Primary care physician referral patterns in Ontario, Canada: a descriptive analysis of self-reported referral data

Showcasing the Saudi e-referral system experience: the epidemiology and pattern of referrals utilising nationwide secondary data

Introduction

Referrals are an integral part of any healthcare system. In the Kingdom of Saudi Arabia (KSA) an electronic referral (e-referral) system known as the Saudi Medical Appointments and Referrals Centre (SMARC) began formally functioning in 2019. This study aims to showcase the Saudi experience of the e-referral system and explore the epidemiology of referrals nationally.

Methods

This retrospective descriptive study utilised secondary collected data between 2020 and 2021 from the SMARC system. Cross tabulations with significance testing and colour-coded maps were used to highlight the patterns across all regions.

Results

The study analysed over 600,000 referral requests. The mean age of patients was 40.70 ± 24.66 years. Males had a higher number of referrals (55.43%). Referrals in 2021 were higher than those in 2020 (56.21%). Both the Autumn and Winter seasons had the highest number of referrals (27.09% and 27.43%, respectively). The Surgical specialty followed by Medicine had the highest referrals (26.07% and 22.27%, respectively). Life-saving referrals in the Central region were more than double those in other regions (14.56%). Emergency referrals were also highest in the Southern regions (44.06%). The Central and Eastern regions had higher referrals due to unavailable sub-speciality (68.86% and 67.93%, respectively). The Southern regions had higher referrals due to both unavailable machine and unavailable beds (18.44% and 6.24%, respectively).

Conclusion

This study shows a unique system in which referrals are between secondary, tertiary, and specialised care. It also highlights areas of improvement for equitable resource allocation and specialised care in slightly problematic areas as well as the use of population density in future planning.

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.

Where does residents' choice of primary medical treatment come from?-A logical analysis based on the perspective of service accessibility and residents' cognition

The uneven distribution of medical and health resources leads to changes in the choice of patients for medical treatment, which is the key to restrict the reform of medical services in China currently. Taking service accessibility and residents' cognition as the starting point, this study utilized the data from the questionnaire and applied logistic regression and mediation test. By taking service accessibility as an explanatory variable and residents' cognition as an intermediary variable, the study examined the differences between residents' choice of medical treatment at the primary and non-primary levels. Thus, the influencing factors of residents' choice of medical treatment at the primary level were explored. The research statistics came from questionnaires of 1,589 residents in Nanjing, Jiangsu Province, China. The results showed that service accessibility and residents' cognition were significantly correlated with the residents' choice of primary medical treatment. Household registration, age, the signing situation with family doctors, hospital service fees, and distance to the hospital were positively related to residents' choice of primary medical treatment; while the reputation, scale, residents' income, and the reimbursement ratio of residents' medical insurance were negatively correlated with the choice. In addition, residents' cognition played an intermediary effect between service accessibility and the residents' choice of primary medical treatment. The signing situation with family doctors indirectly affected the choice of primary medical treatment through residents' cognition, and residents' cognition masked some negative influence of the reimbursement ratio of residents' medical insurance on the choice of primary medical treatment.

Specialist wait time reporting using family physicians' electronic medical record data: a mixed method study of feasibility and clinical utility

BACKGROUND

More than 50% of Canadian adult patients wait longer than four weeks to see a specialist after referral from primary care. Access to accurate wait time information may help primary care physicians choose the timeliest specialist to address a patient's specific needs. We conducted a mixed-methods study to assess if primary to specialist care wait times can be extracted from electronic medical records (EMR), analyzed the wait time information, and used focus groups and interviews to assess the potential clinical utility of the wait time information.

METHODS

Two family practices were recruited to examine primary care physician to specialist wait times between January 2016 and December 2017, using EMR data. The primary outcome was the median wait time from physician referral to specialist appointment for each specialty service. Secondary outcomes included the physician and patient characteristics associated with wait times as well as qualitative analyses of physician interviews about the resulting wait time reports.

RESULTS

Wait time data can be extracted from the primary care EMR and converted to a report format for family physicians and specialists to review. After data cleaning, there were 7141 referrals included from 4967 unique patients. The 5 most common specialties referred to were Dermatology, Gastroenterology, Ear Nose and Throat, Obstetrics and Gynecology and Urology. Half of the patients were seen by a specialist within 42 days, 75% seen within 80 days and all patients within 760 days. There were significant differences in wait times by specialty, for younger patients, and those with urgently labelled medical situations. Overall, wait time reports were perceived by clinicians to be important since they could help family physicians decide how to triage referrals and might lead to system improvements.

CONCLUSIONS

Wait time information from primary to specialist care can aid in decision-making around specialist referrals, identify bottlenecks, and help with system planning. This mixed method study is a starting point to review the importance of providing wait time data for both family physicians, specialists and local health systems. Future work can be directed towards developing wait time reporting functionality and evaluating if wait time information will help increase system efficiency and/or improve provider and patient satisfaction.

Today's referral is tomorrow's repeat patient: referrals to and between medical outpatient clinics in a hospital

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.

Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030

Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.

Referências médicas evitáveis em unidade de saúde de Porto Alegre

Introdução: A análise das referências médicas de pacientes da Atenção Primária à Saúde (APS) para especialidades focais traz questões relevantes para a formulação e administração de políticas do sistema de saúde. A detecção de encaminhamentos potencialmente evitáveis pode permitir um aprimoramento dos processos de trabalho, assim como otimizar a alocação de recursos. Objetivo: Descrever as referências secundárias geradas por médicos de uma Unidade de APS vinculada ao Grupo Hospitalar Conceição (GHC), no ano de 2017, e construir critérios para classificá-las, discutindo sua evitabilidade. Métodos: Estudo descritivo-exploratório, baseado em documentação. Os dados foram obtidos no sistema GERCON® (Sistema de Gerenciamento de Consultas da Secretaria Municipal de Saúde de Porto Alegre/RS). Os encaminhamentos foram classificados conforme seu motivo e também conforme sua evitabilidade. Resultados: Foram gerados 799 encaminhamentos, a 110 especialidades médicas no período. Após a exclusão das especialidades de dermatologia e de pré-natal de alto risco (por mudança nos critérios e fluxos de encaminhamento, durante 2017), restaram 733 referenciamentos. Destes, 582 foram categorizados pelas pesquisadoras como não evitáveis e 151 como evitáveis. Os motivos de encaminhamentos predominantes foram: terapêuticas não disponíveis na APS (34%), recursos diagnósticos não disponíveis em APS (26,5%) e dúvida diagnóstica ou terapêutica (23,2%). Em relação à evitabilidade, foram identificados 20,6% de referenciamentos evitáveis, predominando aqueles que envolviam carência de conhecimentos/habilidades/ atitude do médico. Quanto aos encaminhamentos categorizados como não evitáveis (79,4%), predominaram aqueles efetivados por necessidade de conhecimentos/habilidades/procedimentos não próprios à APS. Conclusão: A construção de um conceito para referências evitáveis, a partir de estudos empíricos, pode enriquecer a gestão de serviços de APS, tendo em vista sua resolutividade. O presente estudo encontrou, nessa Unidade de APS, um baixo percentual de encaminhamentos potencialmente evitáveis.

Effectiveness of the use of an algorithm in the diagnostic approach of joint pain patients by primary care physicians

There is a high percentage of error in the approach of patients with joint pain by primary care physicians. An algorithm can help improve this misdiagnosis problem. Our study seeks to determine the effectiveness of an algorithm when used by primary care physicians for the diagnosis of cases of joint pain patients. A randomized clinical experiment was carried out. Primary care physicians from five cities in Colombia developed a series of clinical cases, which were presented to them through a website on their personal cell phones. Half of the doctors developed the cases using the diagnostic algorithm, and the other half developed the cases without the use of the algorithm. Main measures were proportion of correct diagnosis, number, type of laboratory and diagnostic images requested for the diagnostic approach of clinical cases. Two hundred and twenty-four primary care physicians participated. The overall proportion of cases correctly diagnosed was 37.3% higher in the intervention group; we found a greater difference in cases of spondyloarthritis (60.8%), followed by systemic lupus erythematosus with joint involvement (32.2%), rheumatoid arthritis (30.3%) and osteoarthritis (25.9%). The average number of tests requested to develop clinical cases was lower in the intervention group than in the control group, both globally and for each of the four diseases, with statistically significant differences for each of the comparisons. The diagnostic algorithm proved to be an effective tool when used by primary care physicians; the proportion of correct diagnoses increased, and the number of tests requested in the development of the cases decreased.

How Often, Where, and by Which Specialty Do Long-Term Care Home Residents Receive Specialist Physician Care? A Retrospective Cohort Study

This retrospective cohort study describes the rates, location, and determinants of specialist physician visits among 257,216 long-term care (LTC) residents across 648 LTC homes in Ontario, Canada, between 2007 and 2016. Visit rates in the last year of life were calculated for a sub-cohort of residents who died in LTC between 2013 and 2016. Visits were measured per resident-year using physician billings. Over 10 years, the rate of visits to specialists outside the LTC home was consistently higher than within LTC (2.99 vs. 1.55 visits/resident-year). Residents were less likely to receive specialist care if they were older, had dementia, or lived in urban LTC homes. From 12 months before death to the last week of life, rates of specialist visits increased by 246% and 56% inside and outside of LTC, respectively. Improving access to physician specialist care in LTC homes may reduce burdensome transitions and improve resident quality of life.

The Willingness for Downward Referral and Its Influencing Factors: A Cross-Sectional Study among Older Adults in Shandong, China

Objectives: The aim of this study was to understand the willingness for downward referral among older adults who were hospitalized in the year before the survey and to explore its influencing factors. Methods: The sample was randomly selected by the multi-stage sampling method. A structural questionnaire was used to collect data from participants age 60 and above in Shandong, China, during August 2017. Data were analyzed by using descriptive statistics, one-way ANOVA, chi-square test, and multinomial logistic regression. Results: Of 1198 participants who were hospitalized in the year before the survey, 28.7% self-initiated downward referral, and 33.9% were willing to accept downward referral after a doctor’s advice. Multinomial logistic regression results showed that self-rated health, treatment effect in primary medical institutions, preference for outpatient service, choice of inpatient service, general understanding of essential medicines, the cost of essential medicines after zero-markup policy, and satisfaction with essential medicines’ reimbursement policy significantly correlated with older adults’ willingness for downward referral. Conclusions: The proportion of older adults who self-initiated downward referral was less than one-third. Doctors’ advice plays an important role in willingness for downward referral. More attention should be paid to improving the treatment effect of primary medical institutions, increasing the benefits of zero-markup policy, and ensuring a high reimbursement for the downward referral to work alongside doctors’ advice.

Encounters with Rheumatologists in a Publicly Funded Canadian Healthcare System: A Population-based Study

OBJECTIVE

To quantify population-level and practice-level encounters with rheumatologists over time.

METHODS

We conducted a population-based study from 2000 to 2015 in Ontario, Canada, where all residents are covered by a single-payer healthcare system. Annual total number of unique patients seen by rheumatologists, the number of new patients seen, and total number of encounters with rheumatologists were identified.

RESULTS

From 2000 to 2015, the percentage of the population seen by rheumatologists was constant over time (2.7%). During this time, Ontario had a stable supply of rheumatologists (0.8 full-time equivalents/75,000). From 2000 to 2015, the number of annual rheumatology encounters increased from 561,452 to 786,061, but the adjusted encounter rates remained stable over time (at 62 encounters per 1000 population). New patient assessment rates declined over time from 10 new outpatient assessments per 1000 in 2000 to 6 per 1000 in 2015. The crude volume of new patients seen annually decreased and an increasing proportion of rheumatology encounters were with established patients. We observed a shift in patient case mix over time, with more assessments for systemic inflammatory conditions. Rheumatologists' practice volumes, practice sizes, and the annual number of days providing clinical care decreased over time.

CONCLUSION

Over a 15-year period, the annual percentage of the population seen by a rheumatologist remained constant and the volume of new patients decreased, while followup patient encounters increased. Patient encounters per rheumatologist decreased over time. Our findings provide novel information for rheumatology workforce planning. Factors affecting clinical activity warrant further research.

Quality and continuity of information between primary care physicians and rheumatologists

Background

Good communication is central to a high-quality consultation process. We assessed the quality of referral information from primary care physicians (PCPs) to rheumatologists and the quality and timeliness of consultation letters from rheumatologists back to PCPs.

Methods

We sampled referral letters between 2000 and 2013 from 168 PCPs and performed a retrospective chart review of 2430 patients referred to 146 rheumatologists. We assessed the completeness and timeliness of referral and consultation letters.

Results

Osteoarthritis (n = 787, 32%) and systemic inflammatory rheumatic diseases (n = 745, 31%) comprised the top reasons for referral. Only 55% of referral letters summarized the patients’ medical history. Referral letters provided some details of diagnostic tests (51% labs, 34% imaging) but there was underreporting of this information on referral letters. Almost all referral letters (92%) contained details of at least one patient symptom, with the most common complaint being joint pain (54%). Only half of all referral letters provided symptom duration. The PCP only stressed an urgent consultation among 211 patients (9%). Overall, 69% of consultation letters were returned to PCPs within 30 days of consultation visit.

Conclusion

We found that basic items necessary for appropriate triage, including a description of symptoms or other relevant history and results of investigations were often lacking in referral letters. The delay of receipt of consultation letters may further represent a lost opportunity for coordination and continuity of care, and may affect the quality of care patients receive.