Evaluating the primary-to-specialist referral system for elective hip and knee arthroplasty

Identification of the factors affecting the referral system of veterans' health services: A scoping review

Referral in the health system is a systematic process for the optimal allocation of resources and improves the access of people in need of treatment services. Considering the vulnerability of the veterans and more medical needs in this group, this study aims to identify the components that affect veterans' health services referral system. MEDLINE, Scopus, Web of Science, and ProQuest databases, the international military studies website, and key journals in the field of veterans' health services were searched with related keywords including "veteran," "referral system," and "health services" for the period from January 2000 to July 2022. Studies were screened and selected in accordance with the phases of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) flow diagram 2020. Data extraction was done by two researchers independently and a thematic content analysis method was used to analyze the findings. Among 40,608 studies searched electronically and 16 studies searched manually, 19 studies that met the inclusion criteria were selected. The research method applied here is a combination of quantitative, qualitative, and mixed methods. The most important findings were extracted from the included studies and analyzed in three general categories: components related to the patient, service provider, and the structural-operational mechanisms of the referral system. The effective performance of the referral system for providing health services to veterans is influenced by the factors affecting components related to the patient, the service provider, and the structural-operational mechanisms of the referral system. Evaluating and improving each of these factors improve the performance of the referral system and provision of health services to veterans.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

BACKGROUND

The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.

METHODS

A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.

RESULTS

A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.

CONCLUSIONS

Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.

A single-entry model and wait time for hip and knee replacement in eastern health region of Newfoundland and Labrador 2011-2019

BACKGROUND

A single-entry model in healthcare consolidates waiting lists through a central intake and allows patients to see the next available health care provider based on the prioritization. This study aimed to examine whether and to what extent the prioritization reduced wait times for hip and knee replacement surgeries.

METHOD

The survival regression method was used to estimate the effects of priority levels on wait times for consultation and surgery for hip and knee replacements. The sample data included patients who were referred to the Orthopedic Central Intake clinic at the Eastern Health region of Newfoundland and Labrador and had surgery of hip and knee replacements between 2011 and 2019.

RESULT

After adjusting for covariates, the hazard of having consultation booked was greater in patients with priority 1 and 2 than those in priority 3 when and at 90 days after the referral was made for both hip and knee replacements. Regarding wait time for surgery after the decision for surgery was made, while the hazard of having surgery was lower in priority 2 than in priority 3 when and indifferent at 182 days after the decision was made, it was not significantly different between priority 1 and priority 3 among hip replacement patients. Priority levels were not significantly related to the hazard of having surgery for a knee replacement after the decision for surgery was made. Overall, the hazard of having surgery after the referral was made by a primary care physician was greater for patients in high priority than those in low priority. Preferring a specific surgeon indicated at referral was found to delay consultation and it was not significantly related to the total wait time for surgery. Incomplete referral forms prolonged wait time for consultation and patients under age 65 had a longer total wait time than those aged 65 or above.

CONCLUSION

Patients with high priority could have a consultation booked earlier than those with low priority and prioritization in a single entrance model shortens the total wait time for surgery. However, the association between priority levels and wait for surgery after the decision for surgery was made has not well-established.

Common patterns in the public reporting of waiting time and waiting list information: Findings from a sample of OECD jurisdictions

We present findings from a review of published literature and administrative documentation on waiting time and waiting list reporting models for elective treatment in a sample of international jurisdictions (a subset of OECD countries, with regional reporting regimes treated as distinct jurisdictions). In this paper we identified common patterns in the measurement and reporting of waiting time and waiting list information for elective treatment. We mapped the waiting time, waiting list, and key performance indicator statistics reported by 15 English-speaking international jurisdictions. Three distinct patterns of maximum waiting time target measures for elective treatment were identified amongst our international sample following our patient pathway event time-point analysis: (i) full-pathway maximum wait time targets; (ii) separate wait time targets for "time-to-diagnosis" and "time-to-treatment"; and (iii) "Time-to-Treatment" waiting time target only. Our review also revealed common patterns in the reporting of waiting time and waiting list statistics as well as KPI measures amongst a sub-sample of English-speaking jurisdictions. These common patterns provide a starting point towards more standardised measurement and reporting of waiting time and waiting list statistics in benchmarking access to elective care internationally.

Factors affecting the successful implementation of the referral system: A scoping review

An effective referral system ensures that there is a close relationship among all levels of health care, and individuals can receive the best possible care. The main purpose of the present study was to summarize studies that have addressed factors affecting the successful implementation of the referral system. A scoping review was performed to identify English and Farsi papers that were indexed in PubMed, Scopus, Science Direct, Trip Database, Cochrane Library, Embase, Google Scholar, SID, and Magiran until November 2020. Data was collected from the included studies by a reviewer and was checked by a second reviewer the collected data was analyzed using narrative methods. About 1245 relevant studies were identified in the first stage. After checking titles and abstracts, 63 studies were included. The factors that affected the referral system were classified in 4 themes and fourteen subthemes including technology (electronic referral, coordination, response and feedback), processes (effectiveness, efficiency), organizational (management, policy and planning, rules and regulations), patient centered individual (insurance coverage, social capital, transportation, awareness, attitude, satisfaction, and social influence). Therefore, a wide range of factors are affecting the performance of referral systems. For implementing an effective referral system, it is necessary to consider these factors.

The impact of integrating electronic referral within a musculoskeletal model of care on wait time to receive orthopedic care in Ontario

An MSK model of care for hip and knee patients integrated with an electronic referral solution (eReferral) has been deployed within four subregions across Ontario. Referrals are sent from primary care offices to a central intake (CI), where the referral forms are reviewed and forwarded, if appropriate, to a rapid access clinic (RAC) where patients are assessed by an advanced practice clinician (APC). The pragmatic design of eReferral allows for a seamless flow of electronic orthopedic referrals from primary care to CI. It also enables CI to process and transcribe faxed referrals into the eReferral system for a smooth flow of data electronically to the RACs. In general, wait time is the time interval between receiving the patient's referral at CI or the surgeon's office until receiving the orthopedic surgeon's first consultation. Wait time is further broken down into wait 1 a and wait 1 b. Wait 1 a is the time between the receipt of the referral at CI until the date of the first initial assessment at the RAC. This study aimed at: a) assessing the processing time of orthopedic referrals at central intakes (CI) to be forwarded to the RAC, b) assessing the wait time (wait 1 a) of orthopedic referrals processed through the eReferral system to receive an initial assessment at the RACs. c) comparing the ability of the RACs to meet the target wait time for assessment (four weeks) by the method of referral (eReferrals vs. fax). d) evaluating patients' satisfaction with the length of time they waited to receive care at the RACs with eReferral. We used Ocean eReferral database to access MSK hip and knee referral data processed through the system. Patients whose referrals were initiated electronically through the system and opted to receive email notification of their referral status had the opportunity to take an online satisfaction survey embedded in the booked appointment notification message. There were 1,723 patients initially referred electronically for hip, and knee pain consults, while 13,780 referrals started as paper-based and transcribed into the system to be forwarded later electronically by CI to a RAC. Higher mean processing time at CI by 21.76 days for paper-based referral was detected as opposed to referrals received electronically (p<0.001). RACs took significantly less time to book appointments for referrals initiated electronically with a shorter average wait 1a of 21.42 days for eReferrals compared to paper-based referrals (p<0.001). RACs timeframe to book an appointment was significantly shorter for eReferrals versus fax referrals. A total of 393 patients completed the patient satisfaction survey with a response rate of 16%. Overall, 87.7% were satisfied with their experience with the eReferral process, and 81% agreed that they had waited a reasonable time to receive the needed care. eReferral can elicit faster processing of referrals and shorter wait time for patients, which improved patient satisfaction with the referral process.

A novel methodology to measure waiting times for community-based specialist care in a public healthcare system

BACKGROUND

Monitoring waiting time (WT) in healthcare systems is essential, since long WT are associated with adverse health outcomes, reduced patient satisfaction and increased private financing.

OBJECTIVE

To describe a methodology developed for routine national monitoring of WT for community-based non-urgent specialist appointments, in a public healthcare system.

METHODS

The methodology is based on data from computerized appointment scheduling systems of all Health Maintenance Organizations (HMOs) in Israel. Data included first 50 available appointments for community-based specialists and actual number of visits. Five most frequent specialties: orthopedics, ophthalmology, gynecology, dermatology and otolaryngology, were included. WT offered to HMO members for non-urgent care was calculated for two scenarios: "specific" physician and "any" physician in the region. Distribution of offered WT was calculated separately for each specialty and geographical region, combined to create the nationwide distribution.

RESULTS

The methodology was tested on data extracted between December 2018-June 2019. Estimated national median WT for "specific" physician, ranged from 9 days (ophthalmology/gynecology) to 20 days (dermatology), with large variation between geographic regions. WT were 26-56 % shorter for "any" than for "specific" physician.

CONCLUSIONS

This novel method offers a solution for ongoing national WT measurement, using computerized scheduling systems. It integrates two scenarios for appointment scheduling and allows identification of differences between specialties and regions, setting the ground for interventions to strengthen public healthcare systems.

Analysis of the referral pattern and wait time for hip arthroscopy in a single payer publicly funded health care system

RATIONALE AND OBJECTIVES

To analyse the referral pattern for hip pain and to investigate the wait time for an orthopaedic assessment by a hip arthroscopy surgeon in a single payer health care system. We hypothesized that a significant delay from time of onset of symptoms to time of assessment by a hip arthroscopy surgeon exists.

METHOD

Retrospective review of prospectively collected data in an academic hospital in a single payer health care system. An electronic database analysis was conducted searching for all referrals for hip pain between February 2017 and June 2017. Data were then analysed with the aim to identify the most common reason for hip referral, calculate the duration of symptoms between onset and orthopaedic assessment, and categorize previous investigations and treatments.

RESULTS

A total of 96 patients were included (47 male and 49 female). Main source of referrals was Family Medicine Physicians in 37% of cases and Primary Care Sports Medicine Physicians in 35%. The most common reason for referral was labral tear in 44.7% of cases followed by combined femoroacetabular impingement and labral tear in 21.8%. The duration of symptoms was longer than 2 years in 42% of cases and between 1 and 2 years in 40% of cases. Twenty percent of patients had previous intra-articular injection while 53% of patients had physiotherapy treatment (64% of patient underwent physiotherapy for longer than 6 months).

CONCLUSION

In the Canadian single payer health care system, a significant delay from the time of onset of symptoms to the time of assessment by a hip arthroscopy surgeon exists with the vast majority of patients in our cohort waiting more than 1 year. It is unknown if this delay affects the patient outcomes. This will require further investigation. Certainly, based on our findings, we should advocate for a better screening process, centralized referrals to hip arthroscopy specialists, and appropriate patient work-up.

Clinical pathway efficiency for elective joint replacement surgeries: a case study

PURPOSE

The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation.

DESIGN/METHODOLOGY/APPROACH

This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory.

FINDINGS

There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps.

RESEARCH LIMITATIONS/IMPLICATIONS

The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged.

PRACTICAL IMPLICATIONS

Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations.

SOCIAL IMPLICATIONS

Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients' needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other.

ORIGINALITY/VALUE

Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.

Can the Oxford Knee and Hip Score identify patients who do not require total knee or hip arthroplasty?

Aims

The aim of this study was to determine if the Oxford Knee and Hip Score (OKHS) can accurately predict when a primary knee or hip referral is deemed nonsurgical versus surgical by the surgeon during their first consultation, and to identify nonsurgical OKHS screening thresholds.

Patients and Methods

We retrospectively reviewed pre-consultation OKHS for all consecutive primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) consultations of a single surgeon over three years. The 1436 knees (1016 patients) and 478 hips (388 patients) included were categorized based on the surgeon’s decision into those offered surgery during the first consultation versus those not (nonsurgical). Spearman’s rank correlation coefficients and receiver operating characteristic (ROC) curve analysis were performed.

Results

Oxford Scores were better for the nonsurgical cohorts (p < 0.001) and correlated with the surgical decision (p < 0.001). ROC area under the curve values for knees (0.83, 95% confidence intervals (CI) 0.81 to 0.85) and hips (0.87, 95% CI 0.84 to 0.91) were excellent. A conservative and effective threshold for knees is Oxford Knee Score (OKS) > 32 points (sensitivity = 0.997, negative predictive value (NPV) = 0.992) and for hips is Oxford Hip Score (OHS) > 34 points (sensitivity = 0.997, NPV = 0.978). Severable potential lower OKHS thresholds were identified.

Conclusion

Pre-consultation OKHS demonstrate good ability to predict when a primary TKA or THA referral will be deemed nonsurgical in a single surgeon’s practice. Multiple OKHS thresholds can effectively screen out nonsurgical referrals. Cite this article: Bone Joint J 2019;101-B(6 Supple B):23–30.

A categorisation of problems and solutions to improve patient referrals from primary to specialty care

BACKGROUND

Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated.

METHODS

We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes.

RESULTS

We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies.

CONCLUSION

The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.

Health referral system user acceptance model in Indonesia

Objectives

This study aims to identify a user acceptance model for the health referral system in Indonesia. The following factors classified into dimensions of organization, technology, process, and individual, were examined: patient centricity, regulation, data security, integration, responsiveness, effectiveness, efficiency, personal beliefs, and social influence.

Methods

Quantitative data processing methods were used, including the online distribution of questionnaires to a total of 283 valid respondents who had previously used health referrals. Data processing was performed according to the ordinal logistic regression method using IBM SPSS Statistics 24.0 software.

Results

The user acceptance model fit with a significance of 0.084, while only regulation, data security, integration, responsiveness, effectiveness, efficiency, personal beliefs, and social influence significantly influenced the patients' acceptance of health referrals.

Conclusions

This study may build awareness in the community regarding the health referral system along with the ideal factors that encourage patients to utilize health referrals. In addition, the provision of health services by health facilities and regulators may take these factors into account so they may provide fair and equitable services for all the people of Indonesia; for example, providers and regulators can improve the utilization of information technology and guidebooks on the health referral system to facilitate communication and standardization among health facilities.

Measuring intention to refer: Older adults and social service agencies

The public is encouraged to engage in socially responsible behaviors such as helping people get needed services, possibly by referring them. However, referral behavior is little researched. Informed by the theory of planned behavior, intent to refer older adults in need to the Connecticut's Gatekeeper Program (GP) which identifies elders at risk and connects them with community resources was studied and the Social Service Agency Referral Scale (SSARS) was developed. Senior center attendees, seniors who received GP training, and referrers to the state's GP were involved. SSARS and its subscales were internally consistent (Cronbach's α = .90, with α ≥ .733 for each subscale). SSARS was strongly correlated with a validated social responsibility scale (r = .48). Knowledge gained from the training enhanced the associated intention subscale. With little modification, SSARS could be used to elucidate similar efforts. Additionally, the process used to create SSARS could be replicated to develop related instruments.

Factors influencing orthopedic nurses’ pain management: A focused ethnography

Aim: The aim of this study was to explore the factors influencing orthopedic surgery nurses’ decisions to administer pro re nata (PRN) opioid analgesia for postoperative pain.

Background: Fast-track surgery programs reduce length of stay by identifying and addressing factors causing patients to remain in hospital, including pain (H. Kehlet, Lancet. 2013;381:9878(9878)). The management of acute pain is an important component of quality care for patients after total knee arthroplasty.

Methods: The study used a qualitative design of focused ethnography. Ten nurses working on an orthopedic surgery unit at a large urban hospital in western Canada participated in semistructured interviews that used a patient vignette to examine factors that influenced participants’ pain management in the context of fast-track surgery. Interviews were transcribed and analyzed using thematic analysis and constant comparison.

Findings: Nurses described a complex clinical environment where the interplay of several factors informed decisions to administer PRN opioid analgesia. The unit’s culture and physical space influenced nurses’ assessments of pain and their decisions whether to treat pain with PRN opioids. Each nurse’s self-concept affected pain management decisions because of perceived importance of pain control and perceived duty to provide analgesics. The subjectivity of pain added another layer of complexity as nurses responded to the patient’s expression of pain from within the milieu of the unit culture and their unique self-concept.

Conclusion: Understanding the complexity of factors that influence nurses’ postoperative pain management provides clinical nurses and nursing leaders with directions for future education and research, guided by the goal of continued improvement in pain management in the challenging setting of fast-track surgeries.

Development of key performance indicators to evaluate centralized intake for patients with osteoarthritis and rheumatoid arthritis

Introduction

Centralized intake is integral to healthcare systems to support timely access to appropriate health services. The aim of this study was to develop key performance indicators (KPIs) to evaluate centralized intake systems for patients with osteoarthritis (OA) and rheumatoid arthritis (RA).

Methods

Phase 1 involved stakeholder meetings including healthcare providers, managers, researchers and patients to obtain input on candidate KPIs, aligned along six quality dimensions: appropriateness, accessibility, acceptability, efficiency, effectiveness, and safety. Phase 2 involved literature reviews to ensure KPIs were based on best practices and harmonized with existing measures. Phase 3 involved a three-round, online modified Delphi panel to finalize the KPIs. The panel consisted of two rounds of rating and a round of online and in-person discussions. KPIs rated as valid and important (≥7 on a 9-point Likert scale) were included in the final set.

Results

Twenty-five KPIs identified and substantiated during Phases 1 and 2 were submitted to 27 panellists including healthcare providers, managers, researchers, and patients in Phase 3. After the in-person meeting, three KPIs were removed and six were suggested. The final set includes 9 OA KPIs, 10 RA KPIs and 9 relating to centralized intake processes for both conditions. All 28 KPIs were rated as valid and important.

Conclusions

Arthritis stakeholders have proposed 28 KPIs that should be used in quality improvement efforts when evaluating centralized intake for OA and RA. The KPIs measure five of the six dimensions of quality and are relevant to patients, practitioners and health systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0843-7) contains supplementary material, which is available to authorized users.

Surgical assessment: measuring unobserved health

Background

The federal and provincial governments in Canada have invested an enormous amount of resources to measure, report and reduce surgical wait times. Yet these measures under-report the wait period that patients’ actually experience, because they do not capture the length of time a patient spends waiting to see the surgeon for a surgical assessment. This unmeasured time is referred to as the “wait one” (W1). Little is known about W1 and the effects that this has on patients’ health. Similarly, it is not understood whether patients waiting for surgical assessment actually want or need surgery. Existing administrative and clinical dataset do not capture information on health and decision-making while the patient is waiting for care form a specialist. The objective of this proposed study is to understand the impact that W1 for elective surgeries has on the health of patients and to determine whether this time can be reduced.

Methods/Design

A prospective survey design will be used to measure the health of patients waiting for surgical assessment. Working with the support of the surgical specialities in Vancouver Coastal Health, we will survey patients immediately after being referred for surgical assessment, and every four months thereafter, until they are seen by the surgeon.

Validated survey instruments will be used, including: generic and condition-specific health status questionnaires, pain and depression assessments. Other factors that will be measured include: patients’ knowledge about their condition, and their desired autonomy in the decision making process. We have piloted data collection in one surgical specialty in order to demonstrate feasibility.

Discussion

The results from this study will be used to quantify changes in patients’ health while they wait for surgical assessment. Based on this, policy- and decision-makers could design care interventions during W1, aimed at mitigating any negative health consequences associated with waiting. The results from this study will also be used to better understand whether there are factors that predict patients’ desire to proceed to surgery. These could be used to guide future research into experimenting with interventions to minimize inappropriate referrals and where they are best targeted.