Abstract
Background: Non-compliance with designated referral pathways has ramifications such as increased patient waiting time, overburdening of higher levels of care and increasing healthcare costs on patients and the healthcare system. The purpose of this study was to assess the determinants of self-directed referrals amongst patients attending hospitals in the eThekwini district of KwaZulu-Natal.Methods: An analytic, cross-sectional study was conducted at the Medical Outpatient Departments across five district hospitals in eThekwini using interviewer-administered questionnaires. Descriptive statistics were used to determine the proportion and the most frequent factors contributing towards patient self-referral. The likelihood of patients to self-refer was tested using chisquare (X2) and a multivariate regression model.Results: There were 315 patients interviewed with 35% (n = 109/315) having self-referred. The majority (51%; 55/107) of selfreferrals were male and were of African race (74%; n = 80/107). Five institutional factors, namely: availability of medication at the pharmacy (98%); quality of care at the facility (93%); waiting time at facility (92%); services provided (90%); and attitude of healthcare workers (87%), were ranked as the main drivers of self-referral. Multivariate logistic regression established a significant positive association between patient self-referral and male gender (OR 1.73; CI 1.04–2.87, p 0.05). Age 39 years (OR 0.96; CI 0.94–0.99, p 0.05); and patient awareness of a referral letter (OR 0.28; CI 0.09–0.86, p 0.05) emerged as protective factor against self-referrals.Conclusion: Males patients tend to bypass the referral pathway whilst younger patients and patients who were aware of a referral letter were less likely to bypass the referral system. In addition to addressing the systemic challenges of waiting times, quality of care and availability of medication, a patient-oriented approach that comprises education, encouragement and increased patient awareness is an important strategy to improve referral pathway compliance.
Highlights
Non-compliance with designated referral pathways has ramifications such as increased patient waiting time, overburdening of higher levels of care and increasing healthcare costs on patients and the healthcare system
A total of 315 patients attending the medical outpatient department (MOPD) across two district and three combination district/regional hospitals in eThekwini were recruited to participate in the study during the sevenday study period (May 25–28, 2015 and June 8–10, 2015)
Addington had the largest number of self-referrals (26.6%), followed by Osindisweni (22.9%) and King Dinuzulu hospital (19.3%)
Summary
Non-compliance with designated referral pathways has ramifications such as increased patient waiting time, overburdening of higher levels of care and increasing healthcare costs on patients and the healthcare system. Namely: availability of medication at the pharmacy (98%); quality of care at the facility (93%); waiting time at facility (92%); services provided (90%); and attitude of healthcare workers (87%), were ranked as the main drivers of self-referral. In addition to addressing the systemic challenges of waiting times, quality of care and availability of medication, a patient-oriented approach that comprises education, encouragement and increased patient awareness is an important strategy to improve referral pathway compliance. Prior to 1994, the healthcare system was fragmented (consisting of 14 health departments), inequitable (resources and distribution favoured the whites and urban population), predominantly curative (preventive primary care services were provided in separate facilities) and hospi-centric.[1] The post-democratic government introduced a number of pro-equity reforms to restructure the healthcare system. District hospitals were included as part of the district health system.[2]
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