One Service, Two Models: a comparison of direct-to-specialist and managed specialty models in a provincial eConsult service (Preprint)

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

Importance

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

Objective

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

Evidence Review

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

Findings

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

Conclusions and Relevance

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

Supporting complex care in general practice via an eConsultant model of care: the Australian specialist perspective

BACKGROUND

Accessing timely specialist physician advice and guidance is of critical importance to both Australian GP specialists (GPs) and their patients. The traditional method of referral, triage and subsequent face-to-face (FTF) consultation is facing challenges from an ever increasing volume of referrals and the needs of underserved populations. In response to such issues, electronic consults (eConsults) have been successfully used internationally to provide GPs with a means of asynchronously accessing specialist physician advice and guidance within 72h. Few studies have addressed the potential impact of eConsults from the view of the non-GP specialist receiving the request, and none specifically related to specialist adult medicine physicians. The aim of this study was to determine the perceptions of current Royal Australasian College of Physicians (RACP) adult medicine Fellows towards establishing an eConsult model of care within their own clinical practice.

METHODS

Semi-structured interviews were conducted with 14 RACP adult medicine Fellows between December 2019 and February 2020. Purposive and snowball sampling strategies were used to recruit physicians of differing ages and gender from diverse specialties and healthcare settings. The data were subjected to a descriptive thematic analysis.

RESULTS

We describe five key themes of relevance to study participants: (1) improved access to non-GP specialist care; (2) the business model in relation to remuneration and time; (3) enhanced GP-Physician relationships; (4) impact on physician work-life balance; and (5) the need for a structured model of care. There was broad consensus that a significant number of outpatient referrals to adult medicine physicians would be more appropriately addressed in primary care with support via an asynchronous eConsult arrangement. RACP Fellows agreed this could improve access to timely specialist advice, place downward pressure on outpatient FTF clinic waiting times and reduce unnecessary patient travel.

CONCLUSION

These findings identify the drivers and barriers to the establishment of an Australian eConsultant model of care from the adult medicine physician's perspective.