Referral interventions from primary to specialist care: a systematic review of international evidence

Barriers and facilitators of screening postpartum depression by primary maternal health workers: A mixed methods study based on the normalization process theory

BACKGROUND

Postpartum depression (PPD) significantly impacts mothers and children's health. China aims to incorporate PPD screening in postpartum home visits, but research on implementation barriers and facilitators is scarce. We designed and implemented a new PPD screening program in Changsha, China, requiring maternal health workers to integrate PPD screening into their postpartum home visits.

AIMS

To identify real-world barriers and facilitators associated with integrating PPD screening into routine home visits from the perspective of maternal health workers.

METHODS

We employed a mixed-methods approach. Maternal health workers involved in the newly introduced PPD screening program were included. Guided by Normalization Process Theory (NPT), quantitative data were collected using the NoMAD instrument, and qualitative data were obtained through semi-structured interviews. Data were analyzed using descriptive statistics for the survey and thematic analysis for the interviews.

RESULTS

All 42 maternal health workers involved in the new PPD program completed the quantitative survey, and nine participated in qualitative interviews. The NoMAD survey revealed high scores for Coherence and Cognitive Participation, but lower scores for Collective Action, particularly regarding insufficient skills and resource adequacy. Thematic analysis identified several barriers, including workload concerns, the need for enhanced psychological healthcare capacity, and lack of economic incentives. Facilitators included the integration of structured feedback and clear referral pathways.

CONCLUSION

Addressing identified barriers through targeted skill training, well-defined referral pathways, and formal recognition of the screening program in performance evaluations could help achieve successful normalization.

'ThinkCancer!': randomised feasibility trial of a novel practice-based early cancer diagnosis intervention

BACKGROUND

UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety-netting systems. Few interventions target whole practice teams. We developed a novel whole-practice team intervention to address this.

AIM

To test the feasibility and acceptability of a novel, complex behavioural intervention, 'ThinkCancer!', for assessment in a subsequent Phase III trial.

DESIGN & SETTING

Pragmatic, superiority pilot randomised controlled trial (RCT) with an embedded process evaluation and feasibility economic analysis in Welsh general practices.

METHOD

Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety-netting systems were assessed. Individual practice staff completed evaluation and feedback forms and qualitative interviews. The intervention was adapted and refined.

RESULTS

Trial recruitment and workshop deliveries took place between March 2020 and May 2021. Trial progression criteria for recruitment, intervention fidelity, and routine data collection were met. Staff-level fidelity, retention, and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety-netting plans in detail.

CONCLUSION

'ThinkCancer!' appears feasible and acceptable. The new iteration of the workshops was completed and the Phase III trial has been funded to assess the effectiveness and cost-effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.

The nature of inappropriate referrals to wellness services in primary care setting in Qatar: Outcome of multifaced interventions on rate and quality of referrals

Objectives

The objectives of this study were to explore the rate and types of inappropriate referrals to the wellness services and to assess the impact of multi-level interventions on the rate of inappropriate referrals at Rawdat Al-Khail health center in Qatar.

Methods

This study employed a retrospective analysis of all referrals data to Rawdat Al-Khail wellness services extracted from the Electronic Health Records (EHRs) between July 2022 and August 2023. The monthly rates and types of inappropriate referrals were calculated. In this study, pre-post analyses were performed to evaluate the impact of two sets of interventions on reducing inappropriate referral rates. The first set involved the development and distribution of e-referral pathways training manual in September 2022. The second set, implemented in April 2023, included close monitoring the rate and types of referrals, and the initiation of feedback communication between wellness services supervisors and referring physicians for advice and corrective actions.

Results

A total of 966 referrals were received during the study period, with 1:5 male-to-female ratio. Of all referrals, 34.9 % were classified as inappropriate, exhibiting considerable variations among different referring health centers. The most common reason for inappropriate referrals was due to the lack of "exercise wellness gym assessment form" (23.8 %). While interventions aimed at enhancing the referral process, they did not result in a significant overall reduction in inappropriate referral rates. However, there was a noteworthy reduction in the inappropriate referrals caused by the lack of "exercise wellness gym assessment form" observed from March to August 2023 (41 %-18 %).

Conclusion

This study sheds light on the complexities of wellness services referrals, revealing a high rate of inappropriate referrals that require closer scrutiny. Despite interventions not significantly reducing the rate of these referrals, it emphasizes the need for ongoing improvement strategies. Structured, periodic interventions at higher levels are recommended to enhance referral appropriateness.

Navigating Pathways to Diagnosis in Idiopathic Subglottic Stenosis: A Qualitative Study

OBJECTIVE

Idiopathic subglottic stenosis is a rare disease, and time to diagnosis is often prolonged. In the United States, some estimate it takes an average of 9 years for patients with similar rare disease to be diagnosed. Patient experience during this period is termed the diagnostic odyssey. The aim of this study is to use qualitative methods grounded in behavioral-ecological conceptual frameworks to identify drivers of diagnostic odyssey length that can help inform efforts to improve health care for iSGS patients.

METHODS

Qualitative study using semi-structured interviews. Setting consisted of participants who were recruited from those enrolled in a large, prospective multicenter trial. We use directed content analysis to analyze qualitative semi-structured interviews with iSGS patients focusing on their pathways to diagnosis.

RESULTS

Overall, 30 patients with iSGS underwent semi-structured interviews. The patient-reported median time to diagnosis was 21 months. On average, the participants visited four different health care providers. Specialists were most likely to make an appropriate referral to otolaryngology that ended in diagnosis. However, when primary care providers referred to otolaryngology, patients experienced a shorter diagnostic odyssey. The most important behavioral-ecological factors in accelerating diagnosis were strong social support for the patient and providers' willingness to refer.

CONCLUSION

Several factors affected time to diagnosis for iSGS patients. Patient social capital was a catalyst in decreasing time to diagnosis. Patient-reported medical paternalism and gatekeeping limited specialty care referrals extended diagnostic odysseys. Additional research is needed to understand the effect of patient-provider and provider-provider relationships on time to diagnosis for patients with iSGS.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:815-824, 2024.

Demand management processes to improve access to cognitive-behavioral therapies for anxiety disorders: a grounded theory study

Introduction

Anxiety disorders are impactful mental health conditions for which evidence-based treatments are available, notably cognitive-behavioral therapies (CBTs). Even when CBTs are available, demand-side factors limit their access, and actors in a position to perform demand management activities lack a framework to identify context-appropriate actions.

Methods

We conducted a constructivist grounded theory study in Quebec, Canada, to model demand management targets to improve access to CBTs for anxiety disorders. We recruited key informants with diverse experiences using purposeful, then theoretical sampling. We analyzed data from 18 semi-directed interviews and 20 documents through an iterative coding process centered around constant comparison.

Results

The resulting model illustrates how actors can target clinical-administrative processes fulfilling the demand management functions of detection, evaluation, preparation, and referral to help patients progress on the path of access to CBTs.

Discussion

Modeling clinical-administrative processes is a promising approach to facilitate leveraging the competency of actors involved in demand management at the local level to benefit public mental health.

Does virtual consultation between primary and specialised care improve healthcare quality? A scoping review of healthcare quality domains assessment

BACKGROUND

Virtual consultation has been proposed as a promising tool to improve the coordination and quality of healthcare between primary and specialised care. However, despite its potential facilitators, the evidence on the usefulness of virtual consultation for improving healthcare quality domains is fragmented and unclear. This scoping review aims to assess the impact of virtual consultation on different healthcare quality domains.

MATERIAL AND METHODS

We conducted a scoping review with a rigorous search strategy on PubMed, EMBASE and Cochrane Library databases. The inclusion criteria were original articles, reviews, meta-analyses or letters to the editor, published between 1 January 2017 and 24 June 2022, and available in English, Spanish or French. For each of the articles selected, we identified the addressed healthcare quality domains, their facilitators and barriers, areas of improvement and data gaps. We have adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review reporting standards.

RESULTS

1284 manuscripts were retrieved. Finally, 235 papers were included in this review, most of which were original, descriptive studies. The most evaluated quality domain was effectiveness (223 articles). Safety and patient-centred care were the least evaluated. Simultaneous assessment of more than one domain was observed in 117 papers, being effectiveness and timeliness the most frequent combination. Our analysis revealed that virtual consultation is in development and underused. This tool has the potential to improve access to specialised care and enhance coordination between professionals.

CONCLUSIONS

Virtual consultation has the potential to provide effective, efficient, equitable and timely attention. However, its contribution to safety and patient-centered care needs further evaluation. Our review emphasises the need for more rigorous research and standardised quality assessment criteria to obtain robust evidence on the usefulness of virtual consultation for improving healthcare quality domains.

Factors influencing the implementation of severe acute malnutrition guidelines within the healthcare referral systems of rural subdistricts in North West Province, South Africa

Severe acute malnutrition (SAM) is associated with 30.9% of South Africa's audited under-five children deaths regardless of available guidelines to reduce SAM at each level of a three tyre referral system. Existing research has explored and offered solutions for SAM guidelines implementation at each referral system level, but their connectedness in continuation of care is under-explored. Therefore, I examined implementation of SAM guidelines and factors influencing implementation within subdistrict referral systems. An explanatory qualitative case study design was used. The study was conducted in two subdistricts involving two district hospitals; three community health centres, four clinics, and two emergency service stations. Between February to July 2016 and 2018, data were collected using 39 in-depth interviews with clinical, emergency service and administrative personnel; 40 reviews of records of children younger than five years; appraisals of nine facilities involved in referrals and observations. Thematic content analysis was used to analyse all data except records which were aggregated to elicit whether required SAM guidelines' steps were administered per case reviewed. Record reviews revealed SAM diagnosis discrepancies demonstrated by incomplete anthropometric assessments; non-compliance to SAM management guidelines was noted through skipping some critical steps including therapeutic feeding at clinic level. Record reviews further revealed variations of referral mechanisms across subdistricts, contradictory documentation within records, and restricted continuation of care. Interviews, observations and facility appraisals revealed that factors influencing these practices included inadequate clinical skills; inconsistent supervision and monitoring; unavailability of subdistrict specific referral policies and operational structures; and suboptimal national policies on therapeutic food. SAM diagnosis, management, and referrals within subdistrict health systems need to be strengthened to curb preventable child deaths. Implementation of SAM guidelines needs to be accompanied by job aids and supervision with standardised tools; subdistrict-specific referral policies and suboptimal national policies to ensure availability and accessibility of therapeutic foods.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

BACKGROUND

The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.

METHODS

A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.

RESULTS

A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.

CONCLUSIONS

Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.

Organization of primary care

Strong primary care does not develop spontaneously but requires a well-developed organizational planning between levels of care. Primary care-oriented health systems are required to effectively tackle unmet health needs of the population, and efficient primary care organization (PCO) is crucial for this aim. Via strong primary care, health delivery, health outcomes, equity, and health security could be improved. There are several theoretical models on how primary care can be organized. In this position paper, the key aspects and benchmarks of PCO will be explored based on previously mentioned frameworks and domains. The aim of this position paper is to assist primary care providers, policymakers, and researchers by discussing the current context of PCO and providing guidance for implementation, development, and evaluation of it in a particular setting. The conceptual map of this paper consists of structural and process (PC service organization) domains and is adapted from frameworks described in literature and World Health Organization resources. Evidence we have gathered for this paper shows that for establishing a strong PCO, it is crucial to ensure accessible, continuous, person-centered, community-oriented, coordinated, and integrated primary care services provided by competent and socially accountable multiprofessional teams working in a setting where clear policy documents exist, adequate funding is available, and primary care is managed by dedicated units.

Feasibility of decentralised, task-shifted hepatitis C testing and treatment services in urban Myanmar: implications for scale-up

OBJECTIVES

To assess the feasibility considerations for a decentralised, one-stop-shop model of care implemented in Yangon, Myanmar.

SETTING

Two primary care level clinics in urban Yangon, Myanmar.

DESIGN

This is a feasibility study of a highly effective care model. Using Intervention Complexity Framework by Gericke et al, we collated and analysed programmatic data and evaluation data to outline key project implementation requirements and experiences.

PARTICIPANTS

Programmatic data were collected from clinical records, GeneXpert device test and maintenance reports, national guidelines, product and device instructions and site monitoring visit reports. Healthcare providers involved in delivering care model contributed interview data.

RESULTS

The main feasibility considerations are appropriate storage for test kits and treatments (in response to temperature and humidity requirements), installation of a continuous stable electricity supply for the GeneXpert device, air-conditioning for the laboratory room hosting GeneXpert, access to a laboratory for pretreatment assessments and clear referral pathways for specialist consultation when required. Lessons from our project implementation experiences included the extensive time requirements for patient education, the importance of regular error monitoring and stock storage reviews and that flexible appointment scheduling and robust reminder system likely contributed to high retention in care.

CONCLUSIONS

Detailed documentation and dissemination of feasibility requirements and implementation considerations is vital to assist others to successfully implement a similar model of care elsewhere. We provide 10 recommendations for successful implementation.

TRIAL REGISTRATION NUMBER

The trial was registered at ClinicalTrials.gov NCT03939013 on May 6, 2019. This manuscript presents post-results data on feasibility.

Longer-Term Results of a Universal Electronic Consultation Program at the Cardiology Department of a Galician Healthcare Area

BACKGROUND

Telemedicine models play a key role in organizing the growing demand for care and healthcare accessibility, but there are no described longer-term results in health care. Our objective is to assess the longer-term results (delay time in care, accessibility, and hospital admissions) of an electronic consultation (e-consultation) outpatient care program.

METHODS

Epidemiological and clinical data were obtained from the 41 258 patients referred by primary care to the cardiology department from January 1, 2010, to December 31, 2019. Until 2012, all patients were attended in an in-person consultation (2010-2012). In 2013, we instituted an e-consultation program (2013-2019) for all primary care referrals to cardiologists that preceded patients' in-person consultations when considered. We used an interrupted time series regression approach to investigate the impact of the e-consultation on (1) delay time (days) in care and (2) hospital admissions. We also analyzed (3) total number and referral rate (population-adjusted referred rate) in both periods (in-person consultation and e-consultation), and (4) the accessibility was measured as number of consultations and variation according to distance from municipality and reference hospital.

RESULTS

During the e-consultation, the demand increased (7.2±2.4% versus 10.1±4.8% per 1000 inhabitants, P<0.001), and referrals from different areas were equalized. The reduction in delay to consultation during the in-person consultation (-0.96 [95% CI, -0.951 to -0.966], P<0.001) was maintained with e-consultations (-0.064 [95% CI, 0.043-0.085], P<0.001). After the implementation of e-consultation, we observed that the increasing of hospital admission observed in the in-person consultation (incidence rate ratio, 1.011 [95% CI, 1.003-1.018]), was stabilized (incidence rate ratio, 1.000 [95% CI, 0.985-1.015]; P=0.874).

CONCLUSIONS

Implementing e-consultations in the outpatient management model may improve accessibility of care for patients furthest from the referral hospital. After e-consultations were implemented, the upward trend of hospital admissions observed during the in-person consultation period was stabilized with a slight downward trend.

Exploring the factors that influence the public health impact of changes to the traditional housing officer’s role: insights from a logic modelling approach

Background

Complex interventions can be challenging to summarise and interpret. One approach to attempt to succinctly describe such complexity is through the development of a logic model. This study considers a complex intervention that aimed to widen the role and responsibilities of housing officers, through a neighbourhood-based system.

Methods

We developed a logic model using both primary and secondary data collection alongside expert opinion in order to understand the complex relationships between the intervention being delivered and the actual and potential outcomes. Development of the model was supported by a range of data generation methods, including a scoping review of the literature, telephone survey with housing tenants, in-depth interviews with tenants and housing staff, and workshops with key stakeholders to help to develop and then validate the model.

Results

Our logic model highlights the key role of interpersonal relationships in building coherent neighbourhoods through intervention success and tenant satisfaction. We developed our initial model from analysis of documents relating to the intervention, along with wider literature, which detailed the policy context, theoretical approach and the expected outcomes.

Conclusions

The process of defining our final logic model generated insights that would not have emerged from a more narrative synthesis of secondary and primary data. The most important of these was a clear message about the central role of relationships between neighbourhood officers and tenants. In similar interventions, thought needs to be given on how a relationship can be built between a tenant and a neighbourhood officer.

Improving referrals from primary care to secondary mental health services through an educational intervention: experience from Qatar

Primary care is geared to manage patients with mild to moderate presentations of common mental disorders and to refer patients with more severe mental disorders to specialist mental health services. With growing demand for specialty care, the quality of the referral is increasingly important to ensure efficient patient flow across the primary/secondary care interface and appropriate use of secondary services. We report on an initiative in a Qatari mental health clinic to improve the quality of referrals from primary care to specialist mental health services through an educational intervention for family physicians. We highlight the problem, the intervention and the outcome of our initiative, which was the first of its kind in the region. The number of inappropriate referrals fell by 93%, and the number of referrals with inadequate clinical information declined from 15 (January 2019) to 1 (September 2019). Feedback was very positive; respondents reported feeling supported, with better understanding of care pathways, the scope of primary care and mental health services.

Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach

The recently developed scheduled mobile-telephone referral model (DETELPROG) has achieved especially important results in reducing waiting days for patients, but it has been decided to explore what barriers and positive aspects were detected by both primary care physicians (PCPs) and hospital attending physicians (HAPs) regarding its use. For this, a qualitative descriptive study was carried out through six semi-structured interviews and two focus groups in a sample of eleven PCPs and five HAPs. Interviews were carried out from September 2019 to February 2020. Data were analysed by creating the initial categories, recording the sessions, transcribing the information, by doing a comprehensive reading of the texts obtained, and analysing the contents. The results show that DETELPROG gives the PCP greater prominence as a patient’s health coordinator by improving their relationship and patient safety; it also improves the relationship between PCP and HAP, avoiding unnecessary face-to-face referrals and providing safety to the PCP when making decisions. The barriers for DETELPROG to be used by PCP were defensive medicine, patients’ skepticism in DETELPROG, healthcare burden, and inability to focus on the patient or interpret a sign, symptom, or diagnostic test. For HAP, the barriers were lack of confidence in the PCP and complexity of the patient. As a conclusion, DETELPROG referral model provides a lot of advantages and does not pose any new barrier to face-to-face referral or other non-face-to-face referral models, so it should be implemented in primary care.

Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales

BACKGROUND

Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial.

METHODS

The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation.

DISCUSSION

This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04823559 .

A telemedicine strategy to reduce waiting lists and time to specialist care: A retrospective cohort study

Introduction

The demand for specialty care is rising worldwide. In the state of Rio Grande do Sul, Brazil, more than 150,000 people were waiting for specialist consultations in 2013. A telemedicine programme (RegulaSUS) developed referral protocols, audited waitlisted cases, authorised/prioritised referrals by risk and discuss deferred cases primary-care physician. This study assesses the effectiveness of RegulaSUS.

Methods

A retrospective cohort analysis with contemporaneous controls was performed from June 2014 to June 2016. Six medical specialties included in RegulaSUS (50,185 patients) were compared to 50,124 control patients waitlisted according to the usual routine (scheduled for specialty consultation at the next available date). The groups were matched (1:1) by semester and year of waitlisting and by the specialty demand-to-supply ratio. Primary outcomes were referral-to-consultation time and number of waitlisted patients.

Results

The mean referral-to-consultation time was 584.8 days in the intervention group and 607.0 days in controls ( p<0.001). For specialties regulated by RegulaSUS, the mean referral-to-consultation time was 237.6 days for higher-risk patients. At the end of the observation, 26,708 control patients had been unlisted compared to 31,050 patients in the intervention group (reduction of 53.5% vs. 61.9%, respectively; p<0.001). The number of cancelled referrals was lower in the control group ( n=14,403; 28.7%) than in the intervention group ( n=16,387; 32.7%; p<0.001).

Discussion

Telemedicine support for primary care effectively decreased the time to specialty consultation, reduced the number of waitlisted patients and allowed sicker patients to reach a specialist faster.

General practitioners referring patients to specialists in tertiary healthcare: a qualitative study

BACKGROUND

There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center.

METHODS

Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results.

RESULTS

Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress.

CONCLUSIONS

General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review

INTRODUCTION

Electronic consultation (eConsult)-provider-to-provider electronic asynchronous exchanges of patient health information at a distance-is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services.

METHODS

We applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied.

RESULTS

Among the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult.

CONCLUSION

There are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.

Improving the Referral Process, Timeliness, Effectiveness, and Equity of Access to Specialist Medical Services Through Electronic Consultation: Pilot Study

BACKGROUND

Access to specialty care remains a major challenge in the Canadian health care system. Electronic consultation (eConsult) services allow primary care providers to seek specialist advice often without needing the patient to go for a face-to-face consultation. It improves overall access to specialists and the referral process using an electronic care consultation service in urban and rural primary care clinics. This study describes the preliminary results of a pilot study with an eConsult service across 3 regions in the province of Quebec, Canada.

OBJECTIVE

The main objective of this study was to provide a 1-year snapshot of the implementation of the eConsult Quebec Service in rural and urban primary care clinics to improve access to care and the specialty referral process for primary care providers (PCPs).

METHODS

We established an eConsult service that covers urban and rural communities in 3 regions of Quebec. We conducted a quantitative analysis of all eConsult cases submitted from July 4, 2017, to December 8, 2018.

RESULTS

For over a year, 1016 eConsults have been generated during the course of this study. A total of 97 PCPs submitted requests to 22 specialty groups and were answered by 40 different specialists. The most popular specialty was internal medicine (224/1016, 22%). Overall, 63% (640/1016) of completed cases did not require a face-to-face visit. PCPs rated the service as being of high or very high value for themselves in 98% (996/1016) of cases.

CONCLUSIONS

The preliminary data highlight the success of the implementation of the eConsult Quebec Service across 6 primary care clinics. The eConsult platform proves to be effective, efficient, and well received by both patients and physicians. If used more widely, eConsult could help reducing wait times significantly. Recently, the Ministry of Health and Social Services of Quebec has identified developing a strategic plan to scale eConsults throughout other regions of the province as a top priority.

The Organization of Secondary Outpatient Care at SHS-DF

Secondary Outpatient Care (SOC) is a subject seldom studied in the literature, but of great importance for the strengthening of Primary Health Care (PHC) and the structuring of the Health Care Network. After the increase of PHC coverage following the Family Health Strategy (FHS) model, through the "CONVERTE APS" project, the State Health Secretariat of the Federal District (SHS-DF) identified the need to organize this level of care throughout the Federal District. SHS-DF has, as its Health Care Planning basis, the knowledge experienced in one of its regions, in addition to the theoretical framework produced and systematized by the National Council of Health Secretariats (CONASS) in recent years, as well as successful experiences in other regions of Brazil and countries with public health systems. The strategies to be used include the following: diagnosis and organization of facility structures, creation of a regional managerial level for Secondary Care, personnel sizing, development of the legal framework for level of care regulation, creation of technical milestones, regulation of medical and non-medical consultations in health regions and matrix support as an education strategy, but also of connection between levels of care.

A categorisation of problems and solutions to improve patient referrals from primary to specialty care

BACKGROUND

Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated.

METHODS

We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes.

RESULTS

We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies.

CONCLUSION

The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.

Impact of an integrated practice unit on the value of musculoskeletal care for uninsured and underinsured patients

BACKGROUND

Limited access to specialty care for uninsured and underinsured patients may be exacerbated by traditional fee-for-service approaches to care that incentivize volume and intensity of services over value of care. The purpose of this study was to determine the impact of a value-based integrated practice unit (IPU) on access to musculoskeletal care and surgical outcomes in a safety-net population.

METHODS

A new IPU was implemented on 6/1/2016 at an established safety-net clinic providing musculoskeletal care in central Texas to supplement existing musculoskeletal care provided through a fee-for-service model. This retrospective cohort study compared access and outcomes under the IPU to the parallel fee-for-service clinic through 3/31/2017, as well as the historical fee-for-service clinic from 8/1/2015 through 5/31/2016. Primary outcomes for access included number of referrals addressed; for surgical patients, length of stay, discharge destination, and 30-day readmission rates were assessed.

RESULTS

The baseline waitlist of 1401 referrals on 6/1/2016 was eliminated by 3/31/2017. Among patients undergoing hip or knee replacement, length of stay was 1.4 days compared to 2.6 days for patients referred to the parallel fee-for-service clinic (p < 0.001), and 92% were discharged home versus 89% (p = 0.46). The 30-day readmission rate for the IPU was 2.7%, which did not differ significantly from the HFFS (8.5%, p = 0.23) and PFFS (3.7%, p = 0.64) clinics.

CONCLUSIONS

An IPU increased access and improved short-term surgical outcomes in a population of uninsured and underinsured patients seeking musculoskeletal care. Additional studies of longer duration are needed to assess the sustainability of a value-based approach.

IMPLICATIONS

A value-based approach to musculoskeletal care may improve access and outcomes in safety-net patients.

LEVEL OF EVIDENCE

III, retrospective cohort study.

General practitioner attitudes and experiences of orthopaedic services in the Irish midlands

INTRODUCTION

Disorders of the musculoskeletal system are the main cause of disability and lost working days worldwide, and osteoarthritis affects almost half a million people in Ireland. Appropriate access and resourcing of general practice and orthopaedics is a necessary measure for the provision of a safe and efficient health service. One area that remains particularly challenging in Ireland is that of outpatient waiting lists, and the purpose of this study was to assess the attitudes and experiences of general practitioners in the Irish midlands with regard to orthopaedic services and to evaluate these in the context of national strategies and international best practice.

METHODS

A survey was sent to general practitioners in the midlands looking at five main areas: elective services, trauma services, allied health services, patient access and practice demographics.

RESULTS

98.7% of general practitioners surveyed stated they either agree or strongly agree that there is a significant difference in terms of access between public and private services. The average waiting time for an elective orthopaedic outpatient clinic is more than 1 year as per 92.3% of GPs surveyed with 89.7% of GPs stating that the average waiting time for an elective private outpatient appointment being between 0 and 3 months. Over three quarters of GPs surveyed either disagree or strongly disagree that there is adequate access to physiotherapy and occupational therapy services in the community with nearly 80% and 93.6% stating they have no physiotherapist or occupational therapist respectively attached to their practice.

CONCLUSION

MSK disorders are a significant burden on the Irish health service and inadequate investment in general practice, allied health practitioner-led facilities and orthopaedic services remains a serious challenge that requires considerable attention to insure adequate patient care, safety and best practice.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Implementation of a Practice Development Model to Reduce the Wait for Autism Spectrum Diagnosis in Adults

This study examined waiting times for diagnostic assessment of Autism Spectrum Disorder in 11 adult services, prior to and following the implementation of a 12 month change program. Methods to support change are reported and a multi-level modelling approach determined the effect of the change program on overall wait times. Results were statistically significant (b = − 0.25, t(136) = − 2.88, p = 0.005). The average time individuals waited for diagnosis across all services reduced from 149.4 days prior to the change program and 119.5 days after it, with an average reduction of 29.9 days overall. This innovative intervention provides a promising framework for service improvement to reduce the wait for diagnostic assessment of ASD in adults across the range of spectrum presentations.

Referral Practices Among U.S. Publicly Funded Health Centers That Offer Family Planning Services

BACKGROUND

Referrals to other medical services are central to healthcare, including family planning service providers; however, little information exists on the nature of referral practices among health centers that offer family planning.

MATERIALS AND METHODS

We used a nationally representative survey of administrators from 1,615 publicly funded health centers that offered family planning in 2013-14 to describe the use of six referral practices. We focused on associations between various health center characteristics and frequent use of three active referral practices.

RESULTS

In the prior 3 months, a majority of health centers (73%) frequently asked clients about referrals at clients' next visit. Under half (43%) reported frequently following up with referral sources to find out if their clients had been seen. A third (32%) of all health centers reported frequently using three active referral practices. In adjusted analysis, Planned Parenthood clinics (adjusted odds ratio 0.55) and hospital-based clinics (AOR 0.39) had lower odds of using the three active referral practices compared with health departments, and Title X funding status was not associated with the outcome. The outcome was positively associated with serving rural areas (AOR 1.39), having a larger client volume (AOR 3.16), being a part of an insurance network (AOR 1.42), and using electronic health records (AOR 1.62).

CONCLUSIONS

Publicly funded family planning providers were heavily engaged in referrals. Specific referral practices varied widely and by type of care. More assessment of these and other aspects of referral systems and practices is needed to better characterize the quality of care.

Integrating primary and secondary care for children and young people: sharing practice

OBJECTIVE

To share innovative practice with enough detail to be useful for paediatricians involved in planning services.

DESIGN

A review of practice, adopting a realist approach.

SETTING

We collected detailed information about five initiatives which were presented at two meetings in July and October 2014 and telephone interviews between July and November 2014 with key informants, updating information again in February 2015.

RESULTS

The five case studies involved three clinical commissioning groups (CCGs): Islington CCG and Southwark and Lambeth CCG in London and Taunton CCG in the Southwest. All five initiatives involved acute paediatric units. We heard about four distinct types of services designed to bring paediatric expertise into primary care and/or improve joint working between paediatricians and primary care professionals: telephone multidisciplinary team, hospital at home, general practitioner (GP) outreach clinics, and advice and guidance. We defined four common ways that initiatives might work: promoting shared responsibility; upskilling GPs; establishing relationships between paediatricians and primary healthcare professionals; and by taking specialist care to the patient.

CONCLUSIONS

We derived common aims and mechanisms and generated programme (mid-level) theory for each integrated care initiative about how they might work. These descriptions of what is being done can inform debate about which interventions should be prioritised for wider implementation. There is an urgent need for evaluation of these interventions and more indepth research into how mechanisms and their effectiveness could be assessed.

Referral management centres as a means of reducing outpatients attendances: how do they work and what influences successful implementation and perceived effectiveness?

Background

The rising volume of referrals to secondary care is a continuing concern in the NHS in England, with considerable resource implications. Referral management centres (RMCs) are one of a range of initiatives brought in to curtail this rise, but there is currently limited evidence for their effectiveness, and little is known about their mechanisms of action. This study aimed to gain a better understanding of how RMCs operate and the factors contributing to the achievement of their goals. Drawing on the principles of realist evaluation, we sought to elicit programme theories (the ideas and assumptions about how a programme works) and to identify the key issues to be considered when establishing or evaluating such schemes.

Methods

Qualitative study with a purposive sample of health professionals and managers involved in the commissioning, set-up and running of four referral management centres in England and with GPs referring through these centres. Semi-structured interviews were conducted with 18 participants. Interviews were audio-recorded and transcribed. Data were analysed thematically.

Results

Interview data highlighted the diverse aims and functions of RMCs, reflecting a range of underlying programme theories. These included the overarching theory that RMCs work by ensuring the best use of limited resources and three sub-theories, relating to how this could be achieved, namely, improving the quality of referrals and patient care, reducing referrals, and increasing efficiency in the referral process. The aims of the schemes, however, varied between sites and between stakeholders, and evolved significantly over time. Three themes were identified relating to the context in which RMCs were implemented and managed: the impact of practical and administrative difficulties; the importance and challenge of stakeholder buy-in; and the dependence of perceived effectiveness on the aims and priorities of the scheme. Many RMCs were described as successful by those involved, despite limited evidence of reduced referrals or cost-savings.

Conclusions

The findings of this study have a number of implications for the development of similar schemes, with respect to the need to ensure clarity of aims and to identify indicators of success from the outset, to anticipate scheme evolution and plan for potential changes with respect to IT systems and referral processes. Also identified, is the need for further research that evaluates the effectiveness and cost effectiveness of particular models of RMC.

Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis

Background

The burden of non-communicable disease (NCDs) has grown rapidly in low- and middle-income countries (LMICs), where populations are ageing, with rising prevalence of multimorbidity (more than two co-existing chronic conditions) that will significantly increase pressure on already stretched health systems. We assess the impact of NCD multimorbidity on healthcare utilisation and out-of-pocket expenditures in six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa.

Methods

Secondary analyses of cross-sectional data from adult participants (>18 years) in the WHO Study on Global Ageing and Adult Health (SAGE) 2007–2010. We used multiple logistic regression to determine socio-demographic correlates of multimorbidity. Association between the number of NCDs and healthcare utilisation as well as out-of-pocket spending was assessed using logistic, negative binominal and log-linear models.

Results

The prevalence of multimorbidity in the adult population varied from 3∙9% in Ghana to 33∙6% in Russia. Number of visits to doctors in primary and secondary care rose substantially for persons with increasing numbers of co-existing NCDs. Multimorbidity was associated with more outpatient visits in China (coefficient for number of NCD = 0∙56, 95% CI = 0∙46, 0∙66), a higher likelihood of being hospitalised in India (AOR = 1∙59, 95% CI = 1∙45, 1∙75), higher out-of-pocket expenditures for outpatient visits in India and China, and higher expenditures for hospital visits in Russia. Medicines constituted the largest proportion of out-of-pocket expenditures in persons with multimorbidity (88∙3% for outpatient, 55∙9% for inpatient visit in China) in most countries.

Conclusion

Multimorbidity is associated with higher levels of healthcare utilisation and greater financial burden for individuals in middle-income countries. Our study supports the WHO call for universal health insurance and health service coverage in LMICs, particularly for vulnerable groups such as the elderly with multimorbidity.