Primary Care Clinician Adherence to Specialist Advice in Electronic Consultation

Urinary Incontinence Care in the Academic and Safety-Net Primary Care Settings: Opportunities to Improve Quality of Care

OBJECTIVE

To compare the quality of urinary incontinence care for women in the safety-net and non-safety-net settings prior to referral to a specialist.

METHODS

We performed a retrospective review of 200 women from two non-safety-net hospitals and 188 women from two safety-net hospitals who were referred to Urogynecology and Reconstructive Surgery specialists for bothersome UI between March 2017 and March 2020. We evaluated the care that women received 12-months prior to referral, by measuring adherence to a set of previously developed quality indicators (QIs), for example the performance of a urinalysis or pelvic exam.

RESULTS

Women seen in safety-net hospitals were more likely to receive QI-compliant care than women in the non-safety-net hospitals prior to referral, with 55.53% of appropriate care given in the safety-net vs. 40.3% in the non-safety-net setting (p<0.01). Clinicians in the safety-net hospitals were more likely to adhere to QIs in patients with general, stress, and urgency incontinence.

CONCLUSIONS

Women were more likely to receive timely, quality-based UI care in the safety net compared to the non-safety-net setting. This may be in part due to aspects unique to the safety-net system, including an eConsult referral system, which guides referring clinicians in appropriate management steps that should be taken prior to the specialist visit, as well as women's health focused primary care clinics.

Family Physician-to-Hospital Specialist Electronic Consultation and Access to Hospital Care: A Systematic Review

Importance

Globally, health care systems face challenges in managing health care costs while maintaining access to hospital care, quality of care, and a good work balance for caregivers. Electronic consultations (e-consultations)-defined as asynchronous, consultative communication between family physicians and hospital specialists-may offer advantages to face these challenges.

Objective

To provide a quantitative synthesis of the association of e-consultation with access to hospital care and the avoidance of hospital referrals.

Evidence Review

A systematic search through PubMed, MEDLINE, and Embase was conducted. Eligible studies included original research studies published from January 2010 to March 2023 in English, Dutch, or German that reported on outcomes associated with access to hospital care and the avoidance of hospital referrals. Reference lists of included articles were searched for additional studies. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) scores were assigned to assess quality of evidence.

Findings

The search strategy resulted in 583 records, of which 72 studies were eligible for data extraction after applying exclusion criteria. Most studies were observational, focused on multispecialty services, and were performed in either Canada or the US. Outcomes on access to hospital care and the avoidance of referrals indicated that e-consultation was associated with improved access to hospital care and an increase in avoided referrals to the hospital specialist, although outcomes greatly differed across studies. GRADE scores were low or very low across studies.

Conclusions and Relevance

In this systematic review of the association of e-consultation with access to hospital care and the avoidance of hospital referrals, results indicated that the use of e-consultation has greatly increased over the years. Although e-consultation was associated with improved access to hospital care and avoidance of hospital referrals, it was hard to draw a conclusion about these outcomes due to heterogeneity and lack of high-quality evidence (eg, from randomized clinical trials). Nevertheless, these results suggest that e-consultation seems to be a promising digital health care implementation, but more rigorous studies are needed; nonrandomized trial designs should be used, and appropriate outcomes should be chosen in future research on this topic.

Formalizing the curbside: digitally enhancing access to specialty care

Asynchronous medical care has increased in utilization, patient interest, and industry demand. While E-consults have been discussed extensively in the literature, there are rare examples of a multispecialty implementation within a large health system. Here, we describe our experience in implementing an internal E-consult program for asynchronous, nonurgent communication between ambulatory specialists and primary care providers in our large multispecialty regional health system. To ensure adoption of the program, patient, specialist, and primary care physician concerns were systematically addressed. The program commenced in February 2022 with three high referral rate specialties: cardiology, orthopedics, and dermatology. In the 12 months after implementation, 2243 total E-consults were ordered among 505 ordering providers. Dermatology received the most consultations, and we have expanded to 19 specialties and subspecialties available in the program in the first year. Our E-consult implementation experienced substantial growth in a short time period, demonstrating the viability of E-consult utilization for increasing asynchronous access to ambulatory specialists' expertise in a large healthcare system.

Knowing What We Do Not Know: Analysis of an Online Consultation Service to Identify Provider Knowledge Gaps in Sexually Transmitted Disease Care

The national Sexually Transmitted Diseases (STD) Clinical Consultation Network receives requests regarding complex STD cases. A total of 927 requests from Western states, 2017 to 2019, were analyzed for STD of inquiry and syphilis-specific subtopics. Syphilis requests accounted for most queries, and the number and proportion of syphilis-related requests increased significantly over time.

Improving Equity of Access Through Electronic Consultation: A Case Study of an eConsult Service

Background: Patients with complex circumstances pertaining to geography, socioeconomic status, or functional health often face inequities in accessing care. Electronic consultation (eConsult) is a secure online application that allows primary care providers (PCPs) and specialists to communicate regarding a patient's care. eConsult has demonstrated an ability to improve access to specialist care, and may be of particular use in cases of inequitable access. Methods: We examined how eConsult is used to improve equity of access for patients in complex circumstances by conducting a multiple case study of eConsults from seven patient groups: addiction, frail elderly, homeless, long-term care, rural, special needs, and transgender. Cases from these groups were selected from all eConsult cases completed between January 1 and December 31, 2017 using a data collection strategy tailored to each group. An access framework by Levesque et al. was applied to the data to examine five dimensions of access, arranged in chronological order, that reflect the process of a patient seeking care: approachability, acceptability; availability, affordability, and appropriateness. Two reviewers analyzed the cases using an iterative approach, regularly presenting findings to the research team for discussion and interpretation. Results: Eight hundred and twenty-five cases emerged across the seven target groups. The selected cases highlighted a number of key factors, including the value of the patient-PCP relationship, the importance of considering patient perspectives when providing care, and efforts to accommodate patients facing particular challenges to accessing care. Examples emerged among all five dimensions of the Levesque et al. access framework, with the final dimension, appropriateness, emerging across all cases. Conclusions: By leveraging the eConsult platform, PCPs can help improve equitable access to specialist care. More research is needed to understand why patients with complex circumstances face a longer wait time compared to the general population, and the impact that eConsults can have in improving health outcomes and wait times for this population.