Journal articles on the topic 'Patterns of specialists referrals'
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Schreiner, Andrew D., Keri T. Holmes-Maybank, Jingwen Zhang, Justin Marsden, Patrick D. Mauldin, and William P. Moran. "Specialty Physician Designation in Referrals from a Vertically Integrated PCMH." Health Services Research and Managerial Epidemiology 6 (January 1, 2019): 233339281985038. http://dx.doi.org/10.1177/2333392819850389.
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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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Winpenny, Eleanor M., Céline Miani, Emma Pitchforth, Sarah King, and Martin Roland. "Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary–secondary care interface." Journal of Health Services Research & Policy 22, no. 1 (July 8, 2016): 53–64. http://dx.doi.org/10.1177/1355819616648982.
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Objectives Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’ skills through education or joint consultations with complex patients.
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Ryan, Bridget L., Joshua Shadd, Heather Maddocks, Moira Stewart, Amardeep Thind, and Amanda L. Terry. "Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data." Journal of Innovation in Health Informatics 24, no. 4 (November 17, 2017): 311. http://dx.doi.org/10.14236/jhi.v24i4.888.
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Background: A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. Objective: To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. Method: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location. Proportion of variance in referral rates attributable to the patient and practice levels. Results: On average, males had 0.26, and females 0.31 referrals in a 12-month period. Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p<.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. Conclusions: Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time.
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Goulart, Bernardo H. L., Carolina M. Reyes, Catherine R. Fedorenko, David G. Mummy, Sacha Satram-Hoang, Lisel M. Koepl, David K. Blough, and Scott D. Ramsey. "Referral and Treatment Patterns Among Patients With Stages III and IV Non–Small-Cell Lung Cancer." Journal of Oncology Practice 9, no. 1 (January 2013): 42–50. http://dx.doi.org/10.1200/jop.2012.000640.
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Referrals to all types of cancer specialists increased the likelihood of treatment with standard therapies for patients with non–small-cell lung cancer, particularly stage III. But racial and income disparities still prevent optimal referrals to cancer specialists.
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Hendijani, Rosa, and Diane P. Bischak. "The effect of social relationships on the rates of referral to specialists." International Journal of Operations & Production Management 36, no. 4 (April 4, 2016): 384–407. http://dx.doi.org/10.1108/ijopm-02-2015-0086.
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Purpose – In order to decrease patient waiting time and improve efficiency, healthcare systems in some countries have recently begun to shift away from decentralized systems of patient referral from general practitioners (GPs) to specialists toward centralized ones. From a queueing theory perspective, centralized referral systems can decrease waiting time by reducing the variation in the referral process. However, from a social psychological perspective, a close relationship between referring physician and specialist, which is characteristic of decentralized referral systems, may safeguard against high referral rates; since GPs refer patients directly to the specialists whom they know, they may be reluctant to damage that relationship with an inappropriate referral. The purpose of this paper is to examine the effect upon referral behavior of a relationship between physicians, as is found in a decentralized referral system, vs a centralized referral system, which is characterized by an anonymous GP-specialist relationship. In a controlled experiment where family practice residents made decisions concerning referral to specialists, physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by the design of the service system and will, in turn, affect system performance. Design/methodology/approach – The authors used a controlled experiment to test the research hypotheses. Findings – Physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by system attributes and will, in turn, affect system performance. Research limitations/implications – The current study has some limitations, however. First, the sample consisted only of family practice residents and did not have the knowledge and experience of GPs regarding the referral process. Second, the authors used hypothetical patient case descriptions instead of real-world patients. Repeating this experiment with primary care physicians in real setting would be beneficial. Practical implications – The study indicates that decentralized referral systems may act (rightly or wrongly) as a restraint on the rate of referrals to specialists. Thus, an implementation of a centralized referral system should be expected to produce an increase in referrals simply due to the change in the operational system setup. Even if centralized referral systems are more efficient and can facilitate the referral process by creating a central queue rather than multiple single queues for patients, the removal of social ties such as long-term social relationships that are developed between GPs and specialists in decentralized referral systems may act to counterbalance these theoretical gains. Social implications – This study provide support for the idea that non-clinical factors play an important role in referrals to specialists and hence in the quality of provided care, as was suggested by previous studies in this area (Hajjaj et al., 2010; Reid et al., 1999). The design of the service system may inadvertently influence some doctors to refer too many patients to specialists when there is no need for a specialist visit. In high-utilization health systems, this may cause some patients to be delayed (or even denied) in obtaining specialist access. Healthcare systems may be able to implement behavioral-based techniques in order to mitigate the negative consequences of a shift to centralized referral systems. One approach would be to try to create a feeling of close relationship among doctors in centralized referral systems. High communication and frequent interaction among GPs and specialists can boost the feelings of teamwork and personal efficacy through social comparison (Schunk, 1989, 1991) and vicarious learning (Zimmerman, 2000), which can in turn motivate GPs to take control of the patient care process when appropriate, instead of referring patients to specialists. Originality/value – The authors’ study is the first examining the effect of social relationships between GPs and specialists on the referral patterns. Considering the significant implications of referral decisions on patients, doctors, and the healthcare systems, the study can shed light into a better understanding of the social and behavioral aspects of the referral process.
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Noor, E., NAN Kamaruzaman, NSM Jeffri, NNN Eezammudden, and NZM Noh. "Periodontal Referral Pattern in Periodontal Specialist Clinic in Faculty of Dentistry, Universiti Teknologi MARA (UiTM): A Retrospective Pilot Study." Compendium of Oral Science 5, no. 1 (September 1, 2018): 37–45. http://dx.doi.org/10.24191/cos.v5i0.17506.
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Objectives: Periodontitis is a chronic disease which remain undiagnosed and untreated without proper examination and referral to specialist clinic for further management Therefore, this study was conducted to evaluate the pattern of referrals to Universiti Teknologi MARA (UiTM) Periodontal Specialist Clinic. Materials and methods: A total of 176 periodontal cases referred to UiTM Periodontal Specialist Clinic in year 2011 and 2016 were identified and patient’s referral forms were collected. The data obtained were the referred cases from undergraduate student clinics, other specialist clinics, UiTM primary dental care clinic and private dental clinics. Descriptive data analysis was conducted using frequency distribution by SPSS. Chi square analysis was used to evaluate the association of source of referral, diagnosis and reason for referrals to Periodontal Specialist Clinic. Results: There was increased referral cases to Periodontal Specialist Clinic in 2016 (86.9%) compared to 2011 (13.1%). Most referral to Periodontal Specialist Clinic were received from faculty’s undergraduate student clinic in both 2011 and 2016 (46%), followed by other specialists (27.3%), primary care clinic (25.6%) and private practice (1.1%). 96% of cases were referred for intervention by periodontist as more than half of the cases were referred for the non-surgical periodontal treatment. Chi square analysis showed the association between source of referral and reason for referral was statistically significant (p value=0.000). Conclusion: Proper periodontal screening in all patients and necessary referral to specialist clinic is crucial to prevent undiagnosed periodontal disease.
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Koch, MD, Nancy V., and Richard J. Butterfield III, MA. "Prescribing patterns and attitudes of primary care providers regarding long-term opioid therapy." Journal of Opioid Management 18, no. 5 (September 1, 2022): 407–20. http://dx.doi.org/10.5055/jom.2022.0735.
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Objective: To assess prescribing and referral patterns and attitudes of primary care providers treating patients receiving long-term opioid therapy (LOT) according to recent guidelines.Design, setting, and participants: An anonymous 25-question survey was distributed to all primary care providers at Mayo Clinic in Arizona (from April 30 through May 22, 2020).Main outcome measures: Knowledge and comfort with LOT guidelines, prescribing patterns, referral patterns to behavioral and pain specialties, patients’ concomitant substance use, and response variability by provider sex and specialty. Results: Most of the 31 survey respondents were familiar with LOT guidelines and were comfortable in prescribing opioids; 36 percent reported no increase in prescribing safety. Patient education on naloxone was infrequent. Access affected referral to behavioral and addiction specialties; 87.1 percent referred patients to pain medicine specialists despite reporting little long-term improvement in symptoms. For a significantly larger proportion of internal medicine and women's health (IM/WH) providers, compared with family medicine (FM) providers, Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7-item scale scores were the reasons for behavioral health referral. Many providers prescribed additional substances. More female providers reported that patients used gabapentin concomitantly (p = .03). More FM providers than IM/WH providers typically referred patients receiving LOT to addiction specialists (p = .02). Most expressed a need for a multispecialty LOT clinic, and 83.9 percent supported buprenorphine prescribing. Conclusions: Despite familiarity with LOT guidelines, many providers felt that patient safety and prescribing diligence have not improved. Patient education on naloxone treatment is needed, and access to behavioral specialists is a barrier to referrals.
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Kunin, Marina, Erin Turbitt, Sarah A. Gafforini, Lena A. Sanci, Neil A. Spike, and Gary L. Freed. "General practitioner referrals to paediatric specialist outpatient clinics: referral goals and parental influence." Journal of Primary Health Care 10, no. 1 (2018): 76. http://dx.doi.org/10.1071/hc17030.
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ABSTRACT INTRODUCTION Previous research on general practitioner (GP) referrals in adult populations demonstrated that patient pressure influenced referral practice. No research has been conducted to investigate how involvement of a parent influences paediatric referrals. AIM To investigate whether GPs who report parental influence on their decision to refer paediatric patients differ in their referral patterns from GPs who do not report parental influence. METHOD A mail survey of 400 GPs who had referred at least two children to paediatric specialist outpatient clinics during 2014 was distributed. RESULTS The response rate was 67% (n = 254). For initial referrals, 27% of GPs stated that parental request frequently or almost always influenced their referral decision. For returning referrals, 63% of GPs experienced parental influence to renew a referral because a paediatrician wanted a child to return; 49% of GPs experienced influence to renew a referral because a parent wanted to continue care with a paediatrician. Experiencing parental influence was associated with increased likelihood for frequent referrals in order for a paediatrician to take over management of a child’s condition. DISCUSSION GPs who frequently refer with a goal for a paediatrician to take over management of a child’s condition also report that parental request almost always influences their decision to refer.
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Ghimire, Anukul, Naima Sultana, Feng Ye, Laura N. Hamonic, Allan K. Grill, Alexander Singer, Ayub Akbari, et al. "Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol." BMJ Open 12, no. 4 (April 2022): e055456. http://dx.doi.org/10.1136/bmjopen-2021-055456.
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IntroductionChronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist.Methods and analysisWe developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded.Ethics and disseminationEthics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies.PROSPERO registration numberCRD42021247756.
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Hyder, Omar, David Cosgrove, Hari Nathan, Kenzo Hirose, Christopher Lee Wolfgang, John Bridge, Jean-Francois Geschwind, et al. "Understanding variations in referral patterns and treatment choices for patients with hepatocellular carcinoma." Journal of Clinical Oncology 31, no. 4_suppl (February 1, 2013): 293. http://dx.doi.org/10.1200/jco.2013.31.4_suppl.293.
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293 Background: Patterns of care of physician specialists may differ for patients with hepatocellular carcinoma(HCC). The extent and reasons underlying possible variations are poorly understood. One source of variation may be disparate referral rates to specialists leading to differences in cancer-directed treatments. Methods: We queried the Surveillance, Epidemiology, and End Results(SEER) linked Medicare database for patients with HCC diagnosed between 1998-2007 who consulted one or more physicians following diagnosis. Visit and procedure records were abstracted from Medicare billing records and factors associated with visiting a specialist and subsequent treatment were examined. Results: 6752 patients with HCC were identified;median age was 73 yrs and the majority was male(66%), White(60%) and from a West geographical region(56%). 1379(20%) patients had early-stage disease. In the six months after diagnosis, referral to a specialist varied considerably (hepatology/gastroenterology-60%; medical oncology-62%; surgery-56%; interventional radiology-33%; radiation oncology-9%). 22% patients saw one specialist, while 39% saw ≥3 specialists. Time between diagnosis and visitation with a specialist varied by sub-specialty (surgery-37 days vs. interventional radiology-55 days;P=0.04). Factors associated with referral to a specialist included younger age(OR=2.13), geographic location(Northeast OR=2.09), and presence of early-stage disease(OR=2.21)(all P<0.05). Among patients with early-stage disease, 77% saw a surgeon, while 50% had a medical oncology consultation. Receipt of therapy among patients with early-stage disease varied (no therapy-30%; surgery-39%; interventional radiology-9%; other-22%). Factors associated with receipt of therapy included younger age(OR=2.82), as well as time to consultation with cancer specialist(OR=1.05)(both P<0.05). Conclusions: Following HCC diagnosis, referral to a specialist varied considerably. Both clinical and non-clinical factors were associated with consultation. Variations in referral to a specialist and subsequent therapy need to be better understood to ensure all HCC patients receive appropriate care.
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Muller, Katja, Nazim Ghouri, Lynn Walker, and Sam Philip. "Prospective observational study of referrals to hospital diabetes specialist care team (2004–2008) at a tertiary care centre." British Journal of Diabetes & Vascular Disease 11, no. 6 (November 2011): 298–303. http://dx.doi.org/10.1177/1474651411429951.
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Aims Diabetes inpatient specialist teams (DISTs) support other departments to care for people with diabetes. The aim of this study was to evaluate the role of our adult DIST to ascertain the types of patients referred, reasons for referrals and the frequency of referrals. Methods Using prospectively collected data on our adult DIST activity (patients > 14 yrs), we retrospectively analysed all referrals over a 48-month period (October 2004–October 2008). We also performed a more focused study over a two-month period obtaining more detailed information on DIST–patient interaction. Results Over the 48 months of the study, more referrals were from medical (1879, 66%) than from surgical specialties (641, 23%). Most medical referrals were from the acute medical admissions unit (411, 14.4%); the most common referral being hyperglycaemia (339, 15%). Inpatient review was the most frequent task undertaken (76% of DIST–patient interactions), which included optimisation of medication and re-review, and 15% of reviews occurred at weekends. Following an education strategy for nursing staff, referrals for hypoglycaemia decreased (27.4% in 2005, 14.7% in 2008, p=0.04 for trend). Conclusion A DIST makes important contributions to diabetes care in all major hospital departments. Evaluating referral patterns can help identify educational needs.
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Yong, Candice, Ebere Onukwugha, C. Daniel Mullins, Abdulla M. Abdulhalim, Yi Qian, Jorge Arellano, Arun Balakumaran, Alexander Liede, and Arif Hussain. "Physician referral patterns among men with advanced prostate cancer." Journal of Clinical Oncology 32, no. 4_suppl (February 1, 2014): 211. http://dx.doi.org/10.1200/jco.2014.32.4_suppl.211.
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211 Background: Among men diagnosed with localized prostate cancer (PC), the type of specialist visited has been shown to influence the type of treatment regimen prescribed. There is limited data on referral patterns among men diagnosed with advanced PC. The objective of this study was to characterize referral patterns across physician types who treat men with stage IV nonmetastatic (M0) and metastatic (M1) PC. Methods: Using the linked US SEER (Surveillance, Epidemiology, and End Results) and Medicare database, we identified men aged 66 or older who were diagnosed with incident stage IV M0 or M1 PC between 2000 and 2007. We evaluated patterns of the first and second type of physicians visited after diagnosis of PC for men with visits to the following physician types: urologist, medical oncologist (medonc), radiation oncologist (radonc), or primary care physician (PCP). Results were stratified by M0 and M1 disease. Results: We identified 9,826 men with stage IV PC (median age=77 years). Of these 9,826 men, 8,736 (89%) visited at least two physician types (93% among men with M0 and 87% among men with M1). Across the physician types of interest, 94% of men initially visited a urologist (52%) or PCP (42%). Among men who visited a urologist first, most were referred to a PCP, while smaller percentages were referred to a medonc or radonc (Table). Among men who saw a PCP first, most were referred to a urologist next; smaller proportions were referred to a medonc or radonc. Men with M1 PC had more referrals to medonc and fewer referrals to radonc than men with M0 PC. Conclusions: In this analysis of nearly 10,000 men aged 66 or older with stage IV PC in the US, most men initially visited a urologist or PCP regardless of whether or not they had distant metastasis. Based on the patterns observed, the most frequent referral pattern occurred between urologists and PCPs. More referrals to a medonc were evident if the men had M1 disease. [Table: see text]
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Neill, Anne Marie C. "Service evaluation project – Are local recommendations for onward referral to a specialist menopause clinic required to translate guidelines into practice?" Post Reproductive Health 24, no. 2 (March 22, 2018): 83–96. http://dx.doi.org/10.1177/2053369118762241.
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Objective Referral audit – are local recommendations required to translate guideline to practice? Study design In total, 50 consecutive, anonymised referral letters reviewed during the initial consultation in a specialist menopause clinic; the reasons for referral along with the patient’s age and the source of referral were analysed. Results Several common reasons for referral were identified. Sexual dysfunction, including loss of libido and dyspareunia, resulted in 11 (22%) referrals. Ten (20%) women were troubled by persistent symptoms or side effects from HRT; 9 (18%) women were referred before hormone replacement therapy was discussed or commenced; 7 (14%) women seeking advice for their menopausal symptoms had a family or personal history of cancer; 5(10%) were migraineurs; 2(4%) women had premature ovarian insufficiency; 2(4%) were denied hormone replacement therapy because of concern about venous thromboembolism risk; and 4 (8%) had miscellaneous medical disorders. Over 25% of referrals were older than 60. Conclusion Menopausal symptoms are predominately dealt with in primary care where advice and support is needed. National Institute for Health Care and Excellence published guidance regarding onward referral to a specialist menopause clinic, which is vague and referral patterns are haphazard. Our audit highlighted areas of clinical uncertainty and formed the basis for providing local pre-referral information and advice. Some of the information provided is quite detailed and aimed at healthcare professionals with a special interest in menopause. Further training is now required to improve the quality of referrals. The diversity and complexity of some referrals illustrates the need both for a menopause specialist and clear pathways for further advice or referral within each region.
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McMahon, Des L., Marie Twomey, Maeve O’Reilly, and Mary Devins. "Referrals to a perinatal specialist palliative care consult service in Ireland, 2012–2015." Archives of Disease in Childhood - Fetal and Neonatal Edition 103, no. 6 (November 9, 2017): F573—F576. http://dx.doi.org/10.1136/archdischild-2017-313183.
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ObjectiveTo analyse the referral patterns of perinatal patients referred to a specialist palliative care service (SPCS), their demographics, diagnoses, duration of illness, place of death and symptom profile.DesignA retrospective chart review of all perinatal referrals over a 4-year period to the end of 2015.SettingA consultant-led paediatric SPCS at Our Lady’s Children’s Hospital, Crumlin, Dublin, and the Coombe Women & Infants University Hospital, Dublin.Results83 perinatal referrals were received in a 4-year period. Chromosomal abnormalities accounted for 35% of diagnoses, congenital heart disease 25%, complex neurological abnormalities 11% and renal agenesis 4%. 22 referrals (26.5%) were made antenatally, with 61 (73.5%) postnatally. Of the postnatal referrals, 27 (44%) were asymptomatic on referral. An opioid medication was recommended (regularly or as required) in 46 cases. Symptom control was achieved without dose titration in 43 of these cases (93%). Of 47 deaths in this group referred postnatally, 22 of these (47%) died at home with support from community teams. Discharge home for best supportive care required complex interagency communication and cooperation.ConclusionsPerinatal palliative care requires effective multidisciplinary work, whether delivered in the inpatient setting or in the community. With appropriate support, end-of-life care can be delivered in the community.
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LeBlanc, Thomas William, Jonathan David O'Donnell, Megan Crowley-Makota, Daniel Paul Dohan, Michael W. Rabow, Cardinale B. Smith, Douglas B. White, Greer A. Tiver, Robert Arnold, and Yael Schenker. "Perceptions of palliative care among hematologic malignancy specialists: A mixed-methods study." Journal of Clinical Oncology 32, no. 31_suppl (November 1, 2014): 9. http://dx.doi.org/10.1200/jco.2014.32.31_suppl.9.
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9 Background: Patients with hematologic malignancies have unmet palliative care needs but are less likely to receive specialist palliative care services than patients with solid tumors. This difference is poorly understood. Methods: Multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic oncologists and solid tumor oncologists. Between February and October 2012, oncologists at 3 academic medical centers with well-established palliative care services completed surveys assessing referral practices and in-depth, semi-structured interviews about their views of palliative care. We compared referral patterns using standard statistical methods. We then analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences. Results: Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies, and 43 treated only patients with solid tumors. Seven of 23 hematologic oncologists (30%) reported never referring a patient to palliative care; all solid tumor oncologists had previously referred (p<0.001). In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, while most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex cases and/or offload burden in a busy clinic. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophical concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and a preference to control palliative aspects of patient care. Conclusions: Most hematologic oncologists view palliative care as end-of-life care, while solid tumor oncologists more often view palliative care as a subspecialty for co-managing complex patients. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic oncologists.
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Talcott, Katherine E., Judy E. Kim, Yasha Modi, Darius M. Moshfeghi, and Rishi P. Singh. "The American Society of Retina Specialists Artificial Intelligence Task Force Report." Journal of VitreoRetinal Diseases 4, no. 4 (March 27, 2020): 312–19. http://dx.doi.org/10.1177/2474126420914168.
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Artificial intelligence (AI) is a growing area that relies on the heavy use of diagnostic imaging within the field of retina to offer exciting advancements in diagnostic capability to better understand and manage retinal conditions such as diabetic retinopathy, diabetic macular edema, age-related macular degeneration, and retinopathy of prematurity. However, there are discrepancies between the findings of these AI programs and their referral recommendations compared with evidence-based referral patterns, such as Preferred Practice Patterns by the American Academy of Ophthalmology. The overall focus of this task force report is to first describe the work in AI being completed in the management of retinal conditions. This report also discusses the guidelines of the Preferred Practice Pattern and how they can be used in the emerging field of AI.
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Hicks, Susanne. "The Psychiatric Nurse in Liaison Psychiatry." Australian & New Zealand Journal of Psychiatry 23, no. 1 (March 1989): 89–96. http://dx.doi.org/10.3109/00048678909062597.
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The role of nursing staff in a liaison consultative unit is by no means established in this country although precedents exist in the United States. Nevertheless, there are clear theoretical reasons for including psychiatric nurses in the liaison team. This report concerns a model of intervention based on one of three models identified in the US studies. the model involves a collaborative/consultative relationship between the psychiatric nurse and the psychiatrist, therefore maximising opportunities for successful intervention and cross-referral. Two clinical vignettes illustrate this. the clinical presentations of 200 patients presenting primarily to the nurse specialist are compared with 200 presenting to the psychiatric department. the patterns of referrals and also the agencies referring differed. the differences in those profiles, together with the management implications, are discussed. High stress areas of nursing, such as cardiology, neurosurgery and haematology, provided a fertile area for referrals to the nurse where referrals to the psychiatrists had not been high.
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de Bondt, B., I. H. A. Aartman, and A. Zentner. "Referral patterns of Dutch general dental practitioners to orthodontic specialists." European Journal of Orthodontics 32, no. 5 (January 18, 2010): 548–54. http://dx.doi.org/10.1093/ejo/cjp148.
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Truong, Tina K., Aileen Kenneson, Ami R. Rosen, and Rani H. Singh. "Genetic Referral Patterns and Responses to Clinical Scenarios: A Survey of Primary Care Providers and Clinical Geneticists." Journal of Primary Care & Community Health 12 (January 2021): 215013272110467. http://dx.doi.org/10.1177/21501327211046734.
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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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Steyerberg, Ewout W., Bridget Neville, Jane C. Weeks, and Craig C. Earle. "Referral Patterns, Treatment Choices, and Outcomes in Locoregional Esophageal Cancer: A Population-Based Analysis of Elderly Patients." Journal of Clinical Oncology 25, no. 17 (June 10, 2007): 2389–96. http://dx.doi.org/10.1200/jco.2006.09.7931.
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Purpose To determine the impact of demographics and comorbidity on access to specialists' services, treatment, and outcome for patients with locoregional esophageal cancer. Patients and Methods We performed a retrospective cohort study of 3,538 patients older than age 65 years who were diagnosed with locoregional esophageal cancer between 1991 and 1999 in one of 11 regions monitored by the Surveillance, Epidemiology, and End Results tumor program. We examined linked Medicare claims for assessment by a surgeon, radiation oncologist, or medical oncologist and subsequent treatment with surgery, radiation, or chemotherapy. Logistic regression analyses were performed for seeing a specialist and for undergoing treatment according to age, sex, race, socioeconomic status, geographic region, and presence of comorbidities. Cox proportional hazards analyses were performed to estimate hazard ratios (HRs) for survival with and without adjustment for treatment received. Results Seeing a cancer specialist depended especially on age and region of diagnosis. These same factors were also related to subsequent treatment decisions, but associations were reversed in some regions, such that treatment depended less on region. Older patients had poorer survival (HR = 2.0 for 85+ v 65 to 69 years), which was partly explained by treatment received (HR decreased to 1.5 when adjusted for treatment). Conclusion Older patients have less intensive treatment of esophageal cancer, which is explained by both a lower rate of seeing a cancer specialist and by less intensive treatment once seen. Referring physicians and treating specialists must ensure that elderly patients are not deprived of the opportunity to consider all of their treatment options.
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Worrall, Hannah, Jane Chung, Munro Cullum, and Shane Miller. "Specialist Referral and Outcomes in Adolescent Athletes With Prior Concussion History." Neurology 98, no. 1 Supplement 1 (December 27, 2021): S19.2—S20. http://dx.doi.org/10.1212/01.wnl.0000801916.20997.22.
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ObjectiveTo examine specialist referral patterns and clinical outcomes in adolescents with differing levels of prior concussion history.BackgroundLimited evidence exists on healthcare utilization and outcomes in concussed adolescent athletes with and without a history of prior concussion.Design/MethodsData were prospectively collected from participants aged 12–18 diagnosed with a sport-related concussion and documented prior concussion history between August 2015-March 2020. Participants were separated into 3 groups: 0, 1, and 2 + prior concussions. Demographics, medical history, specialist referrals, and clinical outcome variables obtained at 3-months post-concussion were analyzed.ResultsOne thousand one hundred ninety-seven participants were included: 114 (10.4%) had 2+, 213 (19.4%) had 1, and 770 (70.2%) had 0 prior concussions. There was no difference in sex or time to presentation. A small difference was found across age (15.3 ± 1.6 vs 14.9 ± 1.6 vs 14.5 ± 1.6 years, p < 0.001). Significant differences were also observed between groups in self-reported history of psychological disorders (14.9 vs 15 vs 8.4%, p = 0.01) and headaches/migraines (25.4 vs 20.2 vs 15.5%, p = 0.02). Significant differences between the groups were found in specialist referrals, with more referrals made in the 2 + group to physical therapy (39.6 vs 28.2 vs 23.4%, p = 0.001), neuropsychology (17.1 vs 5.3 vs 7.5%, p = 0.001), and neurology (8.9 vs 2.9 vs 2.2%, p = 0.001). Fewer participants in the 2 + group recovered in = 30 days (53.6 vs 65.6 vs 68.5%, p = 0.04) and reported lower rates of return to activity at 3-months post-concussion (67.9 vs 85.9 vs 87.6%, p < 0.001). No differences were seen in symptom severity, PHQ-8, or GAD-7 scores. All reported as 2 + vs 1 vs 0.ConclusionsConcussed adolescent athletes with a history of 2 or more prior concussions had a higher rate of specialist referrals, were less likely to have returned to prior level of play/activity 3 months following injury, and were less likely to have resolution of symptoms in 30 days or less.
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Jung, Josephine, Jignesh Tailor, Emma Dalton, Laurence J Glancz, Joy Roach, Rasheed Zakaria, Simon P Lammy, et al. "Management Evaluation of Metastasis in the Brain (MEMBRAIN) – A UK & Ireland prospective, multicentre observational study." Neuro-Oncology 21, Supplement_4 (October 2019): iv4. http://dx.doi.org/10.1093/neuonc/noz167.016.
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Abstract Background Over the recent years an increasing number of patients with brain metastasis are being referred to the neuro-oncology multi-disciplinary team (NMDT). Our aim was to determine if referrals of this group of patients to the NMDT in the UK & Ireland comply with NICE guidelines and to assess referral volume, quality of information provided and its impact on NMDT decision-making. Methods Prospective multicentre oberservational study including all adult patients referred with ≥1 cerebral metastasis. Data was collected in neurosurgical units from 11/2017 to 02/2018. Demographics, primary disease, Karnofsky performance status (KPS), imaging and treatment recommendation were entered into an online database. Results 1049 patients were analysed from 24 neurosurgical units. Median age was 63[range 21–93] years with a median number of 3[range 1–17] referrals per NMDT. The most common primary malignancies were lung (36.5%, n=383), breast (18.5%, n=194) and melanoma (12.0%, n=126). 51.6% (n=541) of the referrals to the NMDT were within the NICE 2006 guidelines, and resulted in specialist intervention being offered in 68.8%. 41.2% (n=197) of patients being referred outside of the NICE 2006 guidelines were offered specialist treatment. NMDT decision-making was influenced by number of metastases, age, KPS, primary disease status and extent of extracranial disease (univariate logistic regression, p<0.0001) as well as metastasis location/histology (p<0.05). Conclusions This study confirmed a national change in culture of referral patterns. We identified a delay in NMDT decision-making in ~20%, contributing to increased NMDT workload. New stratification tools may be needed to reflect advancements in diagnostics and treatment modalities.
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Steinmann, Peter, Malika Baimatova, and Kaspar Wyss. "Patient referral patterns by family doctors and to selected specialists in Tajikistan." International Health 4, no. 4 (December 2012): 268–76. http://dx.doi.org/10.1016/j.inhe.2012.09.003.
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Nazriati, Elda, and Nuzelly Husnedi. "Profil Rujukan Kasus Nonspesifik pada Fasilitas Kesehatan Tingkat Primer." Kesmas: National Public Health Journal 9, no. 4 (May 1, 2015): 327. http://dx.doi.org/10.21109/kesmas.v9i4.739.
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AbstrakSalah satu indikator kualitas fasilitas kesehatan tingkat primer (FKTP)adalah rendahnya rujukan nonspesialistik. Rujukan nonspesialistik adalahrujukan dari 144 penyakit yang seharusnya dapat diatur di FKTP.Kenyataannya, masih banyak kasus nonspesialistik yang dirujuk ke fasilitas kesehatan sekunder. Penelitian deskriptif dengan metode campuran kuantitatif dan kualitatif ini bertujuan untuk mengetahui pola dan penyebab kasus penyakit nonspesialistik yang dirujuk ke fasilitas kesehatan tingkat sekunder di Kota Pekanbaru. Gambaran kasus penyakit nonspesialistik dikumpulkan dari data Badan Penyelenggara Jaminan Sosial Kesehatan Kota Pekanbaru periode Desember 2014 - April 2015, sedangkan faktor penyebab rujukan diperoleh dari focus group discussion yang diikuti oleh 40 dokter berdasarkan jenis FKTP. Penelitian ini menampilkan 20 kasus nonspesialistik yang paling sering dirujuk, di antaranya hipertensi esensial, miopia ringan, dan diabetes melitus. Penyebab rujukan kasus penyakit nonspesialistik antara lain kesalahan kode serta terbatasnya fasilitas, sumber daya manusia, manajemen pelayanan, dan kompetensi dokter. Semua faktor keterbatasan tersebut perlu diantisipasi agar upaya rujukan dapat diminimalisir.AbstractOne of primary healthcare facility quality indicators is the low non-specialistreferral. Non-specialist referral is referral of 144 diseases that should bearranged in primary healthcare facilities. In fact, there are many non-specialist cases referred to secondary health care facilities. This descriptive study using quantitative and qualitative method aimed to determine patterns and causes of non-specialist diseases referred to secondary primary health care in Pekanbaru City. Depiction of non-specialist disease cases was collected from data of the state health insurance scheme in Pekanbaru City on December 2014 - April 2015 period, meanwhile causes of referral were obtained from focus group discussion participated by 40 doctors based on types of primary healthcare facilities. This study showed 20 non-specialist cases oftenly referred including essential hypertension, mild myopia and diabetes mellitus. Causes of non-specialist disease referrals were code error as well as limited facilities, human resource, service management and competence of doctors. Such limitations need to be anticipated in order to minimalize act of referrals.
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Dolan, Bridget, and Kingsley Norton. "The predicted impact of the NHS White Paper on the use and funding of a specialist service for personality disordered patients: a survey of clinicians' views." Psychiatric Bulletin 15, no. 7 (July 1991): 402–4. http://dx.doi.org/10.1192/pb.15.7.402.
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In an earlier report (Dolan & Norton, 1990) we commented upon the potential vulnerability of specialist psychiatric units following the implementation of Working for Patients and the NHS Bill. Specialist units provide a valuable resource, not only in terms of treatment, but as sources of practical training, education, development of new therapies and of research. Many such units previously enjoyed financial protection at the regional health authority level. Downloading financial responsibilities to DHAs or NHS trusts will complicate the issue of funding since contracts will now need to be entered with each relevant DHA or NHS trust. This more cumbersome system is inevitably more costly for a specialist unit to operate. Users of such units (customers and consumers) will find referral problematic since funding must be identified in advance. Difficulty in negotiating the new, more complicated contracting system, may lead to a decline in specialist referrals. This will in turn lead to questioning of how necessary such ‘regional’ or (as in the case of Henderson Hospital) ‘national’ specialities really are. Managers may tend to argue that referral patterns will reflect (eventually) the true needs for treatment of particular client groups.
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Williams, S. T. B., and D. Power. "Hand injuries from tools in domestic and leisure settings: relative incidence and patterns of initial management." Journal of Hand Surgery (European Volume) 36, no. 5 (March 15, 2011): 408–12. http://dx.doi.org/10.1177/1753193411399682.
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A search of the UK Department of Trade and Industry’s Home and Leisure Accident database found 16,003 emergency hospital attendances in 2000–2002 following accidents with tools. The hand was the site of injury in 9535 cases (60%). The tool most commonly involved was a Stanley knife, causing as many hand injuries (21%) as all power tools combined. The power tools most frequently causing hand injury were circular saws (28% of power tool injuries), hedge trimmers (21%) and electric drills (17%). Compared to injuries from manual tools, power tool hand injuries were more than twice as likely to be referred to specialists and three times more likely to be admitted to hospital. Specialist referral/admission most commonly occurred following hand injury from mowers (51% admitted/referred), routers (50%) and circular saws (48%). The rate for manual blade injuries was 14%. Missed diagnoses following manual blade injuries may stem from comparatively low rates of specialist assessment.
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Blancquaert, Ingeborg R., Inta Zvagulis, Katherine Gray-Donald, and I. Barry Pless. "Referral Patterns for Children with Chronic Diseases." Pediatrics 90, no. 1 (July 1, 1992): 71–74. http://dx.doi.org/10.1542/peds.90.1.71.
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A sample of 1377 physicians were surveyed by mailed questionnaire to study to what extent primary care physicians are involved in the long-term care of children with chronic disorders. The sample included all pediatricians practicing in the province of Quebec and a stratified random sample of general practitioners (10% sample in urban areas and 25% sample in rural areas). A response rate of 81% was achieved. Referral patterns were studied for asthma, congenital heart disease, and diabetes. Although pediatricians referred their patients less frequently than general practitioners, referral patterns depended mainly on the clinical condition. "No routine referral" was the most popular management strategy for asthma, whereas for congenital heart disease and diabetes more than 20% of physicians referred their patients for all aspects of care. Rural physicians tended to assume patient care to a greater extent than did urban physicians. Most pediatricians referred patients directly to subspecialists practicing in tertiary care centers, whereas general practitioners often sent patients to pediatricians practicing elsewhere, or to other specialists. These data suggest that the availability of medical resources in the community and accessibility to tertiary care centers also influence physicians' involvement in the long-term care of these children.
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Button, Eric J., Elizabeth Benson, Claire Nollett, and Robert L. Palmer. "Don't forget EDNOS (eating disorder not otherwise specified): patterns of service use in an eating disorders service." Psychiatric Bulletin 29, no. 4 (April 2005): 134–36. http://dx.doi.org/10.1192/pb.29.4.134.
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Aims and MethodThe aim of the study was to track service consumption in adult referrals to a specialised NHS eating disorders service over a 3-year period. We examined clinical records of a year's cohort (1999) of 147 referrals (96% female) assessed from the local catchment area.ResultsThe most common diagnostic group (42.8%) presented with some form of eating disorder not otherwise specified (EDNOS). There was no significant relationship between diagnosis and service consumption, so that full syndrome eating disorders were no more labour-intensive overall than EDNOS patients. Indeed, EDNOS patients accounted for 50% of all outpatient appointments and over a half of all in-patient days.Clinical ImplicationsThe results suggest that those planning services for eating disorders need to take into account the substantial demand from EDNOS patients.
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Shayegan, Bobby, Alan I. So, Shawn Malone, Sebastien J. Hotte, Antonio Finelli, Christina M. Canil, Huong Hew, Laura Park-Wyllie, Kim N. Chi, and Fred Saad. "Patterns of prostate cancer management across Canadian prostate cancer treatment specialists." Journal of Clinical Oncology 36, no. 6_suppl (February 20, 2018): 321. http://dx.doi.org/10.1200/jco.2018.36.6_suppl.321.
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321 Background: The Canadian GU Research Consortium (GURC) was recently established to bring comprehensive prostate cancer centres together to collaborate on research, education, and adoption of best practices. As an initial step to inform the work of the GURC, an electronic questionnaire was designed to assess management of advanced prostate cancer care in Canada and better understand patterns of care. Methods: A 59-item online questionnaire was developed by a multidisciplinary scientific committee to measure physician practices, patterns of care, treatment sequencing, and management of mCRPC. After pre-testing, the online questionnaire was sent to 93 urologists, uro-oncologists, medical oncologists, radiation oncologists, and general practitioner oncologists who are actively involved in the treatment of prostate cancer. Results: A total of 49 (53%) respondents completed the questionnaire between April 17, 2017 to May 17, 2017. Although all respondents indicated a role in initiating life-prolonging oral therapy for mCRPC and monitoring treatment and side effects, chemotherapy initiation was mainly a medical oncologist role compared to other specialties (p < 0.05, chi-square). Symptom management such as palliative care and end-of-life care were provided mainly by radiation oncologists (100%) and medical oncologists (81%) compared to urologists (33%) and uro-oncologists (50%), p < 0.05, chi-square). Patient mix varied across the disciplines. Urologist practices were composed primarily of non-metastatic prostate cancer patients (73%), as were radiation oncologist practices (77%), while uro-oncologist practices included both non-metastatic (58%) and metastatic (40%) patients. Medical oncologists practices were mainly (91%) metastatic patients. Referral patterns also varied by discipline. Conclusions: In Canada, prostate cancer treatment involves multiple disciplines providing a range of care at different points across the treatment continuum. We plan to do further research to better understand variation in practice and improve multidisciplinary coordination for patients with advanced prostate cancer.
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Barzilay, Vered, Tal Ratson, Noa Sadan, Nurit Dagon, and Nir Shpack. "Orthodontic knowledge and referral patterns: a survey of paediatric specialists and general dental practitioners." Australasian Orthodontic Journal 36, no. 1 (2021): 55–61. http://dx.doi.org/10.21307/aoj-2020-007.
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Blythe, Robin, Xing Lee, Toni Simmons, Janine Cox, Kathleen McLean, Josephine Barfield, and Sanjeewa Kularatna. "Economic Analysis of Specialist Referral Patterns in Mackay, Queensland Following HealthPathways Implementation." Journal of Primary Care & Community Health 12 (January 2021): 215013272110414. http://dx.doi.org/10.1177/21501327211041489.
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Introduction: HealthPathways is a clinical information portal developed in New Zealand that enables general practitioners to manage and refer their patients in a local context. We analyzed specialist outpatient appointment costs in Mackay, Queensland before and after HealthPathways implementation. Methods: We retrospectively examined specialist outpatient costs for patients referred by Mackay general practitioners for conditions with varying levels of HealthPathways implementation. Ranked from most clinical pathways available to none, chronic diabetes, cardiology, respiratory, and urology visits from January to March 2015, pre-pathways, and January to March 2017, post-pathways, were assessed. Monte Carlo simulation was used to estimate cost changes. Per-visit costs were multiplied by visit numbers to estimate policy impact. Results: The mean cost per visit increased from $220 to $305 for diabetes and $270 to $323 for respiratory, and decreased from $296 to $257 for cardiology and $444 to $293 for urology. The policy impact for each disease group over 3 months after accounting for visit numbers was a likely saving of $30 360 for diabetes and $10 270 for cardiology, and a likely cost increase of $24 449 for respiratory and $20 536 for urology. Conclusions: We observed that conditions with more comprehensive clinical pathways cost Mackay HHS substantially less following implementation. Costs for low and no pathway implementation referrals increased slightly over the same period.
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D'Souza, Anita, Keren Osman, Cristiana Costa Chase, Azah Borham, and Marianna Bruno. "The Hematologist's Role in Amyloidosis Management: Disease Awareness, Diagnostic Workup, and Practice Patterns." Blood 136, Supplement 1 (November 5, 2020): 28–29. http://dx.doi.org/10.1182/blood-2020-137740.
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Introduction: Systemic amyloidoses are progressive, life-threatening diseases characterized by the deposition of amyloid protein fibrils of varying origin in different tissues/organ systems (Merlini G, et al. N Engl J Med 2003;349:583-96). The precursor amyloidogenic protein influences the disease's clinical course, and identification of the specific protein is essential because treatment varies substantially by subtype. While there are 36 known proteins that can aggregate as amyloid in humans (Benson MD, et al. Amyloid 2018;25:215-9), the two most prevalent protein subtypes causing cardiac amyloidosis are derived from immunoglobulin light chains (AL) and transthyretin (ATTR) (Kittleson MM, et al. Circulation 2020;141:e7-22). Both AL and ATTR subtypes often infiltrate the heart, resulting in a restrictive cardiomyopathy along with other multiorgan involvement. Appropriate classification, early identification, and prompt treatment may substantially improve clinical outcomes. Because AL disease occurs in the context of plasma cell dyscrasia, hematologists can play an important role in amyloidosis suspicion, diagnostic workup, and management. However, differentiation of AL and ATTR amyloidoses in patients with signs of cardiac dysfunction is often challenging, and a multidisciplinary approach, including referral to cardiologists, is recommended early in the patient diagnostic workup. To gain insights into hematologists' disease awareness and practices, we interviewed hematologists involved in amyloidosis patient care across the US. Methods: A qualitative double-blind telephone survey was conducted between November 2019 and February 2020 of US hematologists who had diagnosed and/or treated at least 2 patients with AL amyloidosis over the past 2 years. The participants differed based on their experience in various clinical practice settings, including community hospital and private practices, academic institutions, and amyloidosis centers. Results: A total of 16 hematologists participated in the survey (community hospital, n=3; community private practice, n=5; academic institution, n=3; amyloidosis center, n=5). Hematologists at amyloidosis/academic centers (AAC) reported that the AL amyloidosis patient's journey typically involved visits to multiple primary care physicians and specialists in the community over a prolonged period (approximately 1 to 1.5 years) before the patient received a diagnosis (Figure [A]). Community specialists' referrals to academic physicians within the same specialty, due to lack of familiarity with amyloidosis centers, contributed in part to the delay. Several differences were found between hematologists in the community and those at AAC in level of disease awareness and referral/testing practices (Table; Figure [B]). Hematologists in community practice were less likely to be aware of ATTR amyloidosis, refer patients with suspected amyloid to cardiologists, or conduct recommended screening/diagnostic testing. In contrast, hematologists at AAC were highly aware of ATTR amyloidosis, collaborated closely with cardiologists, and used recommended amyloidosis tests. Across practice settings, hematologists consistently conducted biopsies of bone marrow and fat pad in patients with suspected AL amyloidosis to confirm the presence of amyloid. After amyloid was confirmed with Congo red staining, 75% of community hematologists discontinued testing, without establishing the amyloid protein subtype; hematologists at AAC consistently assessed amyloid protein subtype using immunohistochemistry and/or mass spectrometry to differentiate AL and ATTR prior to initiating treatment. Diagnostic algorithms supporting AL and ATTR differentiation were consistently in place and followed at AAC but not in community-based practices. Conclusions: Disease awareness, referral practices, and screening/testing procedures can differ between hematologists in the community setting and those in AAC. Community hematologists may benefit from additional education and wider use of diagnostic algorithms on AL/ATTR amyloidosis. Reinforcing the importance of cardiology referral and guidance on best practices for screening/biopsies/subtyping in patients with suspected amyloidosis who have cardiac symptoms should be prioritized. Disclosures D'Souza: Amgen, Merck, TenoBio: Research Funding; Akcea, Imbrium, Janssen, Pfizer: Consultancy. Costa Chase:Celgene: Speakers Bureau. Borham:Pfizer: Current Employment, Current equity holder in publicly-traded company. Bruno:Pfizer: Current Employment, Current equity holder in publicly-traded company.
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Bernett, Courtney Nicole, Emma Hignett, and Pearl Kwong. "Management and Referral Patterns in Pediatric Atopic Dermatitis: A Survey of Pediatric Healthcare Professionals." SKIN The Journal of Cutaneous Medicine 4, no. 5 (August 29, 2020): 408–16. http://dx.doi.org/10.25251/skin.4.5.3.
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Background: The incidence of pediatric atopic dermatitis (AD) has continued to increase worldwide and pediatric healthcare providers (PHPs) are typically the initial healthcare provider tasked with management of this disease. The consequences of inadequately managed AD and misdiagnosed food allergies are devastating for patients and their families, and the financial burden associated with these scenarios can be overwhelming. Objective: To assess the management and referral patterns of pediatric AD patients by PHPs in the Jacksonville, Florida (FL) area. Methods: An online electronic survey was distributed to 70 PHPs using Survey Monkey©. Data was collected over a 6-week period. The survey yielded a sample size of 28. Results: Most participants were physicians (92.8%), with an average of 21.75 years in practice. Just over half (53%) of PHPs were aware of the American Academy of Dermatology (AAD) Guidelines of care for the management of AD. Dermatologists were the initial referral choice for AD management in 2/3, while 1/3 indicated preference for an allergist. Diet alteration was used by 14.3% as an initial AD management step and 35.7% tried elimination diets prior to referral to an allergist. Referral to specialists were low with 75% PHPs referring <25 % of their AD patients to dermatology. Conclusion: With the number of outpatient AD visits increasing amongst PHPs, knowledge of management guidelines, in-depth understanding of appropriate use and limitations of elimination diets and food allergen testing, and referral to specialists suitable for management of this cutaneous disorder are imperative, but found to be highly variable.
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Dua, Devakshi, and Sandeep Grover. "Profile of Patients Seen in Consultation-Liaison Psychiatry in India: A Systematic Review." Indian Journal of Psychological Medicine 42, no. 6 (November 2020): 503–12. http://dx.doi.org/10.1177/0253717620964970.
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Objectives: This review aimed to evaluate all the published studies from India conducted in the consultation-liaison (CL) psychiatry setting to identify the diagnostic patterns and referral rates in this setting. Understanding the same can help in organizing the services and knowing the training needs. Materials and Methods: A thorough literature search was done in August 2020 using different search engines (PubMed, Medknow, and Google Scholar). This was followed by an individual search of various Indian Psychiatry journals and a hand search of references in the available articles. Only those studies that described patients referred to psychiatry services from various specialties were included. Results: A total of 33 studies were selected for the review. More than half of them were published in the last 5 years. Studies have primarily reported psychiatric profile medically ill inpatients referred to CL psychiatry services, with the majority of the studies reporting the number of patients seen for the duration of at least 1 year. The referral rates for inpatients across different institutes have varied from 0.01% to 3.6%. The referral rates from emergency set-ups have varied from 1.42% to 5.4%, and in outpatients, from 0.06% to 7.17%. The most commonly diagnosed psychiatric disorders across different studies include depression; organic disorders, including delirium; substance use; intentional self-harm; and anxiety disorders. Conclusions: A limited number of studies have reported the profile of patients seen in CL psychiatry setups. Available data from these studies suggest that referral rates to psychiatry services from other specialists are dismal. There is an urgent need to change the focus of psychiatry training at both undergraduate and the postgraduate levels to enhance the psychiatric knowledge of physicians to improve psychiatry referrals.
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Ringus, Daina L., Sylvia H. Li, Thanh-Huyen T. Vu, Amina Guo, Selcen Yuksel, Rebecca S. Arch, Amee K. Patel, Gayatri B. Patel, and Anju T. Peters. "Management and referral patterns for new-onset chronic cough in primary care patients." Allergy and Asthma Proceedings 43, no. 6 (November 1, 2022): e72-e79. http://dx.doi.org/10.2500/aap.2022.43.220071.
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Background: The diagnosis and management of chronic cough in primary care is challenging despite it being one of the most common chronic conditions. Objective: Clinical characterization of patients with new-onset chronic cough in the primary care setting. Methods: This was a retrospective study of adult patients (ages ≥ 18 years) with at least three visits with primary care providers (PCP) for new-onset cough, with at least 8 weeks between the first and third visits, within a tertiary-care center and affiliated clinics between January 1, 2010, and January 1, 2019 (N = 174). We calculated the frequency of primary care visits, diagnostic testing, specialist referrals, and prescribed medications up to 18 months after the third visit with a PCP for cough. Results: Of 174 patients who met the criteria of new-onset chronic cough, >50% had four or more primary care visits related to cough. Despite that, 91 (52.3%) did not receive a referral to a specialist, and 41 (23.5%) did not receive an order for a chest radiograph during the evaluation of the chronic cough. Antibiotics and systemic corticosteroids were prescribed to 106 (61%) and 63 (36%) of the patients, respectively, and 20% were prescribed opiates. No patients were prescribed central-neuromodulating agents, and angiotensin-converting enzyme inhibitors were discontinued in 48% of the patients who were taking them (12/25). Conclusion: We found considerable heterogeneity and discrepancies with clinical guideline recommendations in patients who presented with new chronic cough. There is a substantial unmet need to study chronic cough in the primary care setting to inform important stakeholders.
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Greenwood, Judy. "Six years' experience of sharing the care of Edinburgh's drug users." Psychiatric Bulletin 20, no. 1 (January 1996): 8–11. http://dx.doi.org/10.1192/pb.20.1.8.
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Six yean ago, Edinburgh's community drug problem service established a model of shared care between drug specialists and general practitioners who were encouraged to prescribe oral methadone and other drug substitutes in an attempt to reduce drug injecting and the spread of HIV in a city with a high seroprevalence rate. Of Edinburgh's GPs, 70% now prescribe for around 1200 drug users who have altered their pattern of drug taking, with a marked shift away from injecting drug use, and towards oral pharmaceutical drugs. HIV rates among new referrals to the service have fallen from 21% to 8%.
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Aggarwal, Vishal R., Amy Joughin, Joanna Zakrzewska, Priscilla Appelbe, and Martin Tickle. "Dentists’ preferences for diagnosis, management and referral of chronic oro-facial pain: Results from a national survey." Health Education Journal 71, no. 6 (September 13, 2011): 662–69. http://dx.doi.org/10.1177/0017896911419350.
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Aim: To explore the diagnosis, treatment and referral patterns of chronic oro-facial pain patients by generalist primary care dentists (GDPs) in the UK. Methods: A cross-sectional survey was conducted using a non-stratified random sample of 500 GDPs who were selected from the General Dental Council register. A self-complete postal questionnaire with four hypothetical clinical case scenarios describing sub-types of chronic oro-facial pain (COFP) was used to investigate diagnosis, treatment and referral options of GDPs. Results: Two hundred and twenty (44%) GDPs responded. The majority correctly diagnosed temporomandibular disorder (TMD; 88%) and burning mouth syndrome (BMS; 92%). There was more variation in the diagnosis of the other cases related to persistent oro-facial pain. For TMD there was a clear preference for treatment with occlusal splint therapy, and referral to a temporomandibular joint (TMJ) specialist. The BMS scenario showed drug therapy and referral to an oral medicine specialist to be most popular. The chronic oro-facial pain cases had greater variation in management and choice of psychotherapy was related to duration of pain symptoms. Conclusions: The greater variation in responses to scenarios based on patients with chronic oro-facial pain may reflect the difficulty clinicians face in diagnosing and treating this condition. Management appears to follow a biomedical model and most clinicians chose to refer patients for treatment. There are few specialist services to cater for such referrals, indicating a need to train primary care practitioners in management of chronic COFP, along with the establishment of evidence-based guidelines.
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Kaleem, Tasneem, and Robert Clell Miller. "Trends in cancer care with the Affordable Care Act." Journal of Clinical Oncology 34, no. 7_suppl (March 1, 2016): 46. http://dx.doi.org/10.1200/jco.2016.34.7_suppl.46.
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46 Background: Accountable Care Organizations (ACO), as proposed by the Affordable Care Act, will change the delivery of health care in the United States. ACO serve as a network of providers with primary care providers (PCP) set up as gate-keepers for referrals to specialists. Within the next several years, many trends will emerge and drive progress of change, requiring oncologist to take a lead role to adapt to the evolving landscape of health care. Methods: Literature search of internet-based and academic sources for oncology and the Affordable Care, with a focus on ACO formation. Results: Four main expected trends and strategies to adapt to changes were formulated. Trend 1: Changes in referral patterns towards oncologists. Referral will be based on outcome data and ACO membership. Strategy: Increase communication and education to PCP and other providers. Endorse multidisciplinary clinics, which have shown to improve guideline compliance, coordination, and communication. Trend 2: Formation of large scale oncology provider groups collaborating with PCP/ACO. Physicians will be able to provide around the clock care to patients with the goal of reducing hospital visits. Strategy: Establish oncology homes with goal of reducing inpatient and ED visits by providing telephone symptom management, daily questionnaires and opportunities for end of life discussions. Trend 3: Reimbursement reform to oncologists based on quality measures. ACO can bill fee for service basis and eligibility for bonus payments based on outcomes. Strategy:Adherence to evidence based guidelines chosen by evaluating efficacy, toxicity and cost have been proven to increase quality of patient care. Trend 4: Development to pathway driven medicine.ACO structure lends to a centralized governance committee responsible in choosing guidelines for treatment within an ACO. Strategy: Oncologists should provide a voice for the field and patients when different guidelines are chosen. Conclusions: In the context of the Affordable Care Act, oncology specialists are encouraged to participate in the new organization model to ensure best outcomes for both physicians and patients. Awareness of future trends and ways to contribute will be the first step in adapting to implementation of the Affordable Care Act.
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Brunetto, Andre, David Olmos, Hendrik-Tobias Arkenau, Daniel Tan, Timomy Yap, Johann de Bono, Jorge Barriuso, and Stan Kaye. "Perceptions and Referral Trends into Phase I Oncology Trials: Results of a Clinical Survey." Journal of Oncology 2011 (2011): 1–6. http://dx.doi.org/10.1155/2011/861401.
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Introduction. A survey was sent to referring oncologists (ROs) to explore the reasons behind their referral patterns and perceptions of Phase I studies before and after being provided with outcome data from advanced colorectal cancer (ACRC) patients who participated in Phase I trials at the Royal Marsden Hospital (RMH).Results. The response rate was 32/50 (64%). The most common reason for referral was exhaustion of standard treatments (31%), and the main reason for referring to the RMH was proximity to patients (28%). The most frequent clinical parameter assessed prior to referral was performance status (93%). ROs spent a median of 15 min (range: 5–45 min) discussing general aspects of Phase I trials. In the second part of the questionnaire, after reviewing clinical outcome data of ACRC patients who participated in Phase I trials, 47% would change their approach, specifically, spend more time to discuss risks and benefits of Phase I trials (9%), consider prognostic factors before referral (13%), and increase the number of referrals (25%).Conclusion. This is the first report focusing on communication between ROs and a specialist Phase I unit. Outcome reporting can improve communication with ROs and importantly has the potential for better patient selection considered for Phase I oncology trials.
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Quinn, Gwendolyn P., Susan T. Vadaparampil, Ji-Hyun Lee, Paul B. Jacobsen, Gerold Bepler, Johnathan Lancaster, David L. Keefe, and Terrance L. Albrecht. "Physician Referral for Fertility Preservation in Oncology Patients: A National Study of Practice Behaviors." Journal of Clinical Oncology 27, no. 35 (December 10, 2009): 5952–57. http://dx.doi.org/10.1200/jco.2009.23.0250.
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Purpose Cancer survival rates are improving, and the focus is moving toward quality survival. Fertility is a key aspect of quality of life for cancer patients of childbearing age. Although cancer treatment may impair fertility, some patients may benefit from referral to a specialist before treatment. However, the majority of studies examining patient recall of discussion and referral for fertility preservation (FP) show that less than half receive this information. This study examined the referral practices of oncologists in the United States. Methods This study examined oncologists' referral practice patterns for FP among US physicians using the American Medical Association Physician Masterfile database. A 53-item survey was administered via mail and Internet to a stratified random sample of US physicians. Results Forty-seven percent of respondents routinely refer cancer patients of childbearing age to a reproductive endocrinologist. Referrals were more likely among female physicians (P = .004), those with favorable attitudes (P = .043), and those whose patients routinely ask about FP (odds ratio = 2.09; 95% CI, 1.31 to 3.33). Conclusion Less than half of US physicians are following the guidelines from the American Society of Clinical Oncology, which suggest that all patients of childbearing age should be informed about FP.
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VAN RIEL, E., C. C. WÁRLÁM-RODENHUIS, S. VERHOEF, E. J. T. H. RUTGERS, and M. G. E. M. AUSEMS. "BRCA testing of breast cancer patients: medical specialists' referral patterns, knowledge and attitudes to genetic testing." European Journal of Cancer Care 19, no. 3 (May 2010): 369–76. http://dx.doi.org/10.1111/j.1365-2354.2008.01065.x.
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Cho, Nam Ik, Chang Ju Hwang, Ho Yeon Kim, Jong-Min Baik, Youn Suk Joo, Choon Sung Lee, Mi Young Lee, So Jeong Yoon, and Dong-Ho Lee. "Referral patterns and patient characteristics at the first visit to a scoliosis center: a 2-year experience in South Korea without a school scoliosis-screening program." Journal of Neurosurgery: Pediatrics 21, no. 4 (April 2018): 414–20. http://dx.doi.org/10.3171/2017.10.peds17348.
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OBJECTIVEThe need for scoliosis screening remains controversial. Nationwide school screening for scoliosis has not been performed in South Korea, and there are few studies on the referral patterns of patients suspected of having scoliosis. This study aimed to examine the referral patterns to the largest scoliosis center in South Korea in the absence of a school screening program and to analyze the factors that influence the appropriateness of referral.METHODSThe medical records of patients who visited a single scoliosis center for a spinal deformity evaluation were reviewed. Among 1895 new patients who visited this scoliosis center between April 2014 and March 2016, 1211 with presumed adolescent idiopathic scoliosis were included in the study. Patients were classified into 4 groups according to the referral method: non–health care provider, primary physician, hospital specialist, or school screening program. The appropriateness of referral was labeled as inappropriate, late, or appropriate. In total, 213 of 1211 patients were excluded because they had received treatment at another medical facility; 998 patients were evaluated to determine the appropriateness of referral.RESULTSOf the 998 referrals of new patients with presumed adolescent idiopathic scoliosis, 162 (16.2%) were classified as an inappropriate referral, 272 (27.3%) were classified as a late referral, and 564 (56.5%) were classified as an appropriate referral. Age, sex, Cobb angle of the major curve, and skeletal maturity were identified as statistically significant factors that correlated with the appropriateness of referral. The referral method did not correlate with the appropriateness of referral.CONCLUSIONSUnder the current health care system in South Korea, a substantial number of patients with presumed adolescent idiopathic scoliosis are referred either late or inappropriately to a tertiary medical center. Although patients referred by school screening programs had a significantly lower late referral rate and higher appropriate referral rate than the other 3 groups, the referral method was not a significant factor in terms of the appropriateness of referral.
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Townsley, Carol A., Kendra Naidoo, Gregory R. Pond, Wendy Melnick, Sharon E. Straus, and Lillian L. Siu. "Are Older Cancer Patients Being Referred to Oncologists? A Mail Questionnaire of Ontario Primary Care Practitioners to Evaluate Their Referral Patterns." Journal of Clinical Oncology 21, no. 24 (December 15, 2003): 4627–35. http://dx.doi.org/10.1200/jco.2003.06.073.
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Purpose: Understanding why older patients are frequently underrepresented in cancer services use and clinical research may help to increase their participation in clinical trials and eventually result in better cancer care for this vulnerable population. Methods: To identify potential barriers that may prevent older cancer patients from being referred from a primary care physician (PCP) to an oncology specialist, a self-administered questionnaire was mailed to 9,312 PCPs throughout Ontario. Results: With a one-time mailing, 2,240 questionnaires were returned (response rate, 24%) of which 2,089 (93%) were assessable. Although 86% of respondents would refer most older patients with early-stage, potentially curable cancers to oncologists, only 65% would refer those with advanced-stage, potentially incurable cancers. The factors that most influence referral decisions of PCPs are patient’s desire to be referred (69%), type (54%) and stage (49%) of cancer, and severity of cancer symptoms (49%). Other factors including age do not seem to influence the referral decision. Approximately 9% of respondents found it difficult to refer older cancer patients to oncology specialists, with the most commonly cited barriers being the length of waiting lists, mandatory tissue diagnosis before referral, and the belief that oncologists seldom relate to PCPs. Conclusion: Most PCPs stated that they would refer all elderly patients with cancer to oncologists and that referral decisions were based mainly on patients’ wishes. Continued efforts are needed to overcome barriers in the referral process and to understand the perspectives of elderly patients to enhance their cancer care.
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Barlow, Sarah E., Frederick L. Trowbridge, William J. Klish, and William H. Dietz. "Treatment of Child and Adolescent Obesity: Reports From Pediatricians, Pediatric Nurse Practitioners, and Registered Dietitians." Pediatrics 110, Supplement_1 (July 1, 2002): 229–35. http://dx.doi.org/10.1542/peds.110.s1.229.
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Objective. The primary aim of this study was to identify interventions used by pediatric health care providers in treatment of overweight children and adolescents to identify provider educational needs. A secondary aim was to examine the association of certain provider characteristics with recommended evaluation practices. Study Design. A random sample of pediatricians, pediatric nurse practitioners, and registered dietitians (RDs) received questionnaires about their diet, activity, and medication recommendations for overweight patients and about referrals to specialists and programs. Results were examined for adherence to published recommendations and for associations with certain respondent characteristics. Results. A total of 940 providers responded (response rate: 19%–33%). The majority recommended “changes in eating patterns” and “limitations of specific foods.” Half or more used “low-fat diet” and “modest calorie restriction” in adolescents. Less than 15% used “very low-calorie diet.” Fewer RDs recommended more restrictive diets. More than 60% of all groups followed recommended eating interventions for school-aged children and adolescents. More than 80% followed recommended physical activity interventions for all age groups. In each group, about 5% sometimes recommended prescription medication and herbal remedies for adolescents. None recommended surgery. Two thirds of pediatricians and pediatric nurse practitioners often referred to RDs. Approximately 20% referred to child/adolescent weight programs, but for 27% to 42%, these programs or pediatric obesity specialists were not available. No consistent associations between respondent characteristics and adherence to recommended interventions were identified. Conclusions. The providers generally promoted healthy eating and activity with minimal use of highly restrictive diets or medication to control weight.
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Ward, Jeanette, and Glenys Rikard-Bell. "Improving local services for women with breast cancer: Interviews with general practitioners in Central Sydney." Australian Health Review 23, no. 2 (2000): 123. http://dx.doi.org/10.1071/ah000123.
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We conducted interviews with 85 randomly selected general practitioners (GPs) in Central Sydney to examine patterns of referral of women with breast cancer, satisfaction with local services, awareness of evidence-based guidelines and suggestions for local support.Previous experience was the most frequently cited factor influencing choice of specialist (n=80, 94%)followed by personal knowledge of the consultant's expertise (n=72, 85%). Only one third of respondents agreed women wanted to be more involved in choosing the specialist (n=28, 33%). Of 79 women recently diagnosed with breast cancer, the majority (96%) had been referred to a male surgeon (n=71, 96%).While only 35% of the GPs rated the care received by women with breast cancer in local facilities as 'excellent', significantly fewer rated communication between GPs and specialists as 'excellent' (35% v19%, p<0.01). Younger GPs were less likely to rate communication as 'excellent' compared with GPs aged 55 years or older (p=0.01). Only 18% of GPs considered their patients as having been 'very well informed' about their treatment choices. Younger GPs were more likely than older GPs to recall all available breast cancer guidelines (p=0.02). Significantly more GPs (68%) requested seminars with experts than any other types of educational support (p<0.001).To improve outcomes for women with breast cancer, mechanisms to support communication between GPs and specialists are recommended. Seminars for GPs with experts who emphasize evidence-based guidelines should be funded and evaluated, especially for impact in meeting the needs of older GPs.
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Mutatiri, Clyson, Angela Ratsch, Matthew R. McGrail, Sree Venuthurupalli, and Srinivas Kondalsamy Chennakesavan. "Referral patterns, disease progression and impact of the kidney failure risk equation (KFRE) in a Queensland Chronic Kidney Disease Registry (CKD.QLD) cohort: a study protocol." BMJ Open 12, no. 2 (February 2022): e052790. http://dx.doi.org/10.1136/bmjopen-2021-052790.
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IntroductionChronic kidney disease (CKD) is a rapidly increasing and global phenomenon which carries high morbidity and mortality. Although timely referral from primary care to secondary care confers favourable outcomes, it is not possible for every patient with CKD to be managed at secondary care. With 1 in 10 Australians currently living with markers of CKD against a workforce of about 600 nephrology specialists, a risk stratification strategy is required that will reliably identify individuals whose kidney disease is likely to progress.Methods and analysisThis study will undertake a retrospective secondary analysis of the Chronic Kidney Disease Queensland Registry (CKD.QLD) data of consented adults to examine the referral patterns to specialist nephrology services from primary care providers and map the patient trajectory and outcomes to inform the optimal referral timing for disease mitigation. Patient data over a 5-year period will be examined to determine the impact of the kidney failure risk equation-based risk stratification on the referral patterns, disease progression and patient outcomes. The results will inform considerations of a risk stratification strategy that will ensure adequate predialysis management and add to the discussion of the time interval between referral and initiation of kidney replacement therapy or development of cardiovascular events.Ethics and disseminationThis protocol was approved by the Ethics Committee of the Royal Brisbane and Women’s Hospital in January 2021 (LNR/2020/QRBW/69707 14/01/2021). The HREC waived the requirement for patient consent as all patients had consented for the use of their data for the purpose of research on recruitment into CKD.QLD Registry. The results will be presented as a component of a PhD study with The University of Queensland. It is anticipated that the results will be presented at health-related conferences (local, national and possibly international) and via publication in peer-reviewed academic journals.
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Kenney, Lisa Brazzamano, Bethany Ames, Alexis L. Michaud, David Williams, Nicole A. Ullrich, and Peter Manley. "Managing childhood cancer survivors at risk for stroke: Practice norms and areas of controversy." Journal of Clinical Oncology 36, no. 7_suppl (March 1, 2018): 124. http://dx.doi.org/10.1200/jco.2018.36.7_suppl.124.
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124 Background: Childhood cancer survivors (CCS) treated with cranial radiation (CR) are at increased risk for stroke. There is no evidence to guide stroke prevention strategies for CSS. We aimed to describe regional practice norms for managing survivors at risk for stroke and to define areas where management is controversial. Methods: We conducted a Delphi panel of 30 physicians from the New England region who care for CCS, including primary care and specialists. Panelists anonymously answered 3 rounds of open ended questionnaires querying their management approach to a childhood brain tumor survivor treated with CR formatted as 5 clinical scenarios (asymptomatic, large and small vessel cerebral vascular disease (CVD), TIA, stroke), covering 5 categories of management (imaging, lab testing, medication, counseling, referrals). Consensus was defined as ≥ 90% of panelist agreeing with management option. Results: There was a 100% response rate for all 3 rounds of questionnaires. Of the 25 management questions related to 5 clinical scenarios, consensus was reached on 18 while 7 remained controversial. In the scenario of acute stroke symptoms, consensus was reached in all 5 categories of management. In the scenarios of large vessel CVD with symptoms of a TIA, large-vessel CVD without symptoms, and small-vessel CVD without symptoms panelists did not reach consensus on medication, specifically, aspirin use. The primary reasons for disagreement were no evidence for benefit/risk and beyond area of expertise. In the scenario of an asymptomatic survivor with no history of CVD panelists did not reach consensus on indication for MRI surveillance imaging, the primary reasons for disagreement were no clear benefit and risk of findings with uncertain clinical significance. Consensus was not reached on specialty referral patterns in any scenario except acute stroke. Conclusions: Despite lack of evidence to guide stroke prevention in childhood cancer survivors treated with CR, a panel of regional physicians reached consensus on managing most clinical scenarios. Controversial areas requiring further study are follow-up imaging for asymptomatic survivors, aspirin for stroke prophylaxis, and indications for sub-specialty referral.
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Jensen, Morten Sall, Kim Rose Olsen, Lars Morsø, Jens Søndergaard, and Berit Schiøttz-Christensen. "Does changed referral options affect the use of MRI for patients with low back pain? Evidence from a natural experiment using nationwide data." BMJ Open 9, no. 6 (June 2019): e025921. http://dx.doi.org/10.1136/bmjopen-2018-025921.
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ObjectivesThis study reports lumbar MRI referral patterns in the Region of Southern Denmark (RSD) and investigates the hypothesis that we will see an increase in imaging rates (MRI rates) following new referral options to lumbar MRI in the RSD in comparison with the other regions in Denmark from 2010 to 2013.DesignA difference-in-difference (DD) analysis, using general practitioners (GPs) in other regions as control, was used to test if the new referral options had an effect on the MRI rates.SettingIn 2010, RSD introduced organisational changes affecting the referral options for lumbar MRI. First, the possibility for direct referral to lumbar MRI was introduced GPs, and second, the region gathered all local spine departments into one specialist hospital called the Spine Centre.ParticipantsWe retrieved all lumbar MRIs performed on patients aged 18+ performed on Danish hospitals from 2008 to 2013 using the registries from Statistics Denmark. We use sociodemographic information from all Danish citizens aged 18+ aggregated to GP level. Primary and secondary outcome measures: lumbar MRI scans per 1000 capita enlisted with a GP (MRI rates) were calculated based on GPs patient list. Four referral types were made to describe changes in referral patterns.ResultsIn total 183 389 patients received 240 760 lumbar MRIs in the period. The use of the direct referral option by GPs in the RSD increased by 115% in the period from 2010 to 2013 and accounted for 34% of all referrals (n=6545) in 2013. MRI rates were significantly higher in RSD following the organisational changes (DD 1.389(0.925–1.852) lumbar MRI per 1.000 enlisted with a GP).ConclusionsIntroduction of organisational changes in RSD as direct referral to lumbar MRI from GPs and chiropractors as well as establishing a Spine Centre increase the lumbar MRI rate in comparison with other regions in Denmark.
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Joseph, Kathie-Ann P., Shubhada Dhage, and Kenneth Rifkind. "Genetic counseling and testing of an underserved population at a large city hospital." Journal of Clinical Oncology 32, no. 26_suppl (September 10, 2014): 38. http://dx.doi.org/10.1200/jco.2014.32.26_suppl.38.
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38 Background: Genetic counseling and testing for hereditary breast and ovarian cancer is underutilized in low-income and racial/ethnic women. We examine the number of patients referred for genetic counseling over from 2011-2012, clinic referral pattern, and number of patients tested in a population of largely underserved, immigrant patient population. Methods: The study was conducted in Bellevue Hospital. A retrospective review of patients referred to this institution’s high-risk clinic was analyzed. Demographics, insurance status, BRCA status, if tested, and source of referral were collected. Results: Between 2011-2012, 196 patients were referred for genetic counselling. The majority of the referrals came from specialty clinics: Breast Surgery (42%), Medical Oncology (24%) and Gyn (8.7%). 17.5% were classified as other. One percent of consults came from internal medicine, 0.5% from women’s clinic, 4% were referred from family members. Of those patients counseled, 83 were tested. Breast surgery had the highest yield with 49% of the patients tested, followed by med onc (33%). One patient refused testing. Forty-seven of our patients were able to receive genetic testing through Myriad hardship, thirty-three through Medicaid, two paid by Bellevue Hospital, and one by private insurance. Five patients were BRCA1 positive, five patients were BRCA2 positive (12% of patients tested); An additional five patients were BRCA2 MUS. Racial/ethnic breakdown of the BRCA positive patients were 40% Asian, 20% Latina, 30% African American, 10% White. Four patients had a personal history of BrCa, two patients personal history of OvCa, one patient personal history of BCa/OvCa, and three patients FHBCa/OvCa. Conclusions: Genetic testing for HBOC can be underutilized in low-income and racial/ethnic women due to lack of insurance and lack of education. It is possible to get many high-risk women tested and most patients are receptive to testing when the benefits of testing are clearly explained. Our results indicate that while cancer specialists are referring high-risk patients, there may be room for education on the part of primary care specialists to refer more unaffected high risk patients. This may afford patients the opportunity to make better informed screening and treatment decisions.
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Pelegrina-Cortés, Beatriz, Laura Bermejo, Bricia López-Plaza, Samara Palma-Milla, Natalia García-Vázquez, and Carmen Gómez-Candela. "Nutritional Composition Assessment of 3000 Individualized Parenteral Nutrition Bags in a Tertiary Referral Hospital: Current Prescribing Patterns." Nutrients 10, no. 8 (August 13, 2018): 1079. http://dx.doi.org/10.3390/nu10081079.
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Individualized parenteral nutrition is the most specialized type of nutritional support in the hospital setting. The composition and prescribing patterns for parenteral nutrition have evolved due to new emerging scientific evidence. In the last few years, there has been a tendency to increase the nitrogen and lipid content and decrease the carbohydrate content. To assess the prescribing pattern in a tertiary referral hospital in Spain, the nutritional composition of individualized parenteral nutrition was evaluated retrospectively from January to December of 2016. A total of 3029 parenteral nutrition units were analysed, corresponding to 257 hospitalized adult patients. Medical specialists in General Surgery and Haematology were the most common petitioners. The three most frequently prescribed parenteral nutrition formulae contained 13.4 (28.8%), 15.7 (19.54%) and 17.9 (17.79%) g of nitrogen. The quantity of carbohydrates and lipids showed a mean non-protein calories-to-nitrogen ratio of approximately 78:1 and a carbohydrate-to-lipid ratio that was near 50:50 in most cases. These results suggest a trend towards the administration of parenteral nutrition with a high content of nitrogen and smaller proportion of the non-protein components.