Health Care Referrals Research Articles

502. COMPARING NEOADJUVANT TREATMENTS REGARDING DYSPHAGIA AND WEIGHT CHANGES FOR PATIENTS WITH OESOPHAGEAL OR GASTRO OESOPHAGEAL CANCER

Abstract Background Dysphagia is the main symptom for patients diagnosed with cancer in the oesophagus or gastro oesophageal junction (GOJ), but there are lack of recent studies confirming this. Several studies have reported relief of dysphagia during neoadjuvant treatment but there might also be side effects affecting nutritional status resulting in weight loss. We wanted to investigate if there are differences between the mainly used neoadjuvant treatments in Sweden today, namely CROSS, FLOT, and other treatments (OT), for example prolonged neoadjuvant treatment due to oligometastatic cancer. Aims of this study was to investigate dysphagia, weight changes, and main causes of healthcare referral. Methods All patients with cancer in the oesophagus or GEJ receiving neoadjuvant treatment followed by subsequent oesophagectomy at Karolinska University hospital in Stockholm, Sweden January 2017 to June 2022 were included in the study. Data were extracted from the local prospective database and the electronic medical records. To grade the severity of dysphagia we used the five graded Ogilvie score. The weight as well as the dysphagia score was evaluated before oncological treatment and before surgery. The patients were divided into three groups, them receiving CROSS, FLOT and OT, respectively. Results There were 69 patients receiving CROSS, 68 receiving FLOT and 28 receiving OT. The patients experienced relief of dysphagia in all groups, CROSS p<0.001, FLOT p<0.001 and OT p<0.001. Patients receiving CROSS lost 1.32 kg weight (-8.5 kg to 6.4 kg), while those receiving FLOT gained 0.08 kg (-5.5 kg to 11.1 kg) and OT lost 0.49 kg (-20 kg to 8 kg). Dysphagia was the main symptom for patients diagnosed with oesophageal cancer or GEJ (65%), other causes (9%), followed by anaemia (8 %), reflux (6%), pain (6%) and au passant (5%). Conclusion All groups experienced statistically significant relief of dysphagia during the neoadjuvant treatments. There were small differences in weight changes between the treatment groups, although patients undergoing chemoradiotherapy treatment lost more weight compared to those only receiving chemotherapy. Main cause of referral is dysphagia. Key words Oesophageal cancer, neoadjuvant therapy, dysphagia, weight

Experiences and barriers in downward referral decision-making for palliative care patient caregivers under China's three-tiered linkage model: A qualitative study

ObjectiveThis study aimed to explore hospice caregivers’ downward referral decision-making experiences and barriers under the triadic linkage model in China and to analyze the deeper social dynamics of hospice referral choices. MethodsSemi-structured interviews were conducted with caregivers handling hospice referrals from two primary hospice agencies in Nanjing, China. The themes were analyzed and summarized using the Colaizzi 7-step analysis. ResultsFour themes and nine subthemes were extracted: multidimensional caregiver psychological experience (Dilemma and Guilt, Emotional Support and Psychological Adaptation), perceived disparities between referral organizations (convenience and affordability in the home community, perceived lack of primary health care resources), limitations of caregiver decision-making (cognitive comprehension bias, difficulty in information seeking, and passive acceptance of decision making), and limitations of health care referral support (lack of health care referral guidance, inadequate referral handoffs). ConclusionsFeedback from caregivers of hospice-referred patients reveals many barriers to hospice referral decision making and referral implementation. Overcoming these barriers entails efforts to change the cognitive misunderstandings regarding hospice referrals from patients' perspective, clarify the distribution of responsibilities among hospice agencies, and provide information support and decision-making assistance. These measures must be employed to improve the implementation of hospice referral, realize the multiple benefits of hierarchical diagnosis and treatment, boost patients’ satisfaction with the referrals, and ensure the rational and efficient distribution of hospice resources.

Pastors as Partners in Care: African Immigrant Pastors' on Mental Health Care Referral Processes for Young Congregants Experiencing Symptoms of Psychosis in the US.

Early support for young people experiencing psychosis is key to preventing negative outcomes. First and second-generation Black immigrants to predominantly white countries are at higher risk for psychosis (Bourque et al. in Psychol Med 41(5):897-910, 2011) and novel interventions are needed to help support immigrants youths and families.African immigrant pastors are culturally valued and poised to help congregants with psychosis and their families, but we know little about the supports pastors offer and what kinds of tools they might need to address the needs of their congregants. This qualitative study explores semi-structured interviews with 16 primarily nondenominational, Christian, African immigrant pastors to elucidate how they served young adult congregants experiencing symptoms of psychosis and their families. Using grounded theory analytic methods, five key themes emerged: (1) building supportive relationships; (2) identifying the source; (3) healing the problem; (4) families as partners in care; and, (5) referring congregants to and collaborating with mental health professionals. These findings describe an initial set of care practices as a starting point for understanding the current and future role of African immigrant pastors as partners in providing mental health care.

Differentiated health insurance policy for coordinating healthcare referral in hierarchical healthcare systems with an internet diagnosis platform

The integration of the Internet with traditional medical services is poised to transform health insurance policies. This study aims to explore the coordinating role of differentiated health insurance policies within the context of Internet healthcare. A four-stage sequential game decision-making model is developed within a queuing framework to address scenarios involving online patient referrals and misdiagnoses. The model begins by analyzing the equilibrium arrival strategy of patients, followed by the determination of optimal service capacity strategies for a nonprofit community health center (CHC) and optimal pricing strategies for a for-profit general hospital (GH). Additionally, the model describes an optimal differentiated subsidy strategy for the government aimed at minimizing total social costs. Analysis reveals that under certain conditions, an increase in the service price at GH relative to CHC can lead to a higher influx of online patients visiting GH in person. Furthermore, when the number of online patients exceeds a specific threshold, it not only prompts the government to increase the disparity in health insurance subsidies between the two hospital tiers but also encourages GH to reduce its service prices and offer free services to online patients. Numerical experiments explore the effects of government budgets, sharing ratios, and other variables on the system's equilibrium state, providing several managerial insights. Notably, when patients' misdiagnosis costs are partially covered, increasing GH's misdiagnosis cost-sharing ratio not only enhances the patient arrival rate but also enhances GH's profitability.

Identifying Care Gaps and Referral Patterns in Acute Dermatology at Urgent Care Centers.

Limited urgent access to board-certified dermatologists drives patients to seek dermatologic care at urgent care centers (UCC). UCC are staffed by clinicians with comparatively limited dermatology training, often resulting in lower quality care for acute dermatology conditions. This study investigates health care referral outcomes of patients seeking dermatologic care at UCC, examine the appropriateness of UCC dermatologic care, and assess the feasibility of referral management by eConsult. We utilize a retrospective cohort of 807 patients and a provider survey to examine referral outcomes of patients referred to University of Rochester Dermatology (UR-Derm), a tertiary care university-based teaching hospital, from UR UCC between January 1, 2021, and August 31, 2022. Outcomes for healthcare referrals included patient demographics, referral completion rates, UR-Derm appointment wait times, and diagnostic concordance rates between UCC and UR-Derm. Outcomes from the provider survey included appropriateness of UCC treatment plans, appropriateness of UCC referral to UR-Derm, and feasibility of referral management by eConsult. Patients who utilized UCC were predominately white (77.0%) females (53.9%) with a mean age of 37.9 years. Most patients referred by UCC did not complete an in-person UR-Derm evaluation (58.6%). Of those who did complete a UR-Derm visit, the average wait time was 38.3 days. Only 56% of UCC and UR-Derm diagnoses were concordant. Our surveyed dermatologists deemed 30% of the UCC treatment plans appropriate. The majority of referrals (83.5%) were viewed as manageable with an eConsult with only 10% of referrals requiring in-person visit. Several practice gaps exist in specialty care delivery in UCC and additional inefficiencies exist in the urgent referral process. These gaps could be addressed by targeted educational interventions and availability of dermatology consultation to support urgent care.

Weight stereotypes in eating disorder recognition

ABSTRACT Objective We investigated weight stereotypes in the recognition and referral of eating disorders (EDs) by assessing if recognition, health care referral, perceived acceptability, perceived distress, and perceived prevalence of an ED differ depending on the weight of the subject in the vignette. Method Community participants (N = 180, age = 19–74) read three different vignettes describing three females with different EDs [anorexia nervosa/atypical anorexia nervosa (AN/AAN), bulimia nervosa (BN), binge eating disorder (BED)] and were randomized to three different experimental conditions concerning an individual with a different weight (overweight, normal, and underweight). Results Across EDs, participants were more likely to recognize a problem, refer for treatment, and rate a higher perceived level of distress in the vignettes of overweight individuals than in the vignettes of normal weight individuals. For BED, a larger proportion of participants in the overweight condition classified the issue described in the vignette as a form of eating pathology compared to the normal weight condition. Discussion These results highlight several weight stereotypes that exist in the recognition and health care referral of EDs. Future ED education and awareness programs should emphasize that EDs can occur in any individual, regardless of their weight.

The Diagnostic Significance of the Holter Monitoring in the Evaluation of Palpitation at Tanta University Hospitals

Background: Palpitations are the second-most common cause of primary healthcare referrals to cardiologists and are linked to long-term morbidity. Despite the absence of a significant underlying cause, a considerable number of patients report fear and anxiety. The purpose of this study was to assess individuals who were evaluated for palpitation in order to ascertain the diagnostic yield of 24 or 48 hours of Holter monitoring.
 Methods: 105 participants participated in this prospective observational cross-sectional research, children and adults, with palpitations, dizziness and syncope, with Holter monitoring 24 or 48 hours. Every patient had a thorough medical history, clinical evaluation, and physical assessment, Resting Electrocardiography (ECG), Transthoracic Echocardiography, and Holter monitoring. Patients were further subdivided into two groups: Positive Holter group and Negative Holter group.
 Results: Symptoms among positive Holter response showed that 48.6% had palpitations, 34.2% had dizziness and 13.3% had syncope. Higher age, increased frequency of danger factors (Diabetes mellitus, Hypertension, Ischemic heart disease, cardiomyopathy), symptoms (Palpitations, Dizziness, Syncope), Premature ventricular contractions and lower Ejection fraction was observed in patients with positive Holter response compared to patients with negative Holter response. There was no significant association with sex, smoking, Atrial fibrillation, regular sinus rhythm, and premature atrial contractions (P ≤ 0.05).
 Conclusions: Holter Monitoring retains its value, despite the appearance of new investigations and considered the first line for assessment of palpitations as it is widespread and not expensive. It has a good outcome if the patient’s symptoms are suggestive for arrhythmia, syncope and dizziness.

Evaluation of Diabetes Risk Score Tool for Detecting Undiagnosed Type 2 Diabetes Mellitus in Attendees of Referral Clinics at Primary Health Care Centers, Sudan

Introduction: The prevalence of diabetes in Sudan is increasing; however, suitable risk assessment and screening tools to identify at-risk individuals are lacking. Objective: To evaluate the Diabetes Risk Score (DRS) tool for detecting Type 2 Diabetes Mellitus among undiagnosed individuals. Methods: In this cross-sectional study, 214 individuals were recruited from Primary Health Care Referral Centers in Khartoum State. Attendees were interviewed to fill out the Diabetes Risk Score (DRS) questionnaire. Random blood glucose and glycosylated hemoglobin (HbA1c) were tested. Descriptive statistics and sensitivity analysis were performed to test the applicability of the DRS in Sudan. Results: The prevalence of undiagnosed diabetes was found to be 14%. Regarding blood tests, Random blood glucose (RBG) was normal in 93% of the participants (cutoff ≤140 mg/dl). The HbA1c result was normal in 86% of the participants (cutoff < 6.4%). The DRS was high in 40.2% (cutoff ≥33), while 59.8% were considered moderate to low risk. The DRS had a sensitivity of 83.33% and a specificity of 66.85%. The positive and negative predictive values were 29.07% and 96.09%, respectively. The Area Under the Curve (AUC) for detecting undiagnosed diabetes was 0.751 (95% CI: 0.662-0.840). Conclusion: The DRS tool was found to be applicable with reference to the HbA1c test for predicting undiagnosed diabetic patients.

Evaluation of Diabetes Risk Score Tool for Detecting Undiagnosed Type 2 Diabetes Mellitus in Attendees of Referral Clinics at Primary Health Care Centers, Sudan

Introduction: The prevalence of diabetes in Sudan is increasing; however, suitable risk assessment and screening tools to identify at-risk individuals are lacking. Objective: To evaluate the Diabetes Risk Score (DRS) tool for detecting Type 2 Diabetes Mellitus among undiagnosed individuals. Methods: In this cross-sectional study, 214 individuals were recruited from Primary Health Care Referral Centers in Khartoum State. Attendees were interviewed to fill out the Diabetes Risk Score (DRS) questionnaire. Random blood glucose and glycosylated hemoglobin (HbA1c) were tested. Descriptive statistics and sensitivity analysis were performed to test the applicability of the DRS in Sudan. Results: The prevalence of undiagnosed diabetes was found to be 14%. Regarding blood tests, Random blood glucose (RBG) was normal in 93% of the participants (cutoff ≤140 mg/dl). The HbA1c result was normal in 86% of the participants (cutoff < 6.4%). The DRS was high in 40.2% (cutoff ≥33), while 59.8% were considered moderate to low risk. The DRS had a sensitivity of 83.33% and a specificity of 66.85%. The positive and negative predictive values were 29.07% and 96.09%, respectively. The Area Under the Curve (AUC) for detecting undiagnosed diabetes was 0.95 with a confidence level (CI 0.92 to 0.98). Conclusion: The DRS tool was found to be applicable with reference to the HbA1c test for predicting undiagnosed diabetic patients.

Treatment Referrals Post-prohibition of Alcohol Exclusion Laws: Evidence from Colorado and Illinois

BackgroundIndividuals with alcohol-related disorders often encounter barriers to accessing treatment. One potential barrier is the state alcohol exclusion laws (AELs) that allow insurers to deny coverage for injuries or illnesses caused by alcohol intoxication. Several states have repealed AELs by prohibiting them completely, including banning exclusions in health and accident insurance policies, limiting their scope, or creating exemptions.ObjectivesTo examine whether prohibiting alcohol exclusions in health and accident insurance policies is associated with alcohol-related treatment admissions.DesignWe used the 2002 to 2017 Treatment Episode Data Set and obtained data from several sources to control for state-level factors. We employed a heterogeneous difference-in-differences method and an event study to compare the treatment admissions in Colorado and Illinois, two states that uniquely repealed AELs, with control states that allowed or had no AELs.Main MeasuresWe used aggregated alcohol treatment admission for adults by healthcare referral: (i) with alcohol as the primary substance and (ii) with alcohol as the primary, secondary, or tertiary substance.Key ResultsWe found a significant relationship between AEL repeal and increased referrals. AEL repeal in Colorado and Illinois was associated with higher treatment admissions from 2008 to 2011 (average treatment effect on the treated: 2008 = 653, 2009 = 1161, 2010 = 1388, and 2011 = 2020). We also found that a longer duration of exposure to AEL repeal was associated with higher treatment admissions, but this effect faded after the fourth year post-treatment.ConclusionsOur study reveals a potential positive association between the repeal and prohibition of AELs and increased alcohol-related treatment admissions. These findings suggest that states could enhance treatment opportunities for alcohol-related disorders by reconsidering their stance on AELs. While our study highlights the possible public health benefits of repealing AELs, it also paves the way for additional studies in this domain.

WIC staff and healthcare professional perceptions of an EHR intervention to facilitate referrals to and improve communication and coordination with WIC: A qualitative study.

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has numerous benefits, yet many eligible children remain unenrolled. This qualitative study sought to explore perceptions of a novel electronic health record (EHR) intervention to facilitate referrals to WIC and improve communication/coordination between WIC staff and healthcare professionals. WIC staff in three counties were provided EHR access and recruited to participate. An automated, EHR-embedded WIC participation screening and referral tool was implemented within 8 healthcare clinics; healthcare professionals within these clinics were eligible to participate. The interview guide was developed using the Consolidated Framework for Implementation Research to elicit perceptions of this novel EHR-based intervention. Semi-structured interviews were conducted via telephone. Interviews were recorded, transcribed, coded, and analyzed using thematic analysis. Twenty semi-structured interviews were conducted with eight WIC staff, seven pediatricians, four medical assistants, and one registered nurse. Most participants self-identified as female (95%) and White (55%). We identified four primary themes: (1) healthcare professionals had a positive view of WIC but communication and coordination between WIC and healthcare professionals was limited prior to WIC having EHR access; (2) healthcare professionals favored WIC screening using the EHR but workflow challenges existed; (3) EHR connections between WIC and the healthcare system can streamline referrals to and enrollment in WIC; and (4) WIC staff and healthcare professionals recommended that WIC have EHR access. A novel EHR-based intervention has potential to facilitate healthcare referrals to WIC and improve communication/coordination between WIC and healthcare systems.

소셜 빅데이터로 알아본 소아청소년과에 대한 인식

Objectives: The purpose of this study is to discover the perception of pediatrics as a topic. This study focuses on the perceptions of parents as potential consumers of pediatrics. Methods: We analyzed online community posts about pediatrics. 33,562 documents were analyzed in which ‘Pediatrics’ was mentioned among the posts for the four years from June 2020 to May 2023 were analyzed. The collected data were preprocessed and analyzed using text-mining techniques. Based on the TF value, the top 50 words were identified, a total of 18 topics were derived, and topic names were assigned.
 Results: Discussions on medical institution treatment subjects, use and operation, children, recommendations, and diseases were prominent. There was a difference in topics according to the channel type. Online blogs were dominated by topics about healthcare referrals, while online cafes were dominated by topics about COVID-19, medical treatment, and medical expertise.
 Conclusions: Based on the analysis results of this study, implications for the role of pediatricians and considerations for the treatment of children and families are suggested.

MATERNAL DEATH DETERMINANT AND HEALTH SERVICE DELIVERY DURING COVID-19: WHAT'S THE DIFFERENCE?

Background: The COVID-19 pandemic has provided a new challenge for the delivery of health system in Indonesia. Maternal health services were no exception, as the reduction in antenatal unscheduled home visits were the main issues found in maternal health service disruption during the COVID-19 pandemic. In the last few decades, Indonesia has adopted a range of health strategies to reduce maternal mortality rates. Nganjuk is one of the regencies that enforce the reduction of maternal mortality, which successfully reducing maternal mortality rates from 212 per 100.000 live births in 2010 to 57 per 100.000 live births in 2018. With the emergence of COVID-19, the health system’s capacity and access are once again being shaken. Purpose: This research aimed to analyze the determinants of maternal death before the COVID-19 pandemic situation and during the COVID-19 pandemic. Method: This type of research is non-reactive research using secondary data from maternal mortality reports, Nganjuk Regional Health Office. Analysis was carried out with a chi-Square test using Statistical Package for the Social Sciences (SPSS) version 26.0. Results: A significant increase in maternal deaths (85.29%) was observed during the COVID-19 pandemic. Determinants of maternal death, such as the age of the mother (p<0.00), number of pregnancies (p<0.00), period of death (p=0.02), healthcare referral (p=0.01), and cause of death (p<0.00) showed a significant increase during COVID-19. Conclusion: COVID-19 pandemic contributed to the increase in maternal deaths in Nganjuk Regency. This study has implications for the priority setting in policy development and implementation at reducing maternal mortality.

Factors associated with higher alcohol concentrations in emergency department presentations: PACE study.

The health impact from alcohol is of recognised concern, from acute intoxication as well as increased risk of chronic health issues over time. Identifying factors associated with higher alcohol consumption when presenting to the emergency department (ED) will inform public health policy and enable more targeted health care and appropriate referrals. Secondary testing of blood samples collected during routine clinical care of 1160 ED patients presenting to the Royal Brisbane and Women's Hospital in Queensland, Australia, for 10 days between 22 January and 1 February 2021. Alcohol was measured by blood ethanol (intake in recent hours) and phosphatidylethanol (PEth; intake over 2-4 weeks). Zero-inflated negative binomial regression was used to identify demographic and clinical factors associated with higher alcohol concentrations. Males were found to have 83% higher blood ethanol and 32% higher PEth concentrations than females (adjusted rate ratio [ARR] 1.83, 95% confidence interval [CI] 1.37-2.45 and ARR 1.32, 95% CI 1.04-1.68, respectively). Blood ethanol concentrations were 3.4 times higher for those 18-44 years, compared to those aged 65+ (ARR 3.40, 95% CI 2.40-4.82) whereas PEth concentrations were found to be the highest in those aged 45-64 years, being 70% higher than those aged 65+ (ARR 1.70, 95% CI 1.19-2.44). Patients brought in involuntarily had eight-times higher blood ethanol concentrations than those who self-attended. This study used two alcohol markers to identify factors associated with higher alcohol concentrations in emergency presentations. The findings demonstrate how these biomarkers can provide informative data for public health responses and monitoring of alcohol use trends.

Referral Patterns and Sociodemographic Predictors of Adult and Pediatric Behavioral Health Referrals in a Federally Qualified Health Center.

Federally Qualified Health Centers (FQHCs) provide comprehensive care to medically underserved populations whose access to behavioral health services may be limited. The goal of the current study was to examine referral patterns to specialty mental health and subsequent treatment initiation in an FQHC. In a 13-month period from March 2017 to March 2018, 1201 patients received a specialty mental healthcare referral. Of these patients, 37% reported scheduling an appointment with this referral, 44% refused the referral, 4% reported improvement in symptoms and not needing a referral, and 5% were not able to be reached due to a contact number being out of service. Common referral reasons among adults were depression, anxiety, and stress, and the most prevalent pediatric referral reasons were behavioral problems, depression, attention deficit hyperactivity disorder (ADHD), and anxiety. These data suggest that of the patients who received a specialty mental health referral, only one-third scheduled an appointment. The study also suggested that anxiety problems may be underrecognized in both adult and pediatric patients. Although significant attention has been put on increasing access to behavioral health services, there is still an unmet need. Universal mental health screening and increased coordination with specialty mental health providers in the community may better address this need.

Knowledge and Practices of Female Traditional Healthcare Givers to Mothers on Referral System for Care and Immunization against Childhood Killer Diseases in Hard-to-Reach Areas of Adamawa State - Nigeria

Female Traditional Healthcare Givers’ (FTHGs) knowledge, attitude, and practice on maternal and infant survival from pregnancy, delivery, and after birth has been a contextual matter throughout the globe, especially where the incidence of infant mortality rate is high. This often poses questions as to why, what happened, and where women of childbearing go for health seeking when pregnant, at birth, and after delivery? The impact of FTHGs activities to mothers and infants on their education and referral of mothers and children for treatment and immunization was studied in the three Senatorial Districts of Adamawa State. Self-structured questionnaires with both open and closed-ended responses and oral interviews were used for the purpose of the study and analyzed electronically on SPSS version 25.0. Approaches to improve the knowledge and practice of Female Traditional Healthcare Givers include seminars and workshops by Non-Governmental Organizations’, Antenatal Care at government health facilities, and health professionals’ effort in-home visits and formal education. These have improved FTHGs knowledge, skills, and acceptance of immunization programme against childhood killer diseases in most of the Senatorial District communities. Maternal and infant morbidity and mortality has experienced a great reduction in the process as FTHGs made referrals to health facilities on cases needing treatment and immunization. This underlies the need for training in epidemiological findings to prevent the incidence of infant morbidity and mortality since education is the key to a healthy live. Keywords: Childhood killer diseases, Epidemiological, Female Traditional Health care Givers, Healthcare, Immunization, Infant morbidity, Mortality, and Referral.

Exercise referral scheme participant characteristics, referral mode and completion status

Objective: There is recent evidence that exercise referral schemes (ERSs) are beginning to permit self-referral access. Notwithstanding this, to date it is unknown whether key referral characteristics, such as age, gender and socioeconomic status are associated with a greater likelihood of self-referring to an ERS, and whether self-referral participants are more or less likely to complete schemes, than traditional healthcare referrals. Design/Setting: This study presents an evaluation and cross-sectional exploration of key participant referral characteristics of those ( n = 647) who signed up to ‘Active West Lancs’; a 12-week ERS in the northwest of England. Methods: Chi-square analysis, tests of difference and binary logistic regression were conducted to explore associations between key referral characteristics and (1) the likelihood of accessing Active West Lancs via a self- or healthcare-referral and (2) the likelihood of completion. Results: About 56% of participants accessed the scheme via self-referral. These participants were more likely to be women, to report a musculoskeletal primary health condition, to access a specific site and to do so during spring. The scheme had an overall completion rate of 42.2%. Participants who were older, resided in less socioeconomically deprived neighbourhoods, and accessed a specific site were more likely to complete. Self-referral participants were not more or less likely to complete than those who enrolled via healthcare-referral. Conclusion: These data do not directly identify a clear benefit or detriment to Active West Lancs’ incorporation of self-referral participants. Notwithstanding this, enabling self-referral ERS access may widen scheme participation opportunities among those reluctant to seek referral from a healthcare provider and reduce the administrative burden for healthcare providers themselves.

A multinational survey of patient utilization of and value conveyed through virtual symptom triage and healthcare referral.

To describe the use patterns, impact and derived patient-user value of a mobile web-based virtual triage/symptom checker. Online survey of 2,113 web-based patient-users of a virtual triage/symptom checker was completed over an 8-week period. Questions focused on triage and care objectives, pre- and post-triage care intent, frequency of use, value derived and satisfaction with virtual triage. Responses were analyzed and stratified to characterize patient-user pre-triage and post-triage intent relative to triage engine output. Seventy-eight percent of virtual triage users were female, and 37% were 18-24 years old or younger, 28% were 25-44, 16% were 45-54, and 19% were 55 years or older; 41.2% completed the survey from the U.S., 12.5% from the U.K., 9.1% from Canada, 5.6% from India, 3.8% from South Africa. Motivations were to determine need to consult a physician (44.2%), to secure medical advice without visiting a physician (21.0%), and to confirm a diagnosis received (14.2%). Forty-three percent were first time users of virtual triage, 36.6% utilized a triage engine at least once every few months or more often. Pre-triage, 40.5% did not know what level of healthcare they were planning to utilize, 33.9% stated they intended to seek a physician consultation, 23.7% engage self-care and 1.8% seek emergency care. Virtual triage recommended 56.8% of patient-users consult a physician, 33.8% seek emergency care and 9.4% engage self-care. In three-fourths, virtual triage helped users decide level of care to pursue. Among 74.1%, triage recommended care different than pre-triage intentions. Post-triage, those who remained uncertain of their care path decreased by 25.4%. Patient-user experience and satisfaction with virtual triage was high, with 80.1% stating that they were highly likely or likely to use it again, and interest in and willingness to use telemedicine doubled. Virtual triage successfully redirected patient-users who initially planned to seek an inappropriate level of care acuity, reduced patient uncertainty of care path, and doubled the percentage of patients amenable to telemedicine and virtual health engagement. Patient-users were highly satisfied with virtual triage and the virtual triage patient experience, and a large majority will use virtual triage recurrently in the future.

P880 High incidence of inflammatory bowel disease in Northern Australia: a prospective community population-based Australian incidence study in the Mackay-Isaac-Whitsunday region

Abstract Background The Mackay-Isaac-Whitsunday region encompasses 173,892 people within a 400 km (250mile) radius in Queensland, Australia. We aimed to determine the incidence of Inflammatory Bowel Disease (IBD) in this region in northern Australia (-21.14°S) and to allow a comparison with southern Australian and New Zealand data (Geelong, Australia -38.14°S; Tasmania -41.43°S and -42.88°S [Launceston and Hobart] and Canterbury, New Zealand -43.46 °S). Methods A prospective observational community population-based IBD study was conducted between 1 June 2017 and 31 May 2018. Primary outcome measures include the crude annual incidence rate of IBD, Crohn's disease (CD), Ulcerative colitis (UC) and infammatory bowel disease unspecified (IBDU), while secondary outcomes includes disease phenotype and behaviour. All new cases were identified through primary health care referrals and public and private hospital referrals into the clinic. All new cases of IBD were prospectively defined using rigorously recognised and accepted criteria and categorised using the Montreal Classification. Results Fifty-six new cases of IBD were identified. Twenty-three were CD, 30 were UC and 3 were IBDU. The crude annual incidence rate per 100 000 for IBD, CD, UC and IBDU was 32.2 (95% confidence interval (CI): 24.78–41.84), 13.23 (95% CI: 8.79– 19.90), 17.25 (95% CI: 12.06–24.67) and 1.73 (95% CI: 0.56–5.35). When directly age-standardised to the World Health Organisation Standard Population Distribution, the overall CD, UC and IBDU incidence were 13.19, 17.34 and 1.85 per 100 000, with an overall age-standardised IBD incidence of 32.38. Conclusion This is the first study to define the incidence of IBD in a Northern Australian cohort and to allow a comparison between North and Southern Australia. The IBD crude is the highest reported in Australia. Like others, we found a high and low incidence of upper gastrointestinal Crohn's disease and complicated disease at diagnosis respectively, likely reflective of the increased availability and early uptake of endoscopic procedures.

Care coordination for healthcare referrals under a shared‐savings program

Accountable care organizations (ACOs) are responsible for the quality and cost of care of specified patient populations, including the cost of referrals. Motivated by this environment, we study care coordination for healthcare referrals. We consider an ACO that refers an uncertain number of patients from its attributed population to a preferred external provider for specialized health services. ACOs are typically paid under the Medicare Shared Savings Program (MSSP). Under the MSSP, the payer sets a spending benchmark for the beneficiary population during a fixed time period and shares any gains (losses) relative to it with the ACO. During the billing period, all services delivered to the attributed population by the ACO and external providers continue to be reimbursed under fee‐for‐service. Gains (losses) are determined at the end of the period by comparing the actual spending, which includes all care expenses (regular visits, referrals, and failed treatments) incurred by the payer in the period to the predefined benchmark. In this environment, the ACO and external providers—the latter not compensated under the MSSP—lack incentives to invest enough in care coordination initiatives. We study financial incentive mechanisms between the ACO and its preferred external provider to achieve integrated care coordination in referral markets under the MSSP. We show that traditional fee‐for‐service and capitation agreements do not provide sufficient incentives for care coordination in referral markets. However, a risk‐ and cost‐sharing mechanism can induce integrated care coordination efforts while satisfying the ACO and provider's participation constraints. We characterize a family of such mechanisms and numerically study the variability of the ACO and the external provider's profit. We demonstrate that this type of agreement can be used not only to induce integrated care coordination but can also result in a Pareto improvement in profit variability. We also illustrate the impact of the different MSSP risk tracks parameters on the performance of this care coordination mechanism, including their effect on the quality of care and the payer's mean spending.