Assessment of referrals to a multidisciplinary outpatient clinic for patients with back pain

Healthcare professionals' proposed eHealth needs in elective primary fast-track hip and knee arthroplasty journey: A qualitative interview study

AIMS AND OBJECTIVES

To examine the lived experience of healthcare professionals providing care for patients with total hip and knee arthroplasty and to understand healthcare professionals' proposed eHealth needs in elective primary fast-track hip and knee arthroplasty journey.

BACKGROUND

There is little evidence in nursing literature to indicate how to develop new eHealth services to support surgical care journeys. Evidence is particularly lacking regarding the development of eHealth solutions.

DESIGN

This was a qualitative interview study.

METHODS

Semi-structured interviews were conducted with four surgeons, two anaesthesiologists, ten nurses and four physiotherapists in a single joint replacement centre during autumn 2018. The data were analysed using an inductive content analysis method. NVivo qualitative data analysis software was used. The COREQ checklist for qualitative studies was followed.

RESULTS

Our research addressed the gap in evidence by focusing on the four main parts of the patient journey in the selected context. Analysis of the data revealed nine main categories for the proposed eHealth needs: eligibility criteria, referrals, meeting the Health Care Guarantee, patient flow, postdischarge care, patient counselling, communication, transparency of the journey and receiving feedback. In addition, the requirements and further development needs for eHealth solutions were generally identified.

CONCLUSIONS

From the point of view of healthcare professionals, eHealth solutions have huge potential in supporting the elective primary fast-track hip and knee arthroplasty journey. However, it is important to acknowledge that these needs may be very different depending on the technological and organisational environment in question.

RELEVANCE TO CLINICAL PRACTICE

More effective use of information and communication technologies is needed for organisational optimisation resulting in a streamlined pathway, better access to healthcare services, improved outcomes and an improved patient experience. These results can be used in the development of new eHealth solutions to support surgical care journeys and patient education.

Electronic checklists improve referral letters in gastroenterology: a randomized vignette survey

Objective

Investigate whether gastroenterologists rate the quality of referral letters higher if electronic dynamic checklist items are added to a standard free-text referral letter. Assess how this affects the gastroenterologists’ assessment of the patient’s need for healthcare and the agreement between their assessments.

Design

Randomized vignette study.

Setting

Norwegian primary gastroenterology services.

Participants

Thirty-two Norwegian gastroenterologists.

Intervention

Between June 2015 and January 2016, participants were recruited through an open invitation to all members of the Norwegian Society of Gastroenterology. They were asked to rate 16 referral letters (vignettes) in a web interface: eight letters in free text following a general template and eight letters based on a general referral template combined with diagnosis-specific checklist items. The study was completed in two subsequent rounds ≥3 months apart.

Main Outcome Measures

Quality of referral letters assessed on a rating scale from 0 to 10. Agreement in the referral assessment and accuracy of the selection of correct preliminary diagnosis and appropriate work-up.

Results

The mean quality assesses on the rating scale was 7.0 (95% confidence interval [CI] 6.8–7.2) for all letters combined (n = 511), 6.5(CI 6.2–6.8) for the free-text referrals (n = 256) and 7.5(CI 7.3–7.7) for the checklist referrals (n = 255) (P < 0.001, paired t-test). No difference was observed in the triage of the patients, but fewer gastroenterologists felt the need to collect additional information about the patients in the checklist group.

Conclusion

Checklist items may ease the assessment of the referrals for gastroenterologists. We were not able to show that checklists significantly influence the management of patients.

Assessment of the effect of an Interactive Dynamic Referral Interface (IDRI) on the quality of referral letters from general practitioners to gastroenterologists: a randomised cross-over vignette trial

OBJECTIVES

We evaluated whether interactive, electronic, dynamic, diagnose-specific checklists improve the quality of referral letters in gastroenterology and assessed the general practitioners' (GPs') acceptance of the checklists.

DESIGN

Randomised cross-over vignette trial.

SETTING

Primary care in Norway.

PARTICIPANTS

25 GPs.

INTERVENTION

The GPs participated in the trial and were asked to refer eight clinical vignettes in an internet-based electronic health record simulator. A referral support, consisting of dynamic diagnose-specific checklists, was created for the generation of referral letters to gastroenterologists. The GPs were randomised to refer the eight vignettes with or without the checklists. After a minimum of 3 months, they repeated the referral process with the alternative method.

MAIN OUTCOME MEASURES

Difference in quality of the referral letters between referrals with and without checklists, measured with an objective Thirty Point Score (TPS).Difference in variance in the quality of the referral letters and GPs' acceptance of the electronic dynamic user interface.

RESULTS

The mean TPS was 15.2 (95% CI 13.2 to 16.3) and 22.0 (95% CI 20.6 to 22.8) comparing referrals without and with checklist assistance (p<0.001), respectively. The coefficient of variance was 23.3% for the checklist group and 39.6% for the non-checklist group. Two-thirds (16/24) of the GPs thought they had included more relevant information in the referrals with checklists, and considered implementing this type of checklists in their clinical practices, if available.

CONCLUSIONS

Dynamic, diagnose-specific checklists improved the quality of referral letters significantly and reduced the variance of the TPS, indicating a more uniform quality when checklists were used. The GPs were generally positive to the checklists.

First quality score for referral letters in gastroenterology-a validation study

OBJECTIVE

To create and validate an objective and reliable score to assess referral quality in gastroenterology.

DESIGN

An observational multicentre study.

SETTING AND PARTICIPANTS

25 gastroenterologists participated in selecting variables for a Thirty Point Score (TPS) for quality assessment of referrals to gastroenterology specialist healthcare for 9 common indications. From May to September 2014, 7 hospitals from the South-Eastern Norway Regional Health Authority participated in collecting and scoring 327 referrals to a gastroenterologist.

MAIN OUTCOME MEASURE

Correlation between the TPS and a visual analogue scale (VAS) for referral quality.

RESULTS

The 327 referrals had an average TPS of 13.2 (range 1-25) and an average VAS of 4.7 (range 0.2-9.5). The reliability of the score was excellent, with an intra-rater intraclass correlation coefficient (ICC) of 0.87 and inter-rater ICC of 0.91. The overall correlation between the TPS and the VAS was moderate (r=0.42), and ranged from fair to substantial for the various indications. Mean agreement was good (ICC=0.47, 95% CI (0.34 to 0.57)), ranging from poor to good.

CONCLUSIONS

The TPS is reliable, objective and shows good agreement with the subjective VAS. The score may be a useful tool for assessing referral quality in gastroenterology, particularly important when evaluating the effect of interventions to improve referral quality.

Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study

STUDY DESIGN

Observational multicenter study.

OBJECTIVE

To evaluate if the severity of lumbar spinal stenosis (LSS) on magnetic resonance imaging (MRI) correlates with preoperative disability, pain, or surgical outcomes.

SUMMARY OF BACKGROUND DATA

Surgeons use the morphological appearance of LSS on MRI for clinical decision making. However, the associations between radiological severity of LSS and disability, pain, or surgical outcomes remain unclear.

METHODS

Evaluation of severity of LSS on preoperative MRI according to the Schizas morphological classification. Patient and treatment data were retrieved from the Norwegian Registry for Spine Surgery. Preopertaive outcome measures were Oswestry disability index (ODI) and numeric rating scale (NRS) scores for back and leg pain. Postopertive outcome measures were ODI and NRS scores for back and leg pain at 1 year, changes in ODI and NRS scores after treatment, duration of surgery, length of hospital stay, and perioperative complications.

RESULTS

Of 202 patients included, 7 were found to have mild stenosis, 38 had moderate stenosis, 108 had severe stenosis, and 49 had extreme stenosis. The radiological severity of LSS was not linked to preoperative ODI (P = 0.089), NRS back pain (P = 0.273), or NRS leg pain (P = 0.282) scores. There were no differences in ODI (P = 0.933), NRS back pain (P = 0.652), or NRS leg pain (P = 0.912) scores after 1 year. The radiological severity of stenosis was not associated with change in ODI (P = 0.494), NRS back pain (P = 0.235), NRS leg pain (P = 0.790), duration of surgery (P = 0.661), length of hospital stay (P = 0.739), or perioperative complication rates (P = 0.467).

CONCLUSION

Among patients who underwent decompressive surgery for LSS, radiological severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery. In this patient group, the radiological severity of LSS has no clear clinical correlation and should therefore not be overemphasized in clinical decision making.

LEVEL OF EVIDENCE

2.