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Haye S. Effect of patient death on referrals to cardiac specialists. HEALTH ECONOMICS 2024; 33:1857-1868. [PMID: 38762893 DOI: 10.1002/hec.4840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
In this paper, I examine how patient death affects referrals from referring physicians to cardiac surgeons. I use Medicare data to identify pairs of referring physicians and cardiac surgeons who experience a patient death after a major surgical procedure to examine how these events affect referrals. I construct counterfactuals for affected pairs using pairs that experience a patient death but five quarters in the future. I find that there is a significant decline in the number of referrals and probability of a referral from the referring physician to the cardiac surgeon after the patient's death.
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Affiliation(s)
- Sidra Haye
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
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2
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Luebke MC, Neuner JM, Balza J, Davidson ERW, Hokanson JA, Marowski S, Corey O'Connor R, Schmitt E, Winn AN, Flynn KE. Developing a urinary incontinence primary care pathway: a mixed methods study. Fam Pract 2024:cmae035. [PMID: 39026426 DOI: 10.1093/fampra/cmae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND While nearly 50% of adult women report at least one episode of urinary incontinence (UI), most never receive treatment. OBJECTIVE To better integrate primary and specialty UI care, we conducted (i) an environmental scan to assess the availability of key pathway resources in primary care, (ii) interviews with primary care providers to understand barriers to care, and (iii) a pilot UI care pathway intervention. METHODS Environmental scan: Clinic managers from all primary care clinics within a Midwestern healthcare system were invited to participate in an interview covering the availability of clinic resources. Provider interviews: Primary care providers were invited to participate in an interview covering current practices and perceived barriers to UI care. Pilot UI care pathway: Patients who screened positive for UI were provided resources for first-line behavioral management. Pilot patients completed questionnaires at baseline, 8 weeks, and 6 months. RESULTS While many clinics had point-of-care urinalysis (17/21, 81%), most did not have a working bladder ultrasound (14/21, 67%) or on-site pelvic floor physical therapy (18/21, 86%). Providers (n = 5) described barriers to completing almost every step of diagnosis and treatment for UI. The most persistent barrier was lack of time. Patients (n = 15) reported several self-treatment strategies including avoiding bladder irritants (7/15, 47%) and performing Kegel exercises (4/15, 27%). Five patients (33%) requested follow-up care. At 6 months, patients reported small improvements in UI symptoms. CONCLUSION Promising results from a novel UI care pathway pilot indicate that streamlining UI care may assist primary care providers in the first-line treatment of UI.
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Affiliation(s)
- Marie C Luebke
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joan M Neuner
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joanna Balza
- Medical College of Wisconsin, Milwaukee, WI, United States
| | | | | | - Sarah Marowski
- Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Emily Schmitt
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, WI, United States
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Batool S, Hansen EE, Sethi RKV, Rettig EM, Goguen LA, Annino DJ, Uppaluri R, Edwards HA, Faden DL, Schnipper JL, Dohan D, Reich AJ, Bergmark RW. Perspectives on Referral Pathways for Timely Head and Neck Cancer Care. JAMA Otolaryngol Head Neck Surg 2024; 150:545-554. [PMID: 38753343 PMCID: PMC11099838 DOI: 10.1001/jamaoto.2024.0917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/22/2024] [Indexed: 05/19/2024]
Abstract
Importance Timely diagnosis and treatment are of paramount importance for patients with head and neck cancer (HNC) because delays are associated with reduced survival rates and increased recurrence risk. Prompt referral to HNC specialists is crucial for the timeliness of care, yet the factors that affect the referral and triage pathway remain relatively unexplored. Therefore, to identify barriers and facilitators of timely care, it is important to understand the complex journey that patients undertake from the onset of HNC symptoms to referral for diagnosis and treatment. Objective To investigate the referral and triage process for patients with HNC and identify barriers to and facilitators of care from the perspectives of patients and health care workers. Design, Participants, and Setting This was a qualitative study using semistructured interviews of patients with HNC and health care workers who care for them. Participants were recruited from June 2022 to July 2023 from HNC clinics at 2 tertiary care academic medical centers in Boston, Massachusetts. Data were analyzed from July 2022 to December 2023. Main Outcomes and Measures Themes identified from the perspectives of both patients and health care workers on factors that hinder or facilitate the HNC referral and triage process. Results In total, 72 participants were interviewed including 42 patients with HNC (median [range] age, 60.5 [19.0-81.0] years; 27 [64%] females) and 30 health care workers (median [range] age, 38.5 [20.0-68.0] years; 23 [77%] females). Using thematic analysis, 4 major themes were identified: the HNC referral and triage pathway is fragmented; primary and dental care are critical for timely referrals; efficient interclinician coordination expedites care; and consistent patient-practitioner engagement alleviates patient fear. Conclusions and Relevance These findings describe the complex HNC referral and triage pathway, emphasizing the critical role of initial symptom recognition, primary and dental care, patient information flow, and interclinician and patient-practitioner communication, all of which facilitate prompt HNC referrals.
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Affiliation(s)
- Sana Batool
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Elisabeth E. Hansen
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, Boston
| | - Rosh K. V. Sethi
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Eleni M. Rettig
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Laura A. Goguen
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donald J. Annino
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ravindra Uppaluri
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Heather A. Edwards
- Department of Otolaryngology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Daniel L. Faden
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, Boston
- Department of Otolaryngology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Hospital Medicine Unit and Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Daniel Dohan
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Amanda J. Reich
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Regan W. Bergmark
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Aminpour N, Phan V, Wang H, McDermott J, Valentin M, Mishra A, DeLia D, Noel M, Al-Refaie W. Clinician-to-clinician connectedness and access to gastric cancer surgery at National Cancer Institute-designated cancer centers. J Gastrointest Surg 2024:S1091-255X(24)00480-3. [PMID: 38910084 DOI: 10.1016/j.gassur.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND For patients with gastric cancer, the pathway from primary care (PC) clinician to gastroenterologist to cancer specialist (medical oncologist or surgeons) is referral dependent. The impact of clinician connectedness on disparities in quality gastric cancer care, such as at National Cancer Institute-designated cancer centers (NCI-CC), remains underexplored. This study evaluated how clinician connectedness influences access to gastrectomy at NCI-CC. METHODS Maryland's All-Payer Claims Database was used to evaluate 667 patients who underwent gastrectomy for cancer from 2013 to 2018. Two separate referral linkages, defined as ≥9 shared patients, were examined: (1) PC clinicians to gastroenterologists at NCI-CC and (2) gastroenterologists to cancer specialists at NCI-CC. Multiple logistic regression models determined associations between referral linkages and odds of undergoing gastrectomy at NCI-CC. RESULTS Only 15% of gastrectomies were performed at NCI-CC. Patients of gastroenterologists with referral links to cancer specialists at NCI-CC were more likely to be <65 years, male, White, and privately insured. Every additional referral link between PC clinician and gastroenterologist at NCI-CC and between gastroenterologist and cancer specialist at NCI-CC increased the odds of gastrectomy at NCI-CC by 71% and 26%, respectively. Black patients had half the odds as White patients in receiving gastrectomy at NCI-CC; however, adjusting for covariates including clinician-to-clinician connectedness attenuated this observation. CONCLUSION Patients of clinicians with low connectedness and Black patients are less likely to receive gastrectomy at NCI-CC. Enhancing clinician connectedness is necessary to address disparities in cancer care. These results are relevant to policy makers, clinicians, and patient advocates striving for health equity.
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Affiliation(s)
- Nathan Aminpour
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
| | - Vy Phan
- Georgetown University School of Medicine, Washington, DC, United States
| | - Haijun Wang
- MedStar Health Research Institute, Hyattsville, MD, United States
| | - James McDermott
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Michelle Valentin
- Georgetown University School of Medicine, Washington, DC, United States
| | - Ankit Mishra
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Derek DeLia
- Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ, United States
| | - Marcus Noel
- Department of Medicine, MedStar-Georgetown University Hospital, Washington, DC, United States
| | - Waddah Al-Refaie
- Department of Surgery, Creighton University School of Medicine and CHI Health, Omaha, NE, United States.
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Thomas J, Kuliukas L, Frayne J, Bradfield Z. Factors influencing referral to maternity models of care in Australian general practice. PLoS One 2024; 19:e0296537. [PMID: 38771817 PMCID: PMC11108194 DOI: 10.1371/journal.pone.0296537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/02/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND In the Australian maternity system, general practitioners play a vital role in advising and directing prospective parents to maternity models of care. Optimising model of care discussions and the decision-making process avoids misaligning women with over or under specialised care, reduces the potential for disruptive care transitions and unnecessary healthcare costs, and is critical in ensuring consumer satisfaction. Current literature overwhelmingly focusses on women's decision-making around model of care discussions and neglects the gatekeeping role of the General Practitioner (GP). This study aimed to explore and describe the factors influencing Australian GPs decision-making when referring pregnant women to maternity models of care. METHODS This study used a qualitative descriptive approach. General practitioners (N = 12) with experience referring women to maternity models of care in Australia participated in a semi-structured interview. Interviews occurred between October and November 2021 by telephone or videoconference. Reflexive thematic analysis was facilitated by NVivo-12 data management software to codify and interpret themes from the data. FINDINGS Two broad themes were interpreted from the data. The first theme entitled 'GP Factors', incorporated three associated sub-themes including '1) GPs Previous Model of Care Experience', '2) Gaps in GP Knowledge' and '3) GP Perception of Models of Care'. The second theme, entitled 'Woman's Factors', encapsulated two associated sub-themes including the '4) Woman's Preferences' and '5) Access to Models'. CONCLUSIONS This study provides novel evidence regarding general practitioner perspectives of the factors influencing model of care decision-making and referral. Predominant findings suggest that gaps in GP knowledge regarding the available models of care are present and are largely informed by prior personal and professional experience. Most GPs described referring to models of care they perceive positively and centring their model of care discussions on the woman's preferences and accessibility. The exploration and description of factors influencing model of care decisions provide unique insight into the ways that all stakeholders can experience access to a broader range of models of care including midwifery-led continuity of care models aligned with consumer-demand. In addition, the role of national primary health networks is outlined as a means to achieving this.
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Affiliation(s)
- Jaime Thomas
- School of Nursing, Curtin University, Bentley, Western Australia, Australia
| | - Lesley Kuliukas
- School of Nursing, Curtin University, Bentley, Western Australia, Australia
| | - Jacqueline Frayne
- Medical School, University of Western Australia, Albany, Western Australia, Australia
| | - Zoe Bradfield
- School of Nursing, Curtin University, Bentley, Western Australia, Australia
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Fabrizio GM, Cardillo C, Egol A, Rozell JC, Schwarzkopf R, Aggarwal VK. Factors influencing patient selection of orthopaedic surgeons for total hip (THA) and total knee arthroplasty (TKA). Arch Orthop Trauma Surg 2024; 144:2057-2066. [PMID: 38641682 DOI: 10.1007/s00402-024-05314-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/30/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION The importance of identifying how patients choose their healthcare providers has grown with the prevalence of consumer-centric health insurance plans. There is currently a lack of studies exploring the factors associated with how patients select their hip and knee joint arthroplasty surgeons. The purpose of this study was to determine how patients find their arthroplasty providers and the relative importance of various arthroplasty surgeon characteristics. METHODS An electronic mail survey was sent to 3522 patients who had visited our institution for an arthroplasty surgeon office visit between August 2022 and January 2023. The survey consisted of multiple-choice questions, which aimed to inquire about the patients' referral sources for their current arthroplasty surgeon. In addition, patients were requested to rate the significance of 22 surgeon-related factors, on a scale of 1 (Not Important At All) to 5 (Very Important), in choosing their arthroplasty surgeon. RESULTS Of the 3522 patients that received the survey, 538 patients responded (15.3%). The most common referral sources were physician referral (50.2%), family/friend referral (27.7%), and self-guided research (24.5%). Of those that were referred by a physician, 54.4% of respondents were referred by another orthopaedic provider. Patients rated board certification (4.72 ± 0.65), in-network insurance status (4.66 ± 0.71), fellowship training (4.50 ± 0.81), bedside manner/personality (4.32 ± 0.86), and facility appearance (4.26 ± 0.81) as the five most important factors in picking an arthroplasty surgeon. Television (1.42 ± 0.83), print (1.50 ± 0.88), and online (1.58 ± 0.93) advertisements, along with social media presence (1.83 ± 1.08), and practice group size (2.97 ± 1.13) were rated as the five least important factors. CONCLUSION Patients are most likely to select an arthroplasty surgeon based on referral from other physicians, namely orthopedic surgeons, in addition to board certification status, in-network insurance, and fellowship training. Overall, these findings highlight the importance of physician credentials and reputation within the orthopaedic community in order to attract and retain patients.
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Affiliation(s)
- Grant M Fabrizio
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street, New York, NY, 10003, USA
| | - Casey Cardillo
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street, New York, NY, 10003, USA
| | - Alexander Egol
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street, New York, NY, 10003, USA
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street, New York, NY, 10003, USA.
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Aljerian N, Alharbi A. Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia. Cureus 2024; 16:e53511. [PMID: 38314384 PMCID: PMC10838169 DOI: 10.7759/cureus.53511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.
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Affiliation(s)
- Nawfal Aljerian
- Emergency Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Emergency Medicine, Medical Referrals Centre, Ministry of Health, Riyadh, SAU
| | - Abdullah Alharbi
- Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
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Zander DB, Mähner PM, Reinhard T, Tscheulin DK, Wacker K. Needs and Satisfaction Analysis of Patients and Referring Physicians in an Outpatient Cataract Service. Klin Monbl Augenheilkd 2023. [PMID: 37541660 DOI: 10.1055/a-2148-9290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
BACKGROUND To ensure efficient use of resources within outpatient services, constant patient flow is vital. This can be achieved by addressing the wishes and needs of all relevant stakeholders. MATERIALS AND METHODS The present study aims to show how the needs and present satisfaction of patients and referring physicians can be determined in the context of an outpatient cataract service. It presents the conclusions that can be drawn for the design of the service. To assess needs and satisfaction, we developed a patient questionnaire and a referring physician questionnaire. Promoters and detractors for referral were identified following the concept of the net promoter score, a market research instrument. RESULTS 339 (38%) patients and 26 (45%) referring physicians of the main referring group answered the questionnaires. The most important characteristics for referring physicians were quality of treatment, patient satisfaction, and communication in case of queries as well as speed of sending the doctor's letter. When making their decision on a cataract centre, the patients prioritised professional reputation, previous experience with the clinic, and recommendation of their ophthalmologist as well as customary appointment scheduling. CONCLUSION The two groups influence each other's recommendation or choice. Simultaneous analysis of patients and referring physicians is therefore essential. Overall, patients and referring physicians are highly satisfied with the cataract service of the university medical centre. Beyond that, however, various potentials for improvement could be identified. In summary, this report describes a comprehensive approach to assess needs and satisfaction of patients and referring physicians in an outpatient clinic trying to sustainably improve patient care.
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Affiliation(s)
- Daniel Bernhard Zander
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
- Abteilung für Marketing und Gesundheitsmanagement, Universität Freiburg, Deutschland
| | - Philipp M Mähner
- Abteilung für Marketing und Gesundheitsmanagement, Universität Freiburg, Deutschland
| | - Thomas Reinhard
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
| | - Dieter K Tscheulin
- Abteilung für Marketing und Gesundheitsmanagement, Universität Freiburg, Deutschland
| | - Katrin Wacker
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Deutschland
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Laschke ADL, Blaakær J, Jensen CF, Larsen MB. Differences in the referral process from general practice to resident specialists in gynaecology depending on density of specialists and patients' socioeconomic status. Scand J Prim Health Care 2023:1-10. [PMID: 37837435 DOI: 10.1080/02813432.2023.2268663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 10/04/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND There are significant differences in the densities of resident specialists in gynaecology (RSGs) in various regions of Denmark. It is unclear whether this disparity affects gynaecological patients' experience of the referral process and whether it differs in terms of their socioeconomic status (SES). OBJECTIVE To examine gynaecological patients' experiences of the referral process to an RSG concerning RSG density and patients' SES. DESIGN Cross-sectional questionnaire and registry-based study. SETTING In Denmark, general practitioners (GPs) serve as gatekeepers of secondary care and are responsible for referrals to resident specialists as well as inpatient and outpatient hospital care. SUBJECTS A total of 2917 patients who consulted an RSG participated in this study. MAIN OUTCOME MEASUREMENTS Patients' experiences of referral to an RSG, waiting times, involvement, and how they experienced the referral process. RESULTS Patients who lived in the highest density RSG region were referred to an RSG more promptly after the onset of symptoms, had to visit their GP less frequently to obtain a referral to the RSG, and rarely received a gynaecological examination by their GP compared with those living in regions with lower RSG densities. Moreover, their waiting times were shorter, and more often, the patients themselves proposed to be referred to an RSG. The findings show that RSG density had a greater impact on women's experiences than SES. CONCLUSION To allow equal access to specialist care, RSG density must be equal across all regions in the country.
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Affiliation(s)
- Alexander D L Laschke
- Speciallægeselskabet Alexander Laschke ApS, Aabenraa, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jan Blaakær
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Obstetrics and Gynaecology, Odense University Hospital, Odense C, Denmark
| | | | - Mette Bach Larsen
- Department of Public Health Programmes, Randers Regional Hospital, University Research Clinic for Cancer Screening, Randers, Denmark
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Zhao D, Chen S, Jin S, Chen L, Zheng C, Wang X, Huang Y. Predictors of referral behaviour and intention amongst physicians in a medical consortium based on the theory of planned behaviour: a cross-sectional study in China. Front Public Health 2023; 11:1159207. [PMID: 37655287 PMCID: PMC10466405 DOI: 10.3389/fpubh.2023.1159207] [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: 02/05/2023] [Accepted: 08/01/2023] [Indexed: 09/02/2023] Open
Abstract
Introduction To promote patients' referral across healthcare institutions and integrated care delivery, we identified predictors of physicians' behaviour and intention to refer patients in a county medical consortium in China on the basis of the theory of planned behaviour (TPB). Methods This census-based cross-sectional study was conducted in Yangxi Hospital Group (YHG). All physicians in county hospitals and township health centres were invited to participate. Structural equation modelling was employed to analyse the relationships between referral intention and behaviour and other TPB variables in the group of whole participants and in sub-groups. Results In total, 330 physicians participated in this study. One-third of participants were general practitioners, and half of them were from county hospitals. Referral behaviour of females (χ2 = 20.372, p < 0.001), who had lower education levels (χ2 = 17.859, p = 0.001), lower professional title (χ2 = 14.963, p = 0.005), and lower monthly salary (χ2 = 33.753, p < 0.001) were less frequent than the others. Among them, 116 (35.2%), 108 (32.7%), and 106 (32.1%) respondents reported that they had never referred patients, had referred patients 1-9 times, and had referred patients over 10 times during the past 3 months, respectively. The mean score of referral intention was 4.23/5 (SD = 0.71). In the model with all participants, a stronger referral intention (β = 0.218, 95% CI = 0.080-0.356) was associated with more frequent referral behaviour. The subjective norm (β = 0.703, 95% CI = 0.590-0.817) was the strongest predictor of physicians' referral intention, followed by perceived behavioural control (β = 0.234, 95% CI = 0.090-0.378). Mediated by referral intention, subjective norms (β = 0.153, p < 0.01) and perceived behavioural control (β = 0.190, p < 0.01) had significant indirect effects on physicians' referral behaviour. The model with participants in county hospitals showed similar results to the model with all participants. Meanwhile, in the model with participants in township health centres, there were no significant associations between referral behaviour and other TPB constructs. Conclusion Physicians' referral behaviour was influenced by intention, subjective norms, and perceived behavioural control in Chinese county hospitals.
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Bertha N, Visser T, Haines N. New Patient Referral Patterns May Reflect Gender Biases in Orthopedics. Cureus 2023; 15:e40935. [PMID: 37496543 PMCID: PMC10368298 DOI: 10.7759/cureus.40935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/28/2023] Open
Abstract
Background Orthopedic surgery traditionally has been a male-dominant specialty with the lowest percentage of female residents and female faculty of all medical specialties. Prior studies demonstrate gender biases from both referring providers and patients. This study investigates surgeon, referring provider, and patient demographic differences in new patient orthopedic referrals. Methodology A retrospective chart review was performed to analyze the demographics of new patients referred to male and female orthopedic surgeons within adult reconstruction and shoulder/elbow specialties at a single academic institution. Patients and referring provider demographics were compared for male and female orthopedic surgeons. Statistical analysis utilized Student's t-test and chi-square analyses for quantitative and qualitative data, respectively. Results In total, 2,642 new patients were analyzed, with 2,084 patients being referred from a provider, and 306 patients requesting specific providers. When compared to male surgeons, female surgeons had fewer referrals from male providers (45.3% vs. 50.3%, p = 0.03) and no difference from female providers (30.6% vs, 29.9%, p = 0.72). The female adult reconstruction surgeon had fewer internal referrals compared to a male surgeon of similar experience and time at the institution (8.4% vs. 12.8%, p = 0.03). Female patients requested male surgeons more frequently than female surgeons (76.7% vs. 23.3%, p = 0.02). Conclusions New patient demographics differed between male and female orthopedic surgeons at a single academic institution with more male referring providers referring to male surgeons. Female patients requesting male orthopedic providers may reflect patient and specialty-driven biases. There remains a need for additional female representation in orthopedic surgery, and new patient referral patterns may be a marker to assess and monitor gender biases.
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Affiliation(s)
- Nicholas Bertha
- Department of Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Timothy Visser
- Department of Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Nikkole Haines
- Department of Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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12
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Winkler K, Gerlach N, Donner-Banzhoff N, Berberich A, Jung-Henrich J, Schlößler K. Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds. BMC PRIMARY CARE 2023; 24:110. [PMID: 37131137 PMCID: PMC10152784 DOI: 10.1186/s12875-023-02064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/18/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Chest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs' referral decisions, and to investigate determinants which influenced those decisions. METHODS PCPs working in Hesse, Germany, were interviewed in a qualitative study. We used 'stimulated recall' with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer. RESULTS PCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited. CONCLUSIONS We could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.
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Affiliation(s)
- Katja Winkler
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Navina Gerlach
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Anika Berberich
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Jutta Jung-Henrich
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Kathrin Schlößler
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
- Institute of General Practice and Family Medicine (AM RUB), Ruhr University, Bochum, Germany
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13
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Chen L, McWilliams JM. Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession. JAMA Intern Med 2023; 183:350-359. [PMID: 36848122 PMCID: PMC9972239 DOI: 10.1001/jamainternmed.2023.0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/04/2023] [Indexed: 03/01/2023]
Abstract
Importance Physicians' knowledge about each other's quality is central to clinical decision-making, but such information is not well understood and is rarely harnessed to identify exemplars for disseminating best practices or quality improvement. One exception is chief medical resident selection, which is typically based on interpersonal, teaching, and clinical skills. Objective To compare care for patients of primary care physicians (PCPs) who were former chiefs with care for patients of nonchief PCPs. Design, Setting, and Participants Using 2010 to 2018 Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data (response rate, 47.6%), Medicare claims for random 20% samples of fee-for-service beneficiaries, and medical board data from 4 large US states, we compared care for patients of former chief PCPs with care for patients of nonchief PCPs in the same practice using linear regression. Data were analyzed from August 2020 to January 2023. Exposures Receiving the plurality of primary care office visits from a former chief PCP. Main Outcomes and Measures Composite of 12 patient experience items as primary outcome and 4 spending and utilization measures as secondary outcomes. Results The CAHPS samples included 4493 patients with former chief PCPs and 41 278 patients with nonchief PCPs. The 2 groups were similar in age (mean [SD], 73.1 [10.3] years vs 73.2 [10.3] years), sex (56.8% vs 56.8% female), race and ethnicity (1.2% vs 1.0% American Indian or Alaska Native, 1.3% vs 1.9% Asian or Pacific Islander, 4.8% vs. 5.6% Hispanic, 7.3% vs 6.6% non-Hispanic Black, and 81.5% vs. 80.0% non-Hispanic White), and other characteristics. The Medicare claims for random 20% samples included 289 728 patients with former chief PCPs and 2 954 120 patients with nonchief PCPs. Patients of former chief PCPs rated their care experiences significantly better than patients of nonchief PCPs (adjusted difference in composite, 1.6 percentage points; 95% CI, 0.4-2.8; effect size of 0.30 standard deviations (SD) of the physician-level distribution of performance; P = .01), including markedly higher ratings of physician-specific communication and interpersonal skills typically emphasized in chief selection. Differences were large for patients of racial and ethnic minority groups (1.16 SD), dual-eligible patients (0.81 SD), and those with less education (0.44 SD) but did not vary significantly across groups. Differences in spending and utilization were minimal overall. Conclusions and Relevance In this study, patients of PCPs who were former chief medical residents reported better care experiences than patients of other PCPs in the same practice, especially for physician-specific items. The study results suggest that the profession possesses information about physician quality, motivating the development and study of strategies for harnessing such information to select and repurpose exemplars for quality improvement.
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Affiliation(s)
- Lucy Chen
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - J. Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Associate Editor, JAMA Internal Medicine
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Jakobek BT, Stull JW, Munguia G, Evason M. Veterinarians' Self-Reported Needs and Attitudes on the Atlantic Canada Veterinary College and Associated Teaching Hospital in Relation to Continuing Education, Research, and Clinical Referrals. JOURNAL OF VETERINARY MEDICAL EDUCATION 2023; 50:243-250. [PMID: 35503909 DOI: 10.3138/jvme-2021-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The relationship between veterinary colleges (VCs), associated veterinary teaching hospital referral centers (VTHs), and referring veterinarians (rVets) is important and complex. Despite this, there has been minimal research on rVets with respect to their regional VC and VTH. Our objectives were to evaluate rVets' attitudes and self-reported needs on their regional VC's VTH surrounding (a) continuing education, (b) collaborative research, and (c) referrals for specialty consultation and care. Participants (rVets) were invited to complete an online questionnaire (2018-2019). Respondents (n = 56) indicated multiple (24) unmet continuing education topic needs, of which dermatology and behavior were most selected. Many rVets (70%) reported an interest in collaborative research participation. Communication was frequently selected by respondents when asked what could be improved with respect to the VTH referral center process. Our work provides a benchmark attitudes and needs assessment, identifies areas for improvement, and may aid initiatives regionally, and likely externally, as adapted to other rVet-VC-VTH relationships.
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Affiliation(s)
- Benjamin T Jakobek
- Department of Companion Animals, Atlantic Veterinary College, University of Prince Edward Island, 550 University Avenue, Charlottetown, PE C1A 4P3 Canada
| | - Jason W Stull
- Department of Health Management, Atlantic Veterinary College, University of Prince Edward Island, 550 University Avenue, Charlottetown, PE C1A 4P3 Canada
| | - George Munguia
- Veterinary Emergency Group, 3845 E Colfax Ave, Denver, CO 80206 USA
| | - Michelle Evason
- Department of Companion Animals, Atlantic Veterinary College, University of Prince Edward Island, 550 University Avenue, Charlottetown, PE C1A 4P3 Canada; and Consultant, Michelle Evason Veterinary Internal Medicine & Nutrition Consultations
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15
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Ammoury A, Ameen A, El Sayed MH, Al-Khenaizan S, Hassan N, Ghoubar M. Patterns of Clinical Management of Atopic Dermatitis: A Survey of Three Physician Specialties in the Middle East. Dermatol Ther (Heidelb) 2023; 13:769-785. [PMID: 36750545 PMCID: PMC9984640 DOI: 10.1007/s13555-023-00891-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/13/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION Atopic dermatitis (AD) is a complex inflammatory disease of the skin that has a significant impact on the well-being of patients and their families. The prevalence of AD has increased in developing countries and regions, including the Middle East. Despite similarities in the presentation of the disease, there is a lack of consistent management and treatment guidelines for AD. The objective of this survey was to develop further insight into the management patterns of AD from dermatologists, pediatricians, and primary care/family medicine physicians in the Middle Eastern nations of Egypt, Lebanon, the United Arab Emirates, and Saudi Arabia. METHODS The survey was composed of 47 closed-ended, multiple-choice questions. These questions assessed physician and patient characteristics and treatment familiarity and approach. RESULTS A total of 400 physicians, including 200 dermatologists, 100 pediatricians, and 100 primary care physicians, participated in the survey. The findings provide insight into the management of AD by physician specialty within the region. A diverse array of management approaches was observed for both referral patterns and treatments for AD in the Middle East. CONCLUSION The diversity of management tactics highlights the lack of a standard approach for the management of AD throughout the Middle East.
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Affiliation(s)
- Alfred Ammoury
- Division of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Ahmed Ameen
- NMC Specialty Hospital, Abu Dhabi, United Arab Emirates
| | - Mahira Hamdy El Sayed
- Department of Venereology and Andrology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sultan Al-Khenaizan
- Division of Dermatology, King Abdulaziz Medical City in Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Marcelle Ghoubar
- Medical Affairs, Pfizer Gulf FZ LLC, Central Building, 2nd Floor, Sin El Fil, Beirut, Lebanon.
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Naik A, Syvyk S, Tong J, Wirtalla C, Barg FK, Guerra CE, Mehta SJ, Wender R, Merchant RM, Kelz RR. Factors Associated With Primary Care Physician Decision-making When Making Medication Recommendations vs Surgical Referrals. JAMA Netw Open 2023; 6:e2256086. [PMID: 36790807 PMCID: PMC9932841 DOI: 10.1001/jamanetworkopen.2022.56086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
IMPORTANCE Although objective data are used routinely in prescription drug recommendations, it is unclear how referring physicians apply evidence when making surgeon or hospital recommendations for surgery. OBJECTIVE To compare the factors associated with the hospital or surgeon referral decision-making process with that used for prescription medication recommendations. DESIGN, SETTING, AND PARTICIPANTS This qualitative study comprised interviews conducted between April 26 and May 18, 2021, of a purposive sample of 21 primary care physicians from a large primary care network in the Northeast US. MAIN OUTCOMES AND MEASURES Main outcomes were the factors considered when making prescription medication recommendations vs referral recommendations to specific surgeons or hospitals for surgery. RESULTS All 21 participant primary care physicians (14 women [66.7%]) reported use of evidence-based decision support tools and patient attributes for prescription medication recommendations. In contrast, for surgeon and hospital referral recommendations, primary care physicians relied on professional experience and training, personal beliefs about surgical quality, and perceived convenience. Primary care physicians cited perceived limitations of existing data on surgical quality as a barrier to the use of such data in the process of making surgical referrals. CONCLUSIONS AND RELEVANCE As opposed to the widespread use of objective decision support tools for guidance on medication recommendations, primary care physicians relied on subjective factors when making referrals to specific surgeons and hospitals. The findings of this study highlight the potential to improve surgical outcomes by introducing accessible, reliable data as an imperative step in the surgical referral process.
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Affiliation(s)
- Anusha Naik
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jason Tong
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chris Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Frances K. Barg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Carmen E. Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shivan J. Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Richard Wender
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Raina M. Merchant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel R. Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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17
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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18
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Tanno S, Oka Y, Uetani T, Kikuchi A, Nishimura K, Kawasaki Y, Shimizu H, Fujino Y, Tanno Y. Referrals of pediatric patients to a sleep center during its first 5 years. Sleep Biol Rhythms 2022; 20:605-606. [PMID: 38468621 PMCID: PMC10900016 DOI: 10.1007/s41105-022-00409-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
Affiliation(s)
- Sakurako Tanno
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
| | - Yasunori Oka
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
| | - Teruyoshi Uetani
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
- Second Department of Internal Medicine, Ehime University Hospital, Toon, Japan
| | - Atsushi Kikuchi
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
- Kikuchi Clinic, Yawatahama, Japan
| | - Kazuhisa Nishimura
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
- Second Department of Internal Medicine, Ehime University Hospital, Toon, Japan
| | - Yuri Kawasaki
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
| | - Hiroshi Shimizu
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
| | - Yoko Fujino
- Center for Sleep Medicine, Ehime University Hospital, 454 Shitsukawa, Toon, 791-0295 Japan
| | - Yasuhiko Tanno
- Faculty of Collaborative Regional Innovation, Ehime University, Matsuyama, Japan
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Thorpe S, Iyiewuare P, Ware S, Malone N, Jester JK, Dogan JN, Hargons CN. "Why Would I Talk To Them About Sex?": Exploring Patient-Provider Communication Among Black Women Experiencing Sexual Pain. QUALITATIVE HEALTH RESEARCH 2022; 32:1527-1543. [PMID: 35758050 PMCID: PMC11214809 DOI: 10.1177/10497323221110091] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ineffective patient-provider communication poses a potential health risk to Black women if medical providers are not addressing their needs or concerns. Additionally, less than half of OBGYNs report asking their patients about sexual difficulties, which limits women's opportunities to disclose their experiences of sexual pain. The purpose of this qualitative study is to explore Black women's experiences of patient-provider communication about sexual pain (reoccurring unwanted genital pain). Specifically, we aimed to describe the pathway from sexual pain disclosure to treatment among N = 25 premenopausal Black women living in the southern United States who were experiencing sexual pain. Using constructivist grounded theory, open-ended responses to six interview questions related to healthcare experiences, treatment, and patient-provider communication were qualitatively analyzed and categorized to form a conceptual framework of patient-provider communication about sexual pain. Five key categories emerged related to Black women's experiences with their medical providers regarding sexual pain: (1) provider preferences, (2) healthcare experiences, (3) reasons for non-disclosure, (4) provider responses to sexual pain, and (5) treatment for sexual pain. Useful strategies to improve patient-provider communication are presented for both patients and providers.
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Affiliation(s)
- Shemeka Thorpe
- Department of Educational, School, and Counseling Psychology, University of Kentucky, Lexington, KY, USA
| | - Praise Iyiewuare
- Department of Psychological Science, The University of Vermont, Burlington, VT, USA
| | | | - Natalie Malone
- Department of Educational, School, and Counseling Psychology, University of Kentucky, Lexington, KY, USA
| | - Jasmine K. Jester
- Department of Educational, School, and Counseling Psychology, University of Kentucky, Lexington, KY, USA
| | - Jardin N. Dogan
- Department of Educational, School, and Counseling Psychology, University of Kentucky, Lexington, KY, USA
| | - Candice N. Hargons
- Department of Educational, School, and Counseling Psychology, University of Kentucky, Lexington, KY, USA
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20
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The Online Physician Image. Surg Clin North Am 2022; 102:233-239. [DOI: 10.1016/j.suc.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Novin A, Tavakoli A, Ferzandi T, Coehlo D, Muffly TM. Medicare Patient Referral Networks to Pelvic Floor Physical Therapy Across the United States. Female Pelvic Med Reconstr Surg 2022; 28:e93-e97. [PMID: 35272340 DOI: 10.1097/spv.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the distribution of referrals to pelvic floor physical therapy throughout the United States and to identify specialties with the highest and lowest referral rates. Referral networks to pelvic floor physical therapy were identified, and factors associated with referral connections were determined. METHODS This retrospective network analysis of referrals examined U.S. Centers for Medicare and Medicaid Services data from 2009 to 2017. Pelvic floor physical therapists were identified, and their patient-sharing networks were modeled using social network analytics. RESULTS There were 18,740 Medicare beneficiaries referred to pelvic floor physical therapists between 2009 and 2017. The mean number of referrals to each physical therapy provider or practice was 82 (SD ±46.3). Half of the referrals were made by a general acute care hospital. The remainder were referred by female pelvic medicine and reconstructive surgeons, nurse practitioners, colorectal surgeons, internal medicine, and obstetrician-gynecologists.The number of individual pelvic floor physical therapists, as well as the referrals, increased each year. The geographic representation of the patient referral networks is illustrated. The map reveals that pelvic floor physical therapists often work in groups and treat patients in their geographic vicinity. In this study, we demonstrate intensely fractured referral networks. CONCLUSION Our network analysis of pelvic floor physical therapy referrals in Medicare patients across the United States shows fractured networks with dense geographic connections in some areas, whereas sparse in others. Multidisciplinary approaches and early referrals to pelvic floor physical therapy are recommended as some ways to amend these fractured networks.
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Affiliation(s)
- Atieh Novin
- From the Department of Female Pelvic Medicine and Reconstructive Surgery, University of Southern California, Los Angeles, CA
| | - Amin Tavakoli
- From the Department of Female Pelvic Medicine and Reconstructive Surgery, University of Southern California, Los Angeles, CA
| | - Tanaz Ferzandi
- From the Department of Female Pelvic Medicine and Reconstructive Surgery, University of Southern California, Los Angeles, CA
| | - Diego Coehlo
- Department of Chemical Engineering, Federal University of Sergipe, Sao Cristovao, Brazil
| | - Tyler M Muffly
- Department of Female Pelvic Medicine and Reconstructive Surgery, University of Colorado, Denver, CO
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22
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Maini A, Sun J, Buniak B, Jantsch S, Czajak R, Frey T, Kumar BS, Chawla A. Heartburn Center Set-Up in a Community Setting: Engineering and Execution. Front Med (Lausanne) 2021; 8:662007. [PMID: 34858998 PMCID: PMC8631278 DOI: 10.3389/fmed.2021.662007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a "center of excellence" (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD. Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery. Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, <10% had GERD for <1 year, ~60% had GERD for 1-11 years, and ~30% had GERD for ≥12 years. More than one-quarter had atypical GERD symptoms (27.6%). Only 6.4% had been on PPIs for <1 year and >20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution. Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.
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Affiliation(s)
- Atul Maini
- The Heartburn Center at St. Joseph's Health, Liverpool, NY, United States
| | - John Sun
- The Heartburn Center at St. Joseph's Health, Liverpool, NY, United States
| | - Borys Buniak
- The Heartburn Center at St. Joseph's Health, Liverpool, NY, United States
| | - Stacey Jantsch
- The Heartburn Center at St. Joseph's Health, Liverpool, NY, United States
| | - Rachel Czajak
- The Heartburn Center at St. Joseph's Health, Liverpool, NY, United States
| | - Tara Frey
- The Heartburn Center at St. Joseph's Health, Liverpool, NY, United States
| | - B Siva Kumar
- The Heartburn Center at St. Joseph's Health, Liverpool, NY, United States
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Dossa F, Zeltzer D, Sutradhar R, Simpson AN, Baxter NN. Sex Differences in the Pattern of Patient Referrals to Male and Female Surgeons. JAMA Surg 2021; 157:95-103. [PMID: 34757424 DOI: 10.1001/jamasurg.2021.5784] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Studies have found that female surgeons have fewer opportunities to perform highly remunerated operations, a circumstance that contributes to the sex-based pay gap in surgery. Procedures performed by surgeons are, in part, determined by the referrals they receive. In the US and Canada, most practicing physicians who provide referrals are men. Whether there are sex-based differences in surgical referrals is unknown. Objective To examine whether physicians' referrals to surgeons are influenced by the sex of the referring physician and/or surgeon. Design, Setting, and Participants This cross-sectional, population-based study used administrative databases to identify outpatient referrals to surgeons in Ontario, Canada, from January 1, 1997, to December 31, 2016, with follow-up to December 31, 2018. Data analysis was performed from April 7, 2019, to May 14, 2021. Exposures Referring physician sex. Main Outcomes and Measures This study compared the proportion of referrals (overall and those referrals that led to surgery) made by male and female physicians to male and female surgeons to assess associations between surgeon, referring physician, or patient characteristics and referral decisions. Discrete choice modeling was used to examine the extent to which sex differences in referrals were associated with physicians' preferences for same-sex surgeons. Results A total of 39 710 784 referrals were made by 44 893 physicians (27 792 [61.9%] male) to 5660 surgeons (4389 [77.5%] male). Female patients made up a greater proportion of referrals to female surgeons than to male surgeons (76.8% vs 55.3%, P < .001). Male surgeons accounted for 77.5% of all surgeons but received 87.1% of referrals from male physicians and 79.3% of referrals from female physicians. Female surgeons less commonly received procedural referrals than male surgeons (25.4% vs 33.0%, P < .001). After adjusting for patient and referring physician characteristics, male physicians referred a greater proportion of patients to male surgeons than did female physicians; differences were greatest among referrals from other surgeons (rate ratio, 1.14; 95% CI, 1.13-1.16). Female physicians had a 1.6% (95% CI, 1.4%-1.9%) greater odds of same-sex referrals, whereas male physicians had a 32.0% (95% CI, 31.8%-32.2%) greater odds of same-sex referrals; differences did not attenuate over time. Conclusions and Relevance In this cross-sectional, population-based study, male physicians appeared to have referral preferences for male surgeons; this disparity is not narrowing over time or as more women enter surgery. Such preferences lead to lower volumes of and fewer operative referrals to female surgeons and are associated with sex-based inequities in medicine.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Dan Zeltzer
- Berglas School of Economics, Tel Aviv University, Tel Aviv, Israel.,Institute of Labor Economics, Bonn, Germany
| | - Rinku Sutradhar
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Andrea N Simpson
- Division of Minimally Invasive Gynecologic Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Antonacci CL, Omari AM, Bassora R, Levine HB, Seidenstein A, Klein GR, Inzerillo C, Alberta FG, Sodha S. Success of Various Marketing Strategies for a New-to-the-Area Orthopedic Practice. Cureus 2021; 13:e18122. [PMID: 34692332 PMCID: PMC8527958 DOI: 10.7759/cureus.18122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/05/2022] Open
Abstract
Background Competition for patients among orthopaedic private practices, multi-specialty groups, and hospital systems continues to persist. An effective marketing campaign is essential for a practice to succeed in this competitive environment. The purpose of this study was to investigate the cost-effectiveness and efficacy of each marketing campaign and the influence of patient demographics on efficacy. Methods The first 300 consecutive, new patients were prospectively surveyed on how they initially discovered and then selected the orthopaedic practice. Demographics and marketing costs were tabulated and categorized to analyze the effectiveness of each marketing strategy. Results A substantial portion of the marketing budget was allocated for traditional (67.0%) and online advertising (25.0%). However, only 56/300 (18.7%) patients surveyed were brought to the practice by these methods combined. In contrast, expenditure on a marketing liaison (8.0%) delivered 128 patients (42.7%) through referrals: 80 (26.7%) from physicians, 28 (9.3%) from urgent cares, 17 (5.7%) from physical therapists, and 3 (1.0%) from attorneys. Conclusion Marketing strategies were not proportionally beneficial during the first six months of the orthopaedic practice start-up period. During this early ramping up period, the most cost-effective marketing strategy was utilization of a liaison for direct in-person visits to various healthcare facilities.
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Affiliation(s)
| | - Ali M Omari
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Rocco Bassora
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Paramus, USA
| | - Harlan B Levine
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Montvale, USA
| | - Ari Seidenstein
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Montvale, USA
| | - Gregg R Klein
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Montvale, USA
| | | | - Frank G Alberta
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Paramus, USA
| | - Samir Sodha
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Paramus, USA.,Orthopaedic Surgery, Hackensack University Medical Center, Hackensack, USA
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Truong TK, Kenneson A, Rosen AR, Singh RH. Genetic Referral Patterns and Responses to Clinical Scenarios: A Survey of Primary Care Providers and Clinical Geneticists. J Prim Care Community Health 2021; 12:21501327211046734. [PMID: 34583568 PMCID: PMC8485275 DOI: 10.1177/21501327211046734] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Primary care physicians (PCPs) are considered the gatekeepers of genetic services, but they often underutilize or inappropriately utilize such services, leading to lack of early treatment, incorrect diagnoses, and unnecessary procedures. This study aims to delineate PCP referral patterns, including the frequency of, motivators for, and barriers to genetic referrals and testing in the present landscape of genomics. Methods: A 34-item online survey was distributed to PCPs in the United States (US). PCP demographics, practice characteristics, and referral patterns, motivators, and barriers were analyzed. Six hypothetical clinical scenarios included in the survey also were presented to a cohort of clinical geneticists. We calculated PCPs’ rates of ordering genetic tests and of referral to genetics services in the past year. Rates and responses to clinical scenarios were compared based on respondents’ personal and practice characteristics. Results: A total of 95 PCPs and 25 clinical geneticists participated. Among the PCPs, 79% reported referring and 50% reported ordering genetic testing in the last year. PCPs with genetic counselors (GCs) in their clinic referred at significantly higher rates than those without (P = .008). White PCPs referred at significantly higher rates compared to Black or African American PCPs (P = .009). The most commonly reported motivators for referring patients to genetic services were preference for specialist coordination, lack of knowledge, and family’s desire for risk information. The most commonly reported barriers were patient refusal, provider concerns about costs to patients, and uncertainty of when a genetic referral is appropriate. In response to clinical scenarios, clinical geneticists were in agreement about the need for genetic testing or referral for 2 of the scenarios. For these 2 scenarios, only 48% and 71% of PCPs indicated that they would offer genetic testing or referral, respectively. Conclusions: Responses to clinical scenarios suggest that it is not clear to PCPs when referrals or testing are needed. Collaboration with GCs is one approach to reducing barriers to and improving PCPs’ utilization of genetic services. Clear guidelines from clinical geneticists may help facilitate appropriate use of genetics services by PCPs. Additional research is needed to further describe barriers that PCPs face in genetic testing/referrals.
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Affiliation(s)
- Tina K Truong
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Ami R Rosen
- Emory University School of Medicine, Atlanta, GA, USA
| | - Rani H Singh
- Emory University School of Medicine, Atlanta, GA, USA
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Guglani S, Liddy C, Afkham A, Mitchell R, Keely E. One Service, Two Models: a comparison of direct-to-specialist and managed specialty models in a provincial eConsult service (Preprint). JMIR Form Res 2021; 6:e32101. [PMID: 35451985 PMCID: PMC9077515 DOI: 10.2196/32101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/22/2021] [Accepted: 02/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background The Ontario electronic consultation (eConsult) service allows a primary care provider (PCP) to access specialist advice through 2 models: the direct-to-specialist (DTS) model, where PCPs select a specialist from a directory, and the Building Access to Specialists Through eConsultation (BASE)–managed specialty service, where PCPs choose a specialty group and are assigned a specialist from a qualified pool based on availability. Objective The aim of this study is to examine patterns of use between the 2 models of eConsult delivery. Methods We conducted a cross-sectional analysis of utilization data collected from eConsults completed between October 2018 and September 2019. Cases were grouped based on the model used for submission (ie, BASE or DTS). Each model was assessed for the number of cases over time, specialty distribution, proportion resulting in new or additional information, impact on PCPs’ decisions to refer, and billing time. Results PCPs submitted 26,121 eConsults during the study period. The monthly case volume increased by 43% over the duration of the study, primarily in the BASE model (66% compared to 6% for DTS). PCPs were able to confirm a course of action that they originally had in mind in 41.4% (6373/15,376) of BASE cases and 41.3% (3363/8136) of DTS cases and received advice for a new or additional course of action in 54.7% (8418/15,376) of BASE cases and 56.3% (4582/8136) of DTS cases. A referral was originally contemplated but avoided in 51.3% (7887/15,376) of BASE cases and 53.3% (4336/8136) of DTS cases, originally contemplated and still needed in 19.4% (2986/15,376) of BASE cases and 17.7% (1438/8136) of DTS cases, and neither originally contemplated nor needed in 21.7% (3334/15,376) of BASE cases and 21.9% (1781/8136) of DTS cases. Conclusions Both eConsult models had strong uptake. Use patterns varied between models, with the majority of growth occurring under BASE, but survey responses showed that both models provided similar outcomes in terms of new information offered and impact on decision to refer.
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Affiliation(s)
- Sheena Guglani
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, ON, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Rhea Mitchell
- eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
| | - Erin Keely
- eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
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Enabulele O. The Two-way Referral System: A Survey of Medical and Dental Consultants in a Tertiary Hospital in Nigeria. Niger Med J 2021; 62:183-189. [PMID: 38694217 PMCID: PMC11058444 DOI: 10.60787/nmj-62-4-34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
Background Referral has been defined as a set of activities undertaken by a health care provider or facility in response to its inability to provide the necessary intervention to satisfy a patient's need. In a referral process, both Medical and Dental Consultants (Specialists) and Primary care physicians have essential roles to play. This study assessed the knowledge and practice of the two-way referral system by Medical and Dental Consultants in a tertiary hospital and their attitude towards it. Methodology This was a descriptive cross-sectional questionnaire-based study of Medical and Dental Consultants in a tertiary hospital. Data analysis was done using IBM SPSS Statistics version 21.0 (Chicago, IL, USA)statistical software, with Pearson's chi-square used to determine associations between variables. Statistical significance was set at a P-value of < 0.05. Results There were 118 respondents with 84 males and 34 females (M: F = 1:0.4). Though most of them had good knowledge of the two-way referral system, only 13.6% always referred the patient back to the primary care physician after specialist treatment. Of the respondents who never referred the patient back to the primary care physician, 44.4% stated there was no need for feedback to the primary care physician because they felt the patient became theirs after the initiation of a referral to them (specialist). Conclusion Though most of the Medical and Dental Consultants were aware of the two-way referral system and had good knowledge of it, their practice of the two-way referral system was poor.
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Affiliation(s)
- Osahon Enabulele
- Department of Family Medicine, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
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Sutherland BL, Pecanac K, LaBorde TM, Bartels CM, Brennan MB. Good working relationships: how healthcare system proximity influences trust between healthcare workers. J Interprof Care 2021; 36:331-339. [PMID: 34126853 PMCID: PMC8669032 DOI: 10.1080/13561820.2021.1920897] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Trust between healthcare workers is a fundamental component of effective, interprofessional collaboration and teamwork. However, little is known about how this trust is built, particularly when healthcare workers are distributed (i.e., not co-located and lack a shared electronic health record). We interviewed 39 healthcare workers who worked with proximal and distributed colleagues to care for patients with diabetic foot ulcers and analyzed transcripts using content analysis. Generally, building trust was a process that occurred over time, starting with an introduction and proceeding through iterative cycles of communication and working together to coordinate care for shared patients. Proximal, compared to distributed, dyads had more options available for interactions which, in turn, facilitated communication and working together to build trust. Distributed healthcare workers found it more difficult to develop trusting relationships and relied heavily on individual initiative to do so. Few effective tools existed at the level of interprofessional collaborations, teams, or broader healthcare systems to support trust between distributed healthcare workers. With increasing use of distributed interprofessional collaborations and teams, future efforts should focus on fostering this critical attribute.
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Affiliation(s)
- Bryn L Sutherland
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kristin Pecanac
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | - Taylor M LaBorde
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Meghan B Brennan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Chen YW, Westfal ML, Chang DC, Kelleher CM. Contribution of unequal new patient referrals to female surgeon under-employment. Am J Surg 2021; 222:746-750. [PMID: 33685718 DOI: 10.1016/j.amjsurg.2021.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The literature shows that female surgeons have lower operative volumes than male surgeons. Since volume is dependent on new patient referrals for most surgeons, inequities in referrals may contribute to this employment disparity. METHODS Using 1997-2018 data from a large medical center, we examined the number of new patient referrals for surgeons. Multivariate linear analysis was performed, adjusting for surgeon race, calendar year, seniority, and clinical subspecialty. RESULTS A total of 121 surgeons across 12,410 surgeon-months were included. Overall, surgeons had a median of 14 new patient referrals per month (interquartile range (IQR) = 7, 27). On adjusted analysis, female surgeons saw 5.4 fewer new patient referrals per month (95% CI -6.4 to -4.5). CONCLUSION Female surgeons, with equal training and seniority, received fewer new patient referrals than their male peers, and this may contribute to female surgeon under-employment. Surgeon gender may be one of the factors contributing to this differential referral pattern.
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Affiliation(s)
- Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, 165 Cambridge Street, Suite 403, Boston, MA, USA.
| | - Maggie L Westfal
- Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, 165 Cambridge Street, Suite 403, Boston, MA, USA.
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, 165 Cambridge Street, Suite 403, Boston, MA, USA.
| | - Cassandra M Kelleher
- Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, 165 Cambridge Street, Suite 403, Boston, MA, USA.
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Chernew M, Cooper Z, Hallock EL, Scott Morton F. Physician agency, consumerism, and the consumption of lower-limb MRI scans. JOURNAL OF HEALTH ECONOMICS 2021; 76:102427. [PMID: 33581664 DOI: 10.1016/j.jhealeco.2021.102427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 11/28/2020] [Accepted: 12/30/2020] [Indexed: 06/12/2023]
Abstract
We study where privately insured individuals receive planned MRI scans. Despite significant out-of-pocket costs for this undifferentiated service, privately insured patients often receive care in high-priced locations when lower priced options were available. The median patient in our data has 16 MRI providers within a 30-minute drive of her home. On average, patients bypass 6 lower-priced providers between their homes and their actual treatment locations. Referring physicians heavily influence where patients receive care. The share of the variance in the prices of patients' MRI scans that referrer fixed effects (52 percent) explain is dramatically greater than the share explained by patient cost-sharing (< 1 percent), patient characteristics (< 1 percent), or patients' home HRR fixed effects (2 percent). In order to access lower cost providers, patients must generally diverge from physicians' established referral patterns.
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Affiliation(s)
- Michael Chernew
- Harvard Medical School and the NBER, 180 Longwood Avenue, Boston, MA, 02115, United States.
| | - Zack Cooper
- Yale University and the NBER, 77 Prospect Street, New Haven, CT, 06521, United States.
| | | | - Fiona Scott Morton
- Yale University and the NBER, 165 Whitney Avenue, New Haven, CT, 06511, United States.
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Medicare Patient Referral Networks to Female Pelvic Medicine and Reconstructive Surgeons Across the United States. Female Pelvic Med Reconstr Surg 2021; 27:126-130. [PMID: 31274576 DOI: 10.1097/spv.0000000000000751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The source of urogynecology patient referrals remains poorly understood. We used novel methods to identify referral networks to female pelvic medicine and reconstructive surgeons (FPMRS) and to determine factors associated with physician connections. METHODS A retrospective analysis of Centers for Medicare and Medicaid Services data with physician sharing relationships spanning 180 days during 2015 was performed. All patients studied were Medicare beneficiaries. Provider patient-sharing networks were modeled using social network analytics. To visualize the resulting flow of patients from referring providers to FPMRS, we encoded the node and edge data and mapped the data to a map of the United States. RESULTS We studied 206,568 Medicare beneficiaries who were seen by 618 different board-certified FPMRS. Internal medicine physicians followed by nurse practitioners referred the most patients to FPMRS. Over half of referrals were made locally, with patients traveling less than 5 miles from the referring provider to the female pelvic surgeon. The median number of incoming Medicare patient referrals per FPMRS provider was 15 (interquartile range, 12-20) over a 6-month period. The high modularity of the referral network indicates that most providers refer their patients to a few female pelvic surgeons. CONCLUSIONS Medicare patient referrals to FPMRS are primarily and proportionally the highest from local internal medicine physicians.
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Kierkegaard P, Owen-Smith J. Determinants of physician networks: an ethnographic study examining the processes that inform patterns of collaboration and referral decision-making among physicians. BMJ Open 2021; 11:e042334. [PMID: 33402408 PMCID: PMC7786804 DOI: 10.1136/bmjopen-2020-042334] [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: 07/02/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Most scholarly attention to studying collaborative ties in physician networks has been devoted to quantitatively analysing large, complex datasets. While valuable, such studies can reduce the dynamic and contextual complexities of physician collaborations to numerical values. Qualitative research strategies can contribute to our understanding by addressing the gaps left by more quantitative approaches. This study seeks to contribute to the literature that applies network science approaches to the context of healthcare delivery. We use qualitative, observational and interview, methods to pursue an in-depth, micro-level approach to the deeply social and discursive processes that influence patterns of collaboration and referral decision-making in physician networks. DESIGN Qualitative methodologies that paired ethnographic field observations, semistructured interviews and document analysis were used. An inductive thematic analysis approach was used to analyse, identify and describe patterns in those data. SETTING This study took place in a high-volume cardiovascular department at a major academic medical centre (AMC) located in the Midwest region of the USA. PARTICIPANTS Purposive and snowballing sampling were used to recruit study participants for both the observational and face-to-face in-depth interview portions of the study. In total, 25 clinicians and 43 patients participated in this study. RESULTS Two primary thematic categories were identified: (1) circumstances for external engagement; and (2) clinical conditions for engagement. Thematic subcategories included community engagement, scientific engagement, reputational value, experiential information, professional identity, self-awareness of competence, multidisciplinary programmes and situational factors. CONCLUSION This study adds new contextual knowledge about the mechanisms that characterise referral decision-making processes and how these impact the meaning of physician relationships, organisation of healthcare delivery and the knowledge and beliefs that physicians have about their colleagues. This study highlights the nuances that influence how new collaborative networks are formed and maintained by detailing how relationships among physicians develop and evolve over time.
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Affiliation(s)
- Patrick Kierkegaard
- NIHR London In Vitro Diagnostics Co-operative, Department of Surgery and Cancer, Imperial College London, London, UK
- CRUK Convergence Science Centre, Institute of Cancer Research & Imperial College London, London, UK
| | - Jason Owen-Smith
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
- Department of Sociology, University of Michigan, Ann Arbor, Michigan, USA
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Understanding How Providers and Staff Make Decisions About Where to Refer Their Patients: A Qualitative Study. J Ambul Care Manage 2020; 44:21-30. [PMID: 33234867 DOI: 10.1097/jac.0000000000000367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Value-based payment incentivizes primary care providers (PCPs) to refer patients to specialists inside their own organization. "Outmigration" of patients to specialists in other organizations is common, yet why it occurs is not clear. We conducted qualitative interviews of PCPs, nurses, and administrative staff at primary care practices in a physician organization (PO) to determine reasons for outmigration. While participants reported that they preferred making within-PO referrals, they identified 18 barriers to within-PO referrals, which often led to patients receiving care elsewhere. Many of these barriers are potentially modifiable and could inform the design of future interventions to decrease unnecessary outmigration.
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Salins N, Ghoshal A, Hughes S, Preston N. How views of oncologists and haematologists impacts palliative care referral: a systematic review. BMC Palliat Care 2020; 19:175. [PMID: 33228651 PMCID: PMC7686696 DOI: 10.1186/s12904-020-00671-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/14/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Worldwide, many patients with cancer, are infrequently referred to palliative care or are referred late. Oncologists and haematologists may act as gatekeepers, and their views may facilitate or hinder referrals to palliative care. This review aimed to identify, explore and synthesise their views on referrals systematically. METHODS Databases of MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science and Cochrane were searched for articles from 01/01/1990 to 31/12/2019. All studies were scored for their methodological rigour using Hawker's tool. Findings were synthesised using Popay's narrative synthesis method and interpreted using a critical realist lens and social exchange theory. RESULTS Out of 9336 initial database citations, 23 studies were included for synthesis. Five themes were developed during synthesis. 1. Presuppositions of oncologists and haematologists about palliative care referral: Role conflict, abandonment, rupture of therapeutic alliance and loss of hope were some of the presuppositions that hindered palliative care referral. Negative emotions and perception of self-efficacy to manage palliative care need also hindered referral. 2. Power relationships and trust issues: Oncologists and haematologists preferred to gatekeep the referral process and wished to control and coordinate the care process. They had diminished trust in the competency of palliative care providers. 3. Making a palliative care referral: A daunting task: The stigma associated with palliative care, navigating illness and treatment associated factors, addressing patient and family attitudes, and overcoming organisational challenges made referral a daunting task. Lack of referral criteria and limited palliative care resources made the referral process challenging. 4. Cost-benefit of palliative care referral: Pain and symptom management and psychosocial support were the perceived benefits, whereas inconsistencies in communication and curtailment of care were some of the costs associated with palliative care referral. 5. Strategies to facilitate palliative care referral: Developing an integrated model of care, renaming and augmenting palliative care resources were some of the strategies that could facilitate a referral. CONCLUSION Presuppositions, power relationships, trust issues and the challenges associated with the task of referrals hindered palliative care referral. Oncologists and haematologists appraised the cost-benefit of making a palliative care referral. They felt that an integrated model of care, changing the name of palliative care and augmenting palliative care resources might facilitate a referral.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Arunangshu Ghoshal
- Department of Palliative Medicine, Tata Memorial Centre, MB-G-75, DR E Borges Road, Parel, Mumbai, 400012, India
| | - Sean Hughes
- Division of Health Research, Faculty of Health and Medicine, Furness College, Lancaster University, C051, C - Floor, Bailrigg, LA1 4YW, UK
| | - Nancy Preston
- Division of Health Research, Faculty of Health and Medicine, Furness College, Lancaster University, C051, C - Floor, Bailrigg, LA1 4YW, UK.
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Linde S. The formation of physician patient sharing networks in medicare: Exploring the effect of hospital affiliation. HEALTH ECONOMICS 2019; 28:1435-1448. [PMID: 31657506 PMCID: PMC6899902 DOI: 10.1002/hec.3936] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 07/16/2019] [Accepted: 07/25/2019] [Indexed: 06/01/2023]
Abstract
This study explores the forces that drive the formation of physician patient sharing networks. In particular, I examine the degree to which hospital affiliation drives physicians' sharing of Medicare patients. Using a revealed preference framework where observed network links are taken to be pairwise stable, I estimate the physicians' pair-specific values using a tetrad maximum score estimator that is robust to the presence of unobserved physician specific characteristics. I also control for a number of potentially confounding patient sharing channels, such as (a) common physician group or hospital system affiliation, (b) physician homophily, (c) knowledge complementarity, (d) patient side considerations related to both geographic proximity and insurance network participation, and (e) spillover from other collaborations. Focusing on the Chicago hospital referral region, I find that shared hospital affiliation accounts for 36.5% of the average pair-specific utility from a link. Implications for reducing care fragmentation are discussed.
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Affiliation(s)
- Sebastian Linde
- Department of Economics, Seidman College of BusinessGrand Valley State UniversityAllendaleMichigan
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36
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Fletcher SA, Cole AP, Lu C, Marchese M, Krimphove MJ, Friedlander DF, Mossanen M, Kilbridge KL, Kibel AS, Trinh QD. The impact of underinsurance on bladder cancer diagnosis, survival, and care delivery for individuals under the age of 65 years. Cancer 2019; 126:496-505. [PMID: 31626340 DOI: 10.1002/cncr.32562] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/24/2019] [Accepted: 09/17/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Health insurance is a key mediator of health care disparities. Outcomes in bladder cancer, one of the costliest diseases to treat, may be especially sensitive to a patient's insurance status. METHODS The Surveillance, Epidemiology, and End Results registry and the National Cancer Data Base were used to identify individuals younger than 65 years who were diagnosed with bladder cancer from 2007 to 2014. The associations between the insurance status (privately insured, insured by Medicaid, or uninsured) and the following outcomes were evaluated: diagnosis with advanced disease, cancer-specific survival, delay in treatment longer than 90 days, treatment in a high-volume hospital, and receipt of neoadjuvant chemotherapy (NAC). RESULTS Compared with those with private insurance, uninsured and Medicaid-insured individuals were nearly twice as likely to receive a diagnosis of muscle-invasive bladder cancer (odds ratio [OR] for uninsured individuals, 1.90; 95% confidence interval [CI], 1.70-2.12; OR for Medicaid-insured individuals, 2.03; 95% CI, 1.87-2.20). They were also more likely to die of bladder cancer (adjusted hazard ratio [AHR] for uninsured individuals, 1.49; 95% CI, 1.31-1.71; AHR for Medicaid-insured individuals, 1.61; 95% CI, 1.46-1.79). Delays in treatment longer than 90 days were more likely for uninsured (OR, 1.36; 95% CI, 1.12-1.65) and Medicaid-insured individuals (OR, 1.22; 95% CI, 1.03-1.44) in comparison with the privately insured. Uninsured patients had lower odds of treatment at a high-volume facility, and Medicaid-insured patients had lower odds of receiving NAC (P < .001 for both). CONCLUSIONS Compared with privately insured individuals, uninsured and Medicaid-insured individuals experience worse prognoses and poorer care quality. Expanding high-quality insurance coverage to marginalized populations may help to reduce the burden of this disease.
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Affiliation(s)
- Sean A Fletcher
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander P Cole
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chang Lu
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maya Marchese
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marieke J Krimphove
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - David F Friedlander
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew Mossanen
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kerry L Kilbridge
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Adam S Kibel
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Siddiqui J, Brown K, Zahid A, Young CJ. Current practices and barriers to referral for cytoreductive surgery and HIPEC among colorectal surgeons: A binational survey. Eur J Surg Oncol 2019; 46:166-172. [PMID: 31542240 DOI: 10.1016/j.ejso.2019.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/31/2019] [Accepted: 09/11/2019] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has gained traction for the management of peritoneal metastases. The number of specialist units globally offering CRS/HIPEC is increasing. The aim of this survey was to assess current practices and barriers to referral for CRS/HIPEC among colorectal surgeons in Australia and New Zealand (ANZ). MATERIALS AND METHODS An online questionnaire was emailed to members of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). The survey contained 3 sections: namely; demographics, referral patterns and clinical scenarios. Questions on referral patterns included number of peritoneal metastases patients seen per year and referred to a CRS/HIPEC unit, awareness of such a unit and distance from principle place of practice. Different pathologies referred were also explored, as well as investigations performed. Barriers to referral were also surveyed. RESULTS The response rate was 28% (83/296). Twenty-five percent received CRS training. Most surgeons (95%) were aware of a CRS/HIPEC unit and had referred to one previously. Thirty-nine percent would refer all patients. Provision of good service and/or relationship with CRS/HIPEC specialist were the main reasons for referring to the nearest unit, followed by accessibility. Major factors preventing referral included extent of peritoneal disease (48%), patient characteristics and comorbidities (44%) and lack of evidence (20%). The most common pathologies referred included colorectal and appendiceal peritoneal metastases and pseudomyxoma peritonei. CONCLUSION Colorectal specialist awareness of CRS/HIPEC units and accessibility is high. Strategies to improve referring physician/surgeon knowledge on patient selection and indications for CRS/HIPEC should be investigated and instituted to ensure all appropriate patients are referred to specialist units for discussion of suitability.
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Affiliation(s)
- Javariah Siddiqui
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Kilian Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Assad Zahid
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Christopher John Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Central Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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Buckley FP, Havemann B, Chawla A. Magnetic sphincter augmentation: Optimal patient selection and referral care pathways. World J Gastrointest Endosc 2019; 11:472-476. [PMID: 31523378 PMCID: PMC6715569 DOI: 10.4253/wjge.v11.i8.472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/13/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
Outcomes associated with magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD) have been reported, however the optimal population for MSA and the related patient care pathways have not been summarized. This Minireview presents evidence that describes the optimal patient population for MSA, delineates diagnostics to identify these patients, and outlines opportunities for improving GERD patient care pathways. Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018. Clinical experts contextualized the evidence based on clinical experience. The optimal MSA population may be the 2.2-2.4% of GERD patients who, despite optimal medical management, continue experiencing symptoms of heartburn and/or uncontrolled regurgitation, have abnormal pH, and have intact esophageal function as determined by high resolution manometry. Diagnostic work-ups include ambulatory pH monitoring, high-resolution manometry, barium swallow, and esophagogastroduodenoscopy. GERD patients may present with a range of typical or atypical symptoms. In addition to primary care providers (PCPs) and gastroenterologists (GIs), other specialties involved may include otolaryngologists, allergists, pulmonologists, among others. Objective diagnostic testing is required to ascertain surgical necessity for GERD. Current referral pathways for GERD management are suboptimal. Opportunities exist for enabling patients, PCPs, GIs, and surgeons to act as a team in developing evidence-based optimal care plans.
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Affiliation(s)
- F Paul Buckley
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, United States
| | | | - Amarpreet Chawla
- Department of Health Economics and Market Access, Ethicon Inc. (Johnson and Johnson), Cincinnati, OH 45242, United States
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Schreiner AD, Holmes-Maybank KT, Zhang J, Marsden J, Mauldin PD, Moran WP. Specialty Physician Designation in Referrals from a Vertically Integrated PCMH. Health Serv Res Manag Epidemiol 2019; 6:2333392819850389. [PMID: 31205980 PMCID: PMC6537229 DOI: 10.1177/2333392819850389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 04/20/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction: Primary care referrals to specialty physicians once relied upon the medical skill of
the specialist, the quality of past communication, and previous consultative
experiences. As health systems vertically integrate, patterns of specialty physician
referral designation are not known. Methods: This cross-sectional study from a patient-centered medical home (PCMH) evaluated the
proportion of referrals with named specialists. All outpatient specialty referrals from
the PCMH between July and December of 2014 were eligible for inclusion, and 410 patients
were randomly selected for chart review. The outcome of interest was specialty physician
designation. Other variables of interest included PCMH provider experience, the reason
for referral, and time to specialty visit. Univariate analysis was performed with Fisher
exact tests. Results: Of 410 specialty referrals, 43.7% were made to medical specialties, 41.7% to surgical
specialties, and 14.6% to ancillary specialties. Resident physicians placed 224
referrals (54.6%), faculty physicians ordered 155 (37.8%), and advanced practice
providers ordered 31 (7.6%). Only 11.2% of the specialty referral orders designated a
specific physician. No differences appeared in the reason for referral, the referral
destination, the proportion of visits scheduled and attended, or the time to schedule
between those referrals with and without specialty physician designation. Faculty
physicians identified a specific specialist in 21.4% of referrals compared to residents
doing so in 4.9% (P < .0001). Conclusion: Patient-centered medical home referrals named a specific specialty physician
infrequently, suggesting a shift from the historical reliance on the individual
characteristics of the specialist in the referral process.
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Affiliation(s)
- Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Best C, Coe JB, Hewson J, Meehan M, Kelton D, Black B. Referring equine veterinarians' expectations of equine veterinary specialists and referral centers. J Am Vet Med Assoc 2019; 253:479-489. [PMID: 30058963 DOI: 10.2460/javma.253.4.479] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To explore referring equine veterinarians' expectations of equine veterinary referral centers and specialists. DESIGN Qualitative, focus group interview-based study. SAMPLE 6 focus groups comprised of equine practitioners with experience in referral of clients and patients to equine specialists or referral centers (48 referring veterinarians [rDVMs]). PROCEDURES Focus group sessions were conducted independently and followed a standardized discussion guide consisting of open-ended questions and follow-up probes. Discussions were recorded, and thematic analysis was performed on the content. RESULTS The overarching theme of participants' discussions was that specialists and referral centers are an extension of the care that rDVMs provide to their clients and patients. The 5 areas that participants described as important to this expectation were rDVM-client relationships, rDVM involvement during referral care, collegial rDVM-specialist relationships, communication between rDVMs and specialists, and the boundaries of referral care. Participating practitioners wanted to be involved during the referral process, which was seen as being facilitated by having a collegial relationship with the specialist and through effective communication during the course of referral care. CONCLUSIONS AND CLINICAL RELEVANCE Relationships and communications between rDVMs and specialists are important aspects of equine veterinary medicine. Both rDVMs and specialists are likely to benefit from pursuing opportunities to further their relationship by using up-front communication to establish clear role expectations and clear processes for sharing information.
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Public reporting of hospital quality data: What do referring physicians want to know? Health Policy 2018; 122:1177-1182. [PMID: 30270032 DOI: 10.1016/j.healthpol.2018.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To identify ambulatory care physicians' priorities for hospital quality criteria to support them in counselling patients what hospital to choose. METHODS Three hundred non-hospital-based stratified randomly sampled physicians, representing the five main referring specialties in Germany participated in a cross-sectional survey. Physicians rated the importance of 80 hospital quality criteria to be used in their counselling of patients in need of hospital care. Criteria selection was based on a literature analysis and the content of Germany's mandatory hospital quality reports. We calculated the most important criteria and performed an ordinal regression analysis to examine whether the physicians' characteristics 'age', 'sex', 'specialty', 'practice type' and 'region' affected physicians' importance ratings. RESULTS To counsel patients in need of a hospital referral, physicians preferred hospital quality criteria that reflect their own and their patients' experiences with a hospital. Additionally, hospitals' expertise and results of treatment were rated highly important. In contrast, hospitals' structural characteristics and compliance with external requirements were rated less important. Physicians' characteristics affected importance ratings only negligibly. CONCLUSIONS To support referring physicians' counselling of patients regarding what hospital to choose in order to achieve optimal patient outcomes eventually, hospital report cards must be enriched by information on physicians' and their patients' experiences with hospitals. Hospitals' structural characteristics play a minor role in counselling of patients needing hospital care.
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Manning BT, Bohl DD, Wang KC, Hamid KS, Holmes GB, Lee S. Factors Influencing Patient Selection of a Foot and Ankle Surgeon. Foot Ankle Spec 2018; 11:315-321. [PMID: 28874071 DOI: 10.1177/1938640017729499] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
UNLABELLED An increasingly consumer-centric health insurance market has empowered patients to select the providers of their choice. There is a lack of studies investigating the rationale by which patients select a foot and ankle surgeon. In the present study, 824 consecutive new patients seeking treatment from 3 foot-ankle surgeons were consecutively administered an anonymous questionnaire prior to their first appointment. It included rating the importance of 15 factors regarding specialist selection on a 1 to 10 scale, with 10 designated " Very important" and 1 designated " Not important at all." The remaining questions were multiple choice regarding patient perspectives on other surgeon aspects (appointment availability, waiting room times, clinic proximity, etc). Of 824 consecutive patients administered the survey, 305 (37%) responded. Patients rated board certification (9.24 ± 1.87) and on-site imaging availability (8.48 ± 2.37)-on a 1 to 10 scale, with 10 designated "Very important- as the 2 most important criteria in choosing a foot and ankle surgeon. Patients rated advertisements as least important. Among the patients, 91% responded that a maximum of 30 minutes should elapse between clinic check-in and seeing their physician; 61% responded that a maximum of 20 minutes should elapse between clinic check-in and seeing their physician. In the context of an increasingly consumer-driven paradigm of health care delivery and reimbursement, it is important to understand patients' preferences in specialist selection. LEVELS OF EVIDENCE Level III: Prospective questionnaire.
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Affiliation(s)
- Blaine T Manning
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kevin C Wang
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kamran S Hamid
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - George B Holmes
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Simon Lee
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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43
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Herring EZ, Peck MR, Vonck CE, Smith GA, Mroz TE, Steinmetz MP. Self-referrals versus physician referrals: What new patient visit yields an actual surgical case? J Neurosurg Spine 2018; 29:314-321. [PMID: 29905523 DOI: 10.3171/2018.1.spine17793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgeons in the United States continue to be overwhelmed by an aging population, and patients are waiting weeks to months for appointments. With a finite number of clinic visits per surgeon, analysis of referral sources needs to be explored. In this study, the authors evaluated patient referrals and their yield for surgical volume at a tertiary care center. METHODS This is a retrospective study of new patient visits by the spine surgery group at the Cleveland Clinic Center for Spine Health from 2011 to 2016. Data on all new or consultation visits for 5 identified spinal surgeons at the Center for Spine Health were collected. Patients with an identifiable referral source and who were at least 18 years of age at initial visit were included in this study. Univariate analysis was used to identify demographic differences among referral groups, and then multivariate analysis was used to evaluate those referral groups as significant predictors of surgical yield. RESULTS After adjusting for demographic differences across all referrals, multivariate analysis identified physician referrals as more likely (OR 1.48, 95% CI 1.04-2.10, p = 0.0293) to yield a surgical case than self-referrals. General practitioner referrals (OR 0.5616, 95% CI 0.3809-0.8278, p = 0.0036) were identified as less likely to yield surgical cases than referrals from interventionalists (OR 1.5296, p = 0.058) or neurologists (OR 1.7498, 95% CI 1.0057-3.0446, p = 0.0477). Additionally, 2 demographic factors, including distance from home and age, were identified as predictors of surgery. Local patients (OR 1.21, 95% CI 1.13-1.29, p = 0.018) and those 65 years of age or older (OR 0.80, 95% CI 0.72-0.87, p = 0.0023) were both more likely to need surgery after establishing care with a spine surgeon. CONCLUSIONS In conclusion, referrals from general practitioners and self-referrals are important areas where focused triaging may be necessary. Further research into midlevel providers and nonsurgical spine provider's role in these referrals for spine pathology is needed. Patients from outside of the state or younger than 65 years could benefit from pre-visit screening as well to optimize a surgeon's clinic time use and streamline patient care.
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Affiliation(s)
| | | | | | | | | | - Michael P Steinmetz
- 2Center for Spine Health, Cleveland Clinic; and.,3Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
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Patel MP, Schettini P, O'Leary CP, Bosworth HB, Anderson JB, Shah KP. Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System. J Gen Intern Med 2018; 33. [PMID: 29532299 PMCID: PMC5910374 DOI: 10.1007/s11606-018-4392-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Ideally, a referral from a primary care physician (PCP) to a specialist results in a completed specialty appointment with results available to the PCP. This is defined as "closing the referral loop." As health systems grow more complex, regulatory bodies increase vigilance, and reimbursement shifts towards value, closing the referral loop becomes a patient safety, regulatory, and financial imperative. OBJECTIVE/DESIGN To assess the ability of a large health system to close the referral loop, we used electronic medical record (EMR)-generated data to analyze referrals from a large primary care network to 20 high-volume specialties between July 1, 2015 and June 30, 2016. MAIN MEASURES The primary metric was documented specialist appointment completion rate. Explanatory analyses included documented appointment scheduling rate, individual clinic differences, appointment wait times, and geographic distance to appointments. KEY RESULTS Of the 103,737 analyzed referral scheduling attempts, only 36,072 (34.8%) resulted in documented complete appointments. Low documented appointment scheduling rates (38.9% of scheduling attempts lacked appointment dates), individual clinic differences in closing the referral loop, and significant differences in wait times and distances to specialists between complete and incomplete appointments drove this gap. Other notable findings include high variation in wait times among specialties and correlation between high wait times and low documented appointment completion rates. CONCLUSIONS The rate of closing the referral loop in this health system is low. Low appointment scheduling rates, individual clinic differences, and patient access issues of wait times and geographic proximity explain much of the gap. This problem is likely common among large health systems with complex provider networks and referral scheduling. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve rates of closing the referral loop. More research is necessary to determine the impact of these changes and other potential driving factors.
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Affiliation(s)
- Malhar P Patel
- Duke University School of Medicine, 8 Duke University Medical Center, Durham, NC, USA.
| | - Priscille Schettini
- Duke University School of Medicine, 8 Duke University Medical Center, Durham, NC, USA
| | - Colin P O'Leary
- Duke University School of Medicine, 8 Duke University Medical Center, Durham, NC, USA
| | - Hayden B Bosworth
- Duke University School of Medicine, 8 Duke University Medical Center, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - John B Anderson
- Duke Primary Care, Duke University Health System, Durham, NC, USA
| | - Kevin P Shah
- Duke Primary Care, Duke University Health System, Durham, NC, USA
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Bachand J, Soulos PR, Herrin J, Pollack CE, Xu X, Ma X, Gross CP. Physician peer group characteristics and timeliness of breast cancer surgery. Breast Cancer Res Treat 2018; 170:657-665. [PMID: 29693229 DOI: 10.1007/s10549-018-4789-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/13/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Little is known about how the structure of interdisciplinary groups of physicians affects the timeliness of breast cancer surgery their patients receive. We used social network methods to examine variation in surgical delay across physician peer groups and the association of this delay with group characteristics. METHODS We used linked Surveillance, Epidemiology, and End Results-Medicare data to construct physician peer groups based on shared breast cancer patients. We used hierarchical generalized linear models to examine the association of three group characteristics, patient racial composition, provider density (the ratio of potential vs. actual connections between physicians), and provider transitivity (clustering of providers within groups), with delayed surgery. RESULTS The study sample included 8338 women with breast cancer in 157 physician peer groups. Surgical delay varied widely across physician peer groups (interquartile range 28.2-50.0%). For every 10% increase in the percentage of black patients in a peer group, there was a 41% increase in the odds of delayed surgery for women in that peer group regardless of a patient's own race [odds ratio (OR) 1.41, 95% confidence interval (CI) 1.15-1.73]. Women in physician peer groups with the highest provider density were less likely to receive delayed surgery than those in physician peer groups with the lowest provider density (OR 0.65, 95% CI 0.44-0.98). We did not find an association between provider transitivity and delayed surgery. CONCLUSIONS The likelihood of surgical delay varied substantially across physician peer groups and was associated with provider density and patient racial composition.
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Affiliation(s)
- Jacqueline Bachand
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT, 06520, USA
| | - Jeph Herrin
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA.,Section of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Health Research & Educational Trust, Chicago, IL, USA
| | - Craig E Pollack
- Johns Hopkins School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Xiao Xu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA.,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Xiaomei Ma
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.,Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA. .,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT, 06520, USA.
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46
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Geissler KH, Lubin B, Ericson KMM. The Role of Organizational Affiliations in Physician Patient-Sharing Relationships. Med Care Res Rev 2018; 77:165-175. [PMID: 29676190 DOI: 10.1177/1077558718769403] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Provider consolidation may enable improved care coordination, but raises concerns about lack of competition. Physician patient-sharing relationships play a key role in constructing patient care teams, but it is unknown how organization affiliations affect these. We use the Massachusetts All Payer Claims Database to examine whether patient-sharing relationships are associated with sharing a practice site, medical group, and/or physician contracting network. Physicians were 17 percentage points more likely to have a patient-sharing relationship if they shared a practice site and 4 percentage points more likely if they shared a medical group, as compared with sharing no affiliation. However, there was no detectable increased probability of a patient-sharing relationship within the same physician contracting network. Our finding that physician patient-sharing relationships are concentrated within organizational boundaries at practice site and medical group levels helps illuminate referral incentives and provide insight into the role of organizational affiliations in patient care team construction.
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Prang KH, Canaway R, Bismark M, Dunt D, Kelaher M. The use of public performance reporting by general practitioners: a study of perceptions and referral behaviours. BMC FAMILY PRACTICE 2018; 19:29. [PMID: 29433449 PMCID: PMC5810107 DOI: 10.1186/s12875-018-0719-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 01/29/2018] [Indexed: 11/14/2022]
Abstract
Background Public performance reporting (PPR) of hospital data aims to improve quality of care in hospitals and to inform consumer choice. In Australia, general practitioners (GPs) are gatekeepers to secondary care with patients requiring their referral for non-emergency access. Despite their intermediary role, GPs have been generally overlooked as potential users of PPR of hospital data, with the majority of the PPR research focussing on consumers, surgeons and hospitals. Methods We examined the use of PPR of hospital data by GPs when referring patients to hospitals. Semi-structured interviews were conducted with 40 GPs, recruited via the Victorian Primary Care Practice-Based Research Network and GP teaching practices in Victoria, Australia. The interviews were recorded, transcribed and analysed thematically. Results We found that the majority of GPs did not use PPR when referring patients to hospitals. Instead, they relied mostly on informal sources of information such as their own or patients’ previous experiences. Barriers that prevented GPs’ use of PPR in their decision making included: lack of awareness and accessibility; perceived lack of data credibility; restrictive geographical catchments for certain hospitals; limited choices of public hospitals in regional and rural areas; and no mandatory PPR for private hospitals. Conclusions Our findings suggest that lack of PPR awareness prevented GPs from using it in their referral practice. As gatekeepers to secondary care, GPs are in a position to guide patients in their treatment decisions and referrals using available PPR data. We suggest that there needs to be greater involvement by GPs in the development of hospital performance and quality indicators in Australia if GPs are to make greater use of them. The indicators require further development before GPs perceive them as valid, credible, and of use for informing their referral practices. Electronic supplementary material The online version of this article (10.1186/s12875-018-0719-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3010, Australia
| | - Rachel Canaway
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3010, Australia
| | - Marie Bismark
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3010, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3010, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3010, Australia.
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48
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Tandjung R, Morell S, Hanhart A, Haefeli A, Valeri F, Rosemann T, Senn O. Referral determinants in Swiss primary care with a special focus on managed care. PLoS One 2017; 12:e0186307. [PMID: 29112975 PMCID: PMC5675398 DOI: 10.1371/journal.pone.0186307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 09/28/2017] [Indexed: 11/21/2022] Open
Abstract
Studies have shown large variation of referral probabilities in different countries, and many influencing factors have been described. This variation is most likely explained by different healthcare systems, particularly to which extent primary care physicians (PCPs) act as gatekeepers. In Switzerland no mandatory gatekeeping system exists, however insurance companies offer voluntary managed care plans with reduced insurance premiums. We aimed at investigating the role of managed care plans as a potential referral determinant in a non-gatekeeping healthcare system. We conducted a cross-sectional study with 90 PCPs collecting data on consultations and referrals in 2012/2013. During each consultation up to six reasons for encounters (RFE) were documented. For each RFE PCPs indicated whether a referral was initiated. Determinants for referrals were analyzed by hierarchical logistic regression, taking the potential cluster effect of the PCP into account. To further investigate the independent association of the managed care plan with the referral probability, a hierarchical multivariate logistic regression model was applied, taking into account all available data potentially affecting the referring decision. PCPs collected data on 24’774 patients with 42’890 RFE, of which 2427 led to a referral. 37.5% of patients were insured in managed health care plans. Univariate analysis showed significant higher referral rates of patients with managed care plans (10.7% vs. 8.5%). The difference in referral probability remained significant after controlling for other confounders in the hierarchical multivariate regression model (OR 1.355). Patients in managed care plans were more likely to be referred than patients without such a model. These data contradict the argument that patients in managed care plans have limited healthcare access, but underline the central role of PCPs as coordinator of care.
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Affiliation(s)
- Ryan Tandjung
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Seraina Morell
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Andreas Hanhart
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
- Private Primary Care Practice, Wetzikon, Switzerland
| | | | - Fabio Valeri
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
- * E-mail:
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49
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Koné I, Klein G, Siebenhofer A, Dahlhaus A, Güthlin C. GPs' assessment of cooperation with other health care providers involved in cancer care-a cross-sectional study. Eur J Cancer Care (Engl) 2017; 27. [PMID: 28983996 DOI: 10.1111/ecc.12751] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2017] [Indexed: 11/27/2022]
Abstract
Cancer is a complex disease requiring the involvement of several health care providers. A possible constant in the cancer care process is the general practitioner (GP). The aim of this project was to evaluate GPs' satisfaction with cooperation with other health care providers in the cancer care process of their patients and to explore which variables are associated with higher satisfaction with cooperation with other health care providers. We considered the following health care providers: outpatient oncology specialists, physicians in relatively small hospitals (≤400 beds), physicians in relatively large hospitals (>400 beds), home care services, outpatient psycho(onco)logists/psychotherapists, hospice/palliative care units and specialised palliative home care. The cross-sectional study was carried out as a postal survey all over Germany. Data were analysed descriptively and by means of logistic regression. Overall satisfaction with cooperation with other health care providers involved in cancer care was rather high. Only cooperation with outpatient psycho(onco)logists/psychotherapists was rated as not assessable/irrelevant by a majority of GPs. For all other health care providers under review, both communication and the transfer of sufficient information in good time were associated with overall satisfaction with cooperation. Little association was found between GP and practice variables and overall satisfaction with cooperation with the considered health care providers.
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Affiliation(s)
- I Koné
- Institute of General Practice, University of Frankfurt/Main, Frankfurt am Main, Germany
| | - G Klein
- Institute of General Practice, University of Frankfurt/Main, Frankfurt am Main, Germany
| | - A Siebenhofer
- Institute of General Practice, University of Frankfurt/Main, Frankfurt am Main, Germany.,Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Graz, Austria
| | - A Dahlhaus
- Institute of General Practice, University of Frankfurt/Main, Frankfurt am Main, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - C Güthlin
- Institute of General Practice, University of Frankfurt/Main, Frankfurt am Main, Germany
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50
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Prizer LP, Gay JL, Perkins MM, Wilson MG, Emerson KG, Glass AP, Miyasaki JM. Using social exchange theory to understand non-terminal palliative care referral practices for Parkinson's disease patients. Palliat Med 2017; 31:861-867. [PMID: 28659011 DOI: 10.1177/0269216317701383] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A palliative approach is recommended in the care of Parkinson's disease patients; however, many patients only receive this care in the form of hospice at the end of life. Physician attitudes about palliative care have been shown to influence referrals for patients with chronic disease, and negative physician perceptions may affect early palliative referrals for Parkinson's disease patients. AIM To use Social Exchange Theory to examine the association between neurologist-perceived costs and benefits of palliative care referral for Parkinson's disease patients and their reported referral practices. DESIGN A cross-sectional survey study of neurologists. SETTING/PARTICIPANTS A total of 62 neurologists recruited from the National Parkinson Foundation, the Medical Association of Georgia, and the American Academy of Neurology's clinician database. RESULTS Participants reported significantly stronger endorsement of the rewards ( M = 3.34, SD = 0.37) of palliative care referrals than the costs ( M = 2.13, SD = 0.30; t(61) = -16.10, p < 0.0001). A Poisson regression found that perceived costs, perceived rewards, physician type, and the number of complementary clinicians in practice were significant predictors of palliative care referral. CONCLUSION Physicians may be more likely to refer patients to non-terminal palliative care if (1) they work in interdisciplinary settings and/or (2) previous personal or patient experience with palliative care was positive. They may be less likely to refer if (1) they fear a loss of autonomy in patient care, (2) they are unaware of available programs, and/or (3) they believe they address palliative needs. Initiatives to educate neurologists on the benefits and availability of non-terminal palliative services could improve patient access to this care.
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Affiliation(s)
- Lindsay P Prizer
- 1 Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer L Gay
- 2 Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, Athens, GA, USA
| | - Molly M Perkins
- 1 Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark G Wilson
- 2 Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, Athens, GA, USA
| | - Kerstin G Emerson
- 3 The Institute of Gerontology, College of Public Health, The University of Georgia, Athens, GA, USA
| | - Anne P Glass
- 4 School of Health and Applied Human Sciences, The University of North Carolina Wilmington, Wilmington, NC, USA
| | - Janis M Miyasaki
- 5 Movement Disorders Program, University of Alberta, Edmonton, AB, Canada
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