of CKD and 103 910 visits with SLE. Diabetic patients met endocrinologists (10.2%) at a smaller proportion of their visits than patients with CKD saw nephrologists (41.2%, P < 0.0001). Further, CKD patients met with nephrologists (41.2%) at a significantly fewer proportion of outpatient visits than SLE patients saw rheumatologists (51.8%, P < 0.0001). CONCLUSIONS Differences in primary care physicians' comfort with diagnosis, therapy and adherence to published guidelines affect the rate with which primary care providers seek specialty consultation.
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Affiliation(s)
| | - Kit Simpson
- Medical University of South Carolina, Charleston, SC, USA
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Tuzzio L, Ludman EJ, Chang E, Palazzo L, Abbott T, Wagner EH, Reid RJ. Design and Implementation of a Physician Coaching Pilot to Promote Value-Based Referrals to Specialty Care. Perm J 2017; 21:16-066. [PMID: 28368789 DOI: 10.7812/tpp/16-066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Referral rates to specialty care from primary care physicians vary widely. To address this variability, we developed and pilot tested a peer-to-peer coaching program for primary care physicians. OBJECTIVES To assess the feasibility and acceptability of the coaching program, which gave physicians access to their individual-level referral data, strategies, and a forum to discuss referral decisions. METHODS The team designed the program using physician input and a synthesis of the literature on the determinants of referral. We conducted a single-arm observational pilot with eight physicians which made up four dyads, and conducted a qualitative evaluation. RESULTS Primary reasons for making referrals were clinical uncertainty and patient request. Physicians perceived doctor-to-doctor dialogue enabled mutual learning and a pathway to return joy to the practice of primary care medicine. The program helped physicians become aware of their own referral data, reasons for making referrals, and new strategies to use in their practice. Time constraints caused by large workloads were cited as a barrier both to participating in the pilot and to practicing in ways that optimize referrals. Physicians reported that the program could be sustained and spread if time for mentoring conversations was provided and/or nonfinancial incentives or compensation was offered. CONCLUSION This physician mentoring program aimed at reducing specialty referral rates is feasible and acceptable in primary care settings. Increasing the appropriateness of referrals has the potential to provide patient-centered care, reduce costs for the system, and improve physician satisfaction.
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Affiliation(s)
- Leah Tuzzio
- Research Associate at the Kaiser Permanente Washington Health Research Institute (formerly Group Health Research Institute) in Seattle, WA.
| | - Evette J Ludman
- Senior Research Associate at the Kaiser Permanente Washington Health Research Institute (formerly Group Health Research Institute) in Seattle, WA.
| | - Eva Chang
- Research Public Health Analyst at RTI International in Waltham, MA.
| | - Lorella Palazzo
- Research Associate at the Kaiser Permanente Washington Health Research Institute (formerly Group Health Research Institute) in Seattle, WA.
| | - Travis Abbott
- Family Physician at Group Health Cooperative in Seattle, WA.
| | - Edward H Wagner
- Director Emeritus of the MacColl Center for Health Care Innovation at the Kaiser Permanente Washington Health Research Institute (formerly Group Health Research Institute) in Seattle, WA.
| | - Robert J Reid
- Chief Scientist for Better Health at Trillium Health Partners Institute in Mississauga, Ontario, Canada.
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Chalkley M, McCormick B, Anderson R, Aragon MJ, Nessa N, Nicodemo C, Redding S, Wittenberg R. Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe English NHS faces financial pressures that may render the growth rates of elective admissions seen between 2001/2 and 2011/12 unsustainable. A better understanding of admissions growth, and the influence of policy, are needed to minimise the impact on health gain for patients.ObjectivesThis project had several objectives: (1) to better understand the determinants of elective activity and policy to moderate growth at minimum health loss for patients; (2) to build a rich data set integrating health, practice and local area data to study general practitioner (GP) referrals and resulting admissions; (3) to predict patients whose treatment is unlikely to be cost-effective using patient-reported outcomes and to examine variation in provider performance; and (4) to study how policies that aim to reduce elective admissions may change demand for emergency care. The main drivers of elective admissions growth have increased either supply of or demand for care, and could include, for example, technical innovations or increased awareness of treatment benefits. Of the factors studied, neither system reform nor population ageing appears to be a key driver. The introduction of the prospective payment tariff ‘Payment by Results’ appears to have led to primary care trusts (PCTs) having increasingly similar lengths of stay. In deprived areas, increasing GP supply appears to moderate elective admissions. Reducing the incidence of single-handed practices tends to reduce referrals and admissions. Policies to reduce referrals are likely to reduce admissions but treatments may be particularly reduced in the lowest referring practices, in which resulting health loss may be greatest. In this model, per full-time equivalent, female and highly experienced GPs identify more patients admitted by specialists.ResultsIt appears from our studies that some patient characteristics are associated with not achieving sufficient patient gain to warrant cost-effective treatment. The introduction of independent sector treatment centres is estimated to have caused an increase in emergency activity rates at local PCTs. The explanations offered for increasing elective admissions indicate that they are manageable by health policy.ConclusionsFurther work is required to understand some of the results identified, such as whether or not high-volume Clinical Commissioning Groups are fulfilling unmet need; why some practices refer at low rates relative to admissions; why the period effect, which results from factors that equally affect all in the study at a point in time, dominates in the age–period–cohort analysis; and exactly how the emergency and elective sections of hospital treatment interact. This project relies on the analysis of secondary data. This type of research does not easily facilitate the important input of clinical experts or service users. It would be beneficial if other methods, including surveys and consultation with key stakeholders, could be incorporated into future research now that we have uncovered important questions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Barry McCormick
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Robert Anderson
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | | | - Nazma Nessa
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
- Department for Business, Innovation and Skills, London, UK
| | - Catia Nicodemo
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Stuart Redding
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Raphael Wittenberg
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
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Di Guglielmo MD, Greenspan JS, Abatemarco DJ. Pediatrician preferences, local resources, and economic factors influence referral to a subspecialty access clinic. Prim Health Care Res Dev 2016; 17:628-635. [PMID: 27185320 PMCID: PMC5065399 DOI: 10.1017/s1463423616000165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Pediatric patients seek timely access to subspecialty care within a complex delivery system while facing barriers: distance, economics, and clinician shortages. Aim We examined stakeholder perceptions about solutions to the access challenge. We engaged over 300 referring primary care pediatricians in the evaluation of Access Clinics at an academic children's hospital. METHODS Using an anonymous online survey, we asked pediatricians about their and their patients' experiences and analyzed factors that may influence referrals. Findings Referring pediatricians reported satisfaction; they provided feedback about their patients' experiences, physician communication, and referral influences. Distance from the Access Clinic does not correlate with differences in referral volume; living in areas with higher child populations and higher median income is associated with more referrals. Referring pediatricians have strong opinions about referrals, are attuned to patient experiences, and desire bi-directional communication. Multiple factors influence referral to and acceptance of Access Clinics, but external influences have less impact than expected.
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Affiliation(s)
- Matthew D. Di Guglielmo
- Clinical Assistant Professor of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Jay S. Greenspan
- Professor of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
- Department of Pediatrics, Nemours/Alfred I., duPont Hospital for Children, Wilmington, DE, USA
| | - Diane J. Abatemarco
- Associate Professor of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
- Department of Pediatrics, Nemours/Alfred I., duPont Hospital for Children, Wilmington, DE, USA
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Gleason N, Prasad PA, Ackerman S, Ho C, Monacelli J, Wang M, Collado D, Gonzales R. Adoption and impact of an eConsult system in a fee-for-service setting. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2016; 5:40-45. [PMID: 27469441 DOI: 10.1016/j.hjdsi.2016.05.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 05/04/2016] [Accepted: 05/18/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Nathaniel Gleason
- Division of General Internal Medicine, University of California, San Francisco, United States.
| | - Priya A Prasad
- Division of General Internal Medicine, University of California, San Francisco, United States
| | - Sara Ackerman
- Division of General Internal Medicine, University of California, San Francisco, United States
| | - Chanda Ho
- California Pacific Medical Center, Division of Hepatology, United States
| | | | - Michael Wang
- Division of General Internal Medicine, University of California, San Francisco, United States
| | - Don Collado
- Division of General Internal Medicine, University of California, San Francisco, United States
| | - Ralph Gonzales
- Division of General Internal Medicine, University of California, San Francisco, United States
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Thorsen O, Hartveit M, Johannessen JO, Fosse L, Eide GE, Schulz J, Bærheim A. Typologies in GPs' referral practice. BMC FAMILY PRACTICE 2016; 17:76. [PMID: 27430983 PMCID: PMC4949760 DOI: 10.1186/s12875-016-0495-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 07/13/2016] [Indexed: 12/04/2022]
Abstract
Background GPs’ individual decisions to refer and the various ways of working when they refer are important determinants of secondary care use. The objective of this study was to explore and describe potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. Methods Observational cross-sectional study using data from 128 Norwegian GPs who filled in a questionnaire with statements on how they regarded the referral process, and who were invited to collect data when they actually referred to hospital during one month. Only elective referrals were recorded. The 57 participants (44,5 %) recorded data from 691 referrals. The variables were included in a principal component analysis. A multiple linear regression analysis was conducted to identify typologies with GP’s age, gender, specialty in family medicine and location as independent variables. Results Eight principal components describe the different ways GPs think and work when they refer. Two typologies summarize these components: confidence characterizing specialists in family medicine, mainly female, who reported a more patient-centred practice making priority decisions when they refer, who confer easily with hospital consultants and who complete the referrals during the consultation; uncertainty characterizing young, mainly male non-specialists in family medicine, experiencing patients’ pressure to be referred, heavy workload, having reluctance to cooperate with the patient and reporting sparse contact with hospital colleagues. Conclusions Training specialists in family medicine in patient-centred method, easy conference with hospital consultant and cooperation with patients while making the referral may foster both self-reflections on own competences and increased levels of confidence. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0495-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olav Thorsen
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway. .,Department of Research, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.
| | - Miriam Hartveit
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway.,Section for Research and Innovation, Helse Fonna HF, Box 2170, Haugesund, N-5504, Norway
| | - Jan Olav Johannessen
- Centre for Clinical Psychosis Research, Division of Psychiatry, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.,Faculty of Social Sciences, University of Stavanger, Box 8100, Stavanger, N-4068, Norway
| | - Lars Fosse
- Department of Orthopaedics, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway.,Centre for Clinical Research, Haukeland University Hospital, Box 1400, Bergen, N-5021, Norway
| | - Jörn Schulz
- Department of Research, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.,Section of Biostatistics, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway
| | - Anders Bærheim
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway
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Wrenn K, Catschegn S, Cruz M, Gleason N, Gonzales R. Analysis of an electronic consultation program at an academic medical centre: Primary care provider questions, specialist responses, and primary care provider actions. J Telemed Telecare 2016; 23:217-224. [DOI: 10.1177/1357633x16633553] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction Electronic consultations (eConsults) increase access to specialty care, but little is known about the types of questions primary care providers (PCPs) ask through eConsults, and how they respond to specialist recommendations. Methods This is a retrospective descriptive analysis of the first 200 eConsults completed in the UCSF eConsult program. Participating PCPs were from eight adult primary care sites at the University of California, San Francisco (UCSF), USA. Medicine subspecialties participating were Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine. We categorized eConsult questions into “diagnosis,” “treatment,” and/or “monitoring.” We performed medical record reviews to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the eConsult, emergency department visit, or hospital admission during the subsequent six months. Results PCP questions related to diagnosis in 71% of cases, treatment in 46%, and monitoring in 21%. Specialist responses related to diagnosis in 76% of cases, treatment in 64%, and monitoring in 40%. PCPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the eConsult, 14% of patients had a specialist visit within the UCSF system in the same specialty as the eConsult. Discussion eConsults provide guidance to PCPs across the spectrum of patient care. PCPs implement specialists’ recommendations in the large majority of cases, and few patients subsequently require in-person specialty care related to the reason for the eConsult.
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Affiliation(s)
- Katherine Wrenn
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Sereina Catschegn
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Marisa Cruz
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Nathaniel Gleason
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Ralph Gonzales
- Division of General Internal Medicine, University of California, San Francisco, USA
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Examining the variation in GPs' referral practice: a cross-sectional study of GPs' reasons for referral. Br J Gen Pract 2015; 64:e426-33. [PMID: 24982495 PMCID: PMC4073728 DOI: 10.3399/bjgp14x680521] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND There is a large variation in referral rates to secondary care among GPs, which is partly unexplained. AIM To explore associations between reasons for referral to secondary care and patient, GP, and healthcare characteristics. DESIGN AND SETTING A cross-sectional study in Northern Norway. METHOD Data were derived from 44 (42%) of 104 randomly selected GPs between 2008 and 2010. GPs scored the relevance of nine predefined reasons for 595 referrals from 4350 consecutive consultations on a four-level categorical scale. Associations were examined by multivariable ordered and multivariable multilevel logistic regression analyses. RESULTS Medical necessity was assessed as a relevant reason in 93% of the referrals, 43.7% by patient preference, 27.5% to avoid overlooking anything, and 14.6% to reassure the patient. The higher the referral rates, the more frequently the GPs referred to avoid overlooking anything. Female GPs referred to reassure the patient and due to perceived deficient medical knowledge significantly more often than male GPs. However, perceived easy accessibility of specialists was significantly less frequently given as a reason for referral by female GPs compared with male GPs. When the GPs scored the referrals to be of lesser medical necessity, male GPs referred significantly more frequently than female GPs to reassure the patient due to patient preference and perceived deficient medical knowledge. CONCLUSION There are striking differences in reasons for referral between Norwegian male and female GPs and between GPs with high and low referral rates, which reflects difficulties in handling professional uncertainty. Referring to reassure the patients, especially when referrals are less medically necessary, may reflect consideration and acquiescence towards the patients.
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Rübsam ML, Esch M, Baum E, Bösner S. Diagnosing skin disease in primary care: a qualitative study of GPs' approaches. Fam Pract 2015; 32:591-5. [PMID: 26160890 DOI: 10.1093/fampra/cmv056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Skin diseases are a common reason for consulting a GP. This regular occurrence happens despite most GPs' lack of knowledge and training in skin disease. OBJECTIVES We aimed to explore different diagnostic approaches of GPs in patients presenting with a dermatological problem. In addition, we aimed to identify strategies used by GPs to handle diagnostic uncertainty in these patients. METHODS We conducted interviews (20-40 minutes) with 14 GPs using a semi-structured guideline. Recalling encounters with patients with skin disease, GPs described their individual diagnostic strategies. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters using a deductive-inductive approach. RESULTS We identified several aspects of a complex decision-making process in GPs' diagnostic management of patients with dermatological problems. In the general diagnostic workup, GPs used a broad spectrum of different strategies such as spot diagnosis, stepwise refinement, pattern recognition trigger or test of treatment. GPs reduced diagnostic uncertainty through the identification of red flags, the application of the test of time, therapeutic trials and asking for further advice, including patient referral. CONCLUSIONS GPs encounter a broad range of dermatological problems in their daily work using a variety of strategies in the workup of these patients. However, in a significant number of patients, there remains diagnostic uncertainty that is mainly reduced by specialist referral. Regular training in the diagnosis and treatment of common dermatological diseases should be offered to all GPs.
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Affiliation(s)
- Marie-Luise Rübsam
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Maximilian Esch
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Erika Baum
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
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Dunlea R, Lenert L. Understanding Patients' Preferences for Referrals to Specialists for an Asymptomatic Condition. Med Decis Making 2015; 35:691-702. [PMID: 25589523 PMCID: PMC4501911 DOI: 10.1177/0272989x14566640] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A specialty referral is a common but complex decision that often requires a primary care provider to balance his or her own interests with those of the patient. OBJECTIVE To examine the factors that influence a patient's choice of a specialist for consultation for an asymptomatic condition and better understand the tradeoffs that patients are and are not willing to make in this decision. DESIGN Stratified cross-sectional convenience sample of subjects selected to parallel US population demographics. PARTICIPANTS Members of an Internet survey panel who reported seeing a physician in the past year whose responses met objective quality metrics for attention. MAIN MEASURES Respondents completed an adaptive conjoint analysis survey comparing specialists regarding eight attributes. The reliability of assessments and the predictive validity of models were measured using holdout samples. The relative importance (RI) of different attributes was computed using paired t tests. The implications of utility values were studied using market simulation methods. KEY RESULTS Five hundred and thirty subjects completed the survey and had responses that met quality criteria. The reliability of responses was high (86% agreement), and models were predictive of patients' preferences (82.6% agreement with holdout choices). The most important attribute for patients was out-of-pocket cost (RI of 19.5%, P < 0.0001 v. other factors). Among the nonfinancial factors, "collaboration and communication" with the primary care provider was the most important attribute (RI of 13.1% P < 0.001). Third in importance was whether the specialist practiced shared decision making (RI of 12.2% P < 0.001 v. other factors except delay in consultation). Cost did not dominate decision making. In market simulations, patients frequently preferred more expensive providers. For example, most patients (76.3%) were willing to pay more ($80) to see a specialist who both collaborated well with their primary care provider and practiced shared decision making. Most patients prefer to wait for a doctor who practices shared decision making: Only one-third (32.3%) of patients preferred a paternalistic doctor who was available in 2 weeks over a doctor who practiced decision making but was available in 4 weeks. CONCLUSIONS In the setting of a referral for an asymptomatic but serious condition, out-of-pocket costs are important to patients; however, they also value specialists who collaborate and communicate well with their primary care providers and who practice shared decision making. Patients have wide variability in preferences for specialists, and referral decisions should be individualized.
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Affiliation(s)
- Robert Dunlea
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT (RD, LL)
| | - Leslie Lenert
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT (RD, LL)
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, SC (LL)
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Abstract
ABSTRACTObjective:We sought to determine the degree and possible causes of variability in admission practices among individual emergency physicians (EPs) at 1 emergency department (ED) using a Canadian Emergency Department Triage Acuity Scale (CTAS)–matched ED patient population.Methods:We distributed a survey measuring attitudes and demographics to all EPs (n= 30) at a large regional hospital. Hospital admissions data from 1 calendar year were matched to individual EP survey results. Emergency physicians were ranked as “lower,” “average” or “higher” admitters and, using these categorical variables, the data set was analyzed for correlations and trends.Results:Overall, 97.0% of the EPs responded to the survey. Admissions by EPs ranged from 8.7% to 17.0%, (mean 12.52, standard deviation [SD] 2.21) of all patients seen. CTAS category–specific admission data demonstrated variability in the admission ranking of individual EPs. No EPs consistently performed at any 1 admission ranking across all CTAS categories. More years of emergency medicine experience was significantly correlated with higher admissions in the CTAS-2 ranking (r= 0.4,p< 0.05). Whether a physician worked full-time, part-time or as a locum was not associated with patterns of admission, nor was any particular postgraduate certification (e.g., CCFP, CCFP EM, FRCPC) or any of the surveyed attitudinal traits.Conclusion:Individual EPs' overall and CTAS-specific admissions varied substantially, and followed an approximately normal distribution curve. Emergency physicians with more years of experience had a statistically higher CTAS-2 admission rate; however, other variables, including postgraduate certification status, decision-related attitudes toward admission, and reported practices were not associated with admission proportions. Emergency physicians tend to have uniquely individual admission ranking profiles across all the CTAS categories.
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Montero Ruiz E, Monte Secades R. Definiciones de la actividad de Medicina Interna fuera de su propio servicio. Rev Clin Esp 2015; 215:182-5. [DOI: 10.1016/j.rce.2014.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/16/2014] [Accepted: 08/18/2014] [Indexed: 11/26/2022]
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Ang KT, Ho BK, Mimi O, Salmah N, Salmiah MS, Noridah MS. Factors influencing the role of primary care providers as gatekeepers in the Malaysian public healthcare system. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2014; 9:2-11. [PMID: 26425299 PMCID: PMC4568720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Primary care providers play an important gatekeeping role in ensuring appropriate referrals to secondary care facilities. This cross-sectional study aimed to determine the level, pattern and rate of referrals from health clinics to hospitals in the public sector, and whether the placement of resident family medicine specialist (FMS) had made a significant difference. The study was carried out between March and April in 2012, involving 28 public primary care clinics. It showed that the average referral rate was 1.56% for clinics with resident FMS and 1.94% for those without resident FMS, but it was not statistically significant. Majority of referred cases were considered appropriate (96.1%). Results of the multivariate analysis showed that no prior consultation with senior healthcare provider and illnesses that were not severe and complex were independently associated with inappropriate referrals. Severity, complexity or uncertain diagnosis of patients' illness or injury significantly contributed to unavoidable referrals. Adequate facilities or having more experienced doctors could have avoided 14.5% of the referrals. The low referral rate and very high level of appropriate referrals could indicate that primary care providers in the public sector played an effective role as gatekeepers in the Malaysian public healthcare system.
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Affiliation(s)
- K T Ang
- Ang Kim Teng, MPH, Institute for Health Management, Jalan Rumah Sakit, Off Jalan Bangsar, 59200 Kuala Lumpur Malaysia
| | - B K Ho
- Ho Bee Kiau, MMed (FamMed), Selangor Health Department, Malaysia
| | - O Mimi
- Mimi Omar, MMed (FamMed), Selangor Health Department, Malaysia
| | - N Salmah
- Salmah Nordin MMed (FamMed) Selangor Health Department, Malaysia
| | - M S Salmiah
- Salmiah Mohd Sharif MMed (FamMed) Selangor Health Department, Malaysia
| | - M S Noridah
- Noridah bt. Mohd Saleh MPH Family Health Division, Ministry of Health, Malaysia
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Brown MG, Campbell D, Maydom BW. The undivided patient: a retrospective cohort analysis of specialty referrals made from inpatient general medical units comparing regional to metropolitan practice. Intern Med J 2014; 44:884-9. [DOI: 10.1111/imj.12480] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 05/15/2014] [Indexed: 11/26/2022]
Affiliation(s)
- M. G. Brown
- Department of General Medicine; Monash Medical Centre; Melbourne Australia
| | - D. Campbell
- Department of General Medicine; Monash Medical Centre; Melbourne Australia
| | - B. W. Maydom
- Department of Medicine; West Gippsland Heath Care Group; Warragul Victoria Australia
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Montero Ruiz E, Rebollar Merino Á, García Sánchez M, Culebras López A, Barbero Allende J, López Álvarez J. Análisis de las interconsultas hospitalarias al servicio de medicina interna. Rev Clin Esp 2014; 214:192-7. [DOI: 10.1016/j.rce.2013.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 12/04/2013] [Accepted: 12/15/2013] [Indexed: 01/17/2023]
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Sewell JL, Guy J, Kwon A, Chen AH, Yee HF. Preconsultation exchange for ambulatory hepatology consultations. Am J Med 2013; 126:523-8. [PMID: 23597797 PMCID: PMC3684175 DOI: 10.1016/j.amjmed.2012.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/08/2012] [Accepted: 12/16/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Preconsultation exchange is an emerging model of specialty care proposed by the American College of Physicians that seeks to answer a clinical question without a formal patient visit to the specialty clinic. This form of specialty care has been little studied. We sought to determine the appropriateness of preconsultation exchange for ambulatory hepatology consultations within our urban health care system. METHODS Retrospective study of referrals for ambulatory hepatology consultation in the safety net health care system of San Francisco, Calif from January 2007 through April 2010. RESULTS Of the 500 referrals reviewed, 87 were excluded as repeat requests. The most common reasons for referral were hepatitis B (34.9%) and hepatitis C (32.0%). Fifty-six referrals (13.6%) were appropriate for preconsultation exchange, and 190 (46.0%) were inappropriate for preconsultation exchange. One hundred sixty-seven (40.4%) referrals did not include enough information to determine appropriateness for preconsultation exchange. Most of these (83.8%) were made for hepatitis B or hepatitis C, despite the presence of explicit referral guidelines. Midlevel providers were more likely than physicians to provide enough information to determine appropriateness for preconsultation exchange. CONCLUSION In our urban health care system, preconsultation exchange appears to be an appropriate form of specialty care for some ambulatory hepatology consultations. Communication between primary care provider and specialist appears to be an important barrier to broader implementation of preconsultation exchange. Optimizing the preconsultation exchange is critical to improve the primary-specialty care interface, and to build a true Patient-Centered Medical Home Neighborhood.
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Affiliation(s)
- Justin L Sewell
- Center for Innovation in Access and Quality, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA 94110, USA.
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Báez Montilla JM, Sánchez Oropesa A, Garcés Redondo G, González Carnero R, Santos Béjar L, López de Castro F. [Reasons and determining factors for referrals between primary and specialised care]. Semergen 2012; 39:89-94. [PMID: 23452534 DOI: 10.1016/j.semerg.2012.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 10/27/2011] [Accepted: 02/28/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine the reasons and characteristics of referrals from Primary to Specialised Care in the Health Area of Toledo (Spain). MATERIAL AND METHODS A descriptive, cross-sectional study was conducted by reviewing a sample of the referrals to specialists made by 26 general practitioners from eight Teaching Health Centres during February 2011. All of them completed a questionnaire which recorded patient data, and reason and characteristics of the referral. RESULTS A total of 332 referrals were recorded; the mean age of the patients was 51.3 years (SD; 17.9); 60.1% females; 30.7% pensioners; 54.8% had a chronic disease; 85.8% were from an urban environment. The most consulted specialists were: Traumatology (63), Gynaecology (53), and Ophthalmology (41). More than three-quarters (78.9%) were by the normal route, and 47.4% were first consultations. Around 12.7% were scheduled reviews, with a majority (51.4%) by a hospital specialist. More than two thirds (69.8%, 95% CI; 64.5-74.7%) required follow-up or treatment by the specialist. More than half (57.7%, 95% CI; 52.3-63.1%) required special diagnostic tests, and in 29.8% (95% CI; 25.0-35.1%) there was no clear diagnosis. There was a history of a repeated consultation for the same symptomatology in 28.9% of the referrals. Around 38.4% (95% CI; 33.0-43.7%) were requested specifically by the family or patient. Around 5.4% had a poor relationship with the patient. CONCLUSIONS The majority of referrals are made by the normal route, and to surgical specialities. The need for hospital specialist follow-up and/or treatment, or the impossibility to request specific tests from Primary Care were the main reasons for requesting care from a second health care level. There were a high percentage of referrals requested by the family/patient.
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Bronstein JM, Ounpraseuth S, Jonkman J, Fletcher D, Nugent RR, McGhee J, Lowery CL. Use of specialty OB consults during high-risk pregnancies in a Medicaid-covered population: initial impact of the Arkansas ANGELS intervention. Med Care Res Rev 2012; 69:699-720. [PMID: 22951314 DOI: 10.1177/1077558712458157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examines the impact of a Medicaid-supported intervention (Antenatal and Neonatal Guidelines, Education and Learning System) to expand a high-risk obstetrics consulting service on the use of specialty consults between 2001 and 2006. Using a Medicaid claims-birth certificate data set, we find a decline over time in use of specialty consults for lower risk diagnoses and a shift to remote modalities for contact. Local physician participation in grand rounds via teleconference was associated both with specialty contact and use of remote modalities. Local physician use of a Call Center service was also associated with patient specialty contact. Expansion of telemedicine remote sites did not increase the likelihood of contact but was associated with the shift toward remote modalities. Specialty consult use and modality were influenced by the care context of the patient, particularly level of pregnancy risk, the specialty of the primary prenatal care provider, the timing of her prenatal care, and her ethnicity and education level.
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Affiliation(s)
- Janet M Bronstein
- School of Public Health, University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL 35294, USA.
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Hirsch O, Träger S, Bösner S, Ilhan M, Becker A, Baum E, Donner-Banzhoff N. Referral from primary to secondary care in Germany: Developing a taxonomy based on cluster analysis. Scand J Public Health 2012; 40:571-8. [DOI: 10.1177/1403494812455113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims: Referrals from primary to secondary care may differ regarding motivation and initiative. Previous research on the frequency and variation of referrals has mostly treated referrals as homogeneous. We intended to develop a taxonomy regarding referrals from primary to secondary care in Germany that could support decision making on a macro level. Methods: We analyzed 3,988 referrals by 29 German general practitioners (GPs). GPs were asked to document all referrals during one week; in subsequent audits they stated the reasons and initiative for any referral. We postulated the following five referral types: clinical problem, shared care, administrative, patient initiated and shared cost. The data were analyzed with k-means cluster analysis. Results: We identified three of our five postulated referral types with cluster analytic techniques: shared care, clinical problem, and patient initiated. This solution accounted for 11.7% of total variance. The majority of referrals in German primary care practices were initiated by the GP, or they were part of a shared decision with patients. Conclusions: We suggest a taxonomy of referrals that might offer insights regarding the allocation of resources within the German health system. Referrals might be reduced by improved training of primary care physicians and by giving them more competencies in routine care of chronic patients.
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Affiliation(s)
- Oliver Hirsch
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Susanne Träger
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Muazzez Ilhan
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Annette Becker
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Erika Baum
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
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Abstract
BACKGROUND China has been engaged in the process of reforming its health care system recently. The government has attempted to rebuild the referral system to lower cost and enhance equity of the medical services. OBJECTIVE This study was undertaken to evaluate the current status of mutual referral pilot programme, perceived factors that affect referral behaviour and changes that would improve the current referral process in Beijing. METHODS Using a cross-sectional study design, we sent a postal questionnaire to 138 urban district community health service (CHS) centres in Beijing. Questions were chosen from a formal consensus process based on a nominal group technique. RESULTS One hundred twenty-five of 138 (90.6%) CHS centres responded to the survey. Seventy-six (61.8%) CHS centres reported that the mutual referral system was feasible. Twenty-six (21.1%) CHS centres reported that the mutual referral programme was running smoothly. Uncertainties of diagnosis/management and access to particular medical specialty interest or skills were the two most common factors that were suggested as affecting referral behaviour. The presence of a dedicated department to accept referrals in hospitals and the use of referral guidelines were the most preferred choices as likely to improve the current referral process. CONCLUSIONS Since a system of gatekeeper role by GPs at CHS organizations has not been established in Beijing, most CHS doctors agree that to ensure the smooth operation of referrals, a dedicated department should be assigned by hospitals to receive referred patients. Official guidelines on referral should be developed, and health authorities should strengthen their supervision of referrals.
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Affiliation(s)
- Juan Du
- Department of Family Medicine, School of Public Health and Family Medicine, Capital Medical University, Beijing, China
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Poulin Y, Wasel N, Chan D, Bernstein G, Andrew R, Fraquelli E, Papp K. Evaluating practice patterns for managing moderate to severe plaque psoriasis: role of the family physician. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2012; 58:e390-e400. [PMID: 22859642 PMCID: PMC3395546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe practice patterns for care of Canadian patients with moderate to severe plaque psoriasis. DESIGN Online survey of a consumer panel. SETTING Participants were drawn from a population-wide Canadian consumer database. PARTICIPANTS To be eligible to participate, respondents had to have been diagnosed with plaque psoriasis within the past 5 years, and to have had body surface area involvement of 3% or greater in the past 5 years, or to have psoriasis on a sensitive area of the body (hands, feet, scalp, face, or genitals), or to be currently receiving treatment with systemic agents or phototherapy for psoriasis. MAIN OUTCOME MEASURES Proportion of respondents with psoriasis managed by FPs and other specialists, psoriasis therapies, comorbidities, and patient satisfaction. RESULTS Invitations were sent to 3845 panelists with self-reported psoriasis, of which 514 qualified to complete the survey. Family physicians were reported to be the primary providers for diagnosis and ongoing care of psoriasis in all provinces except Quebec. Overall physician care was reported to be satisfactory by 62% of respondents. Most respondents receiving over-the-counter therapies (55%) or prescribed topical therapies (61%) reported that their psoriasis was managed by FPs. Respondents receiving prescription oral or injectable medications or phototherapy were mainly managed by dermatologists (42%, 74%, and 71% of respondents, respectively). Ongoing management of respondents with body surface area involvement of 10% or greater was mainly split between dermatologists (47%) and FPs (45%), compared with rheumatologists (4%) or other health care professionals (4%). Of those respondents receiving medications for concomitant health conditions, treatment for high blood pressure was most common (92%), followed by treatment for heart disease (75%) and elevated cholesterol and lipid levels (68%). CONCLUSION Patient-reported practice patterns for the diagnosis and management of moderate to severe psoriasis vary among provinces and in primary and secondary care settings.
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Affiliation(s)
- Yves Poulin
- Centre de Recherche Dermatologique du Québec métropolitain, 105-2880 chemin Quatre-Bourgeois, Quebec, QC, Canada.
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Factores asociados a la variabilidad en la utilización de recursos en la consulta de los médicos de atención primaria. Semergen 2011. [DOI: 10.1016/j.semerg.2011.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bronstein JM, Ounpraseuth S, Jonkman J, Lowery CL, Fletcher D, Nugent RR, Hall RW. Improving perinatal regionalization for preterm deliveries in a Medicaid covered population: initial impact of the Arkansas ANGELS intervention. Health Serv Res 2011; 46:1082-103. [PMID: 21413980 PMCID: PMC3165179 DOI: 10.1111/j.1475-6773.2011.01249.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001-2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice. DATA SOURCES A dataset of linked Medicaid claims and birth certificates for the time period by clustering Medicaid claims by pregnancy episode. Pregnancy episodes were linked to residential county-level demographic and medical resource characteristics. Deliveries occurring before 35 weeks gestation (n=5,150) were used for analysis. STUDY DESIGN Logistic regression analysis was used to examine time trends and individual, county, and intervention characteristics associated with delivery at hospitals with NICU, and delivery at the academic medical center. PRINCIPAL FINDINGS Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting. CONCLUSION Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.
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Affiliation(s)
- Janet M Bronstein
- University of Alabama at Birmingham University of Arkansas for Medical Sciences, Little Rock, AR, USA
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LOU BENJAMIN, DE CIVITA MIRELLA, EHRMANN FELDMAN DEBBIE, BISSONAUTH ASVINA, BERNATSKY SASHA. Care Partnerships Between Family Physicians and Rheumatologists. J Rheumatol 2011; 38:1981-5. [DOI: 10.3899/jrheum.101150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To describe care partnerships between family physicians and rheumatologists.Methods.A random sample (20%, n = 478) of family physicians was mailed a questionnaire, asking if there was at least 1 particular rheumatologist to whom the physician tended to refer patients. If the answer was affirmative, the physician would be considered as having a “care partnership” with that rheumatologist. The family physician then rated, on a 5-point scale, factors of importance regarding the relationship with that rheumatologist.Results.The questionnaire was completed by 84/462 (18.2%) of family physicians; 52/84 (61.9%) reported having rheumatology care partnerships according to our definition. Regarding interactions with rheumatologists, most respondents rated the following as important (score ≥ 4): adequate communication and information exchange (44/50, 88.0%); waiting time for new patients (40/50, 80.0%); clear and appropriate balance of responsibilities (39/49, 79.6%); and patient feedback and preferences (34/50, 68%). Male family physicians were more likely than females to accord high importance to personal knowledge of the rheumatologist, and to physical proximity of the rheumatologist’s practice. Regarding relationships with rheumatologists, 30/50 (60.0%) of respondents felt communication and information exchange were adequate, and 35/50 (70.0%) felt they had a clear balance of responsibilities.Conclusion.Almost two-thirds of family physicians have rheumatology care partnerships, according to our definition. In this partnership, establishing adequate communication and shorter waiting time seem of paramount importance to family physicians. A balanced sharing of responsibilities and patients’ preferences are also valued. Although many physicians reported adequate communication and clear and appropriate balance of responsibilities in their current interactions with rheumatologists, there appears to be room for improvement.
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Abstract
CONTEXT In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines. METHODS This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care. FINDINGS PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management). CONCLUSIONS There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.
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Affiliation(s)
- Ateev Mehrotra
- University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA 15213, USA.
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