Health Care Referrals Research Articles

Understanding high rates of stillbirth and neonatal death in a disadvantaged, high-migrant district in France: A perinatal audit.

The objective of this study is to investigate factors associated with risks of perinatal death in a disadvantaged, high-migrant French district with mortality rates above the national average. The study design is a perinatal audit in 2014 in all 11 maternity units in the Seine-Saint-Denis district (25 037 births). The data come from medical chart abstraction, maternal interviews and peer assessor confidential review of deaths. A representative sample of live births in the same district, from the 2010 French Perinatal Survey, was used for comparisons (n = 429). The main outcome measures were stillbirth and neonatal death (0-27 days) at ≥22 weeks of gestation. The audit included 218 women and 227 deaths (156 stillbirths, 71 neonatal deaths); 75 women were interviewed. In addition to primiparity and multiple pregnancy, overweight and obesity increased mortality risks (50% of cases, adjusted odds ratios [aOR] 1.7, 95% confidence interval [CI] 1.1-2.8, and aOR 1.9 [95% CI 1.1-3.2], respectively) as did the presence of preexisting medical/obstetric conditions (28.6% of cases, aOR 3.2, 95% CI 2.0-5.3). Problems accessing or complying with care were noted in 25% of medical records and recounted in 50% of interviews. Assessors identified suboptimal factors in 73.2% of deaths and judged 33.9% to be possibly or probably preventable. Care not adapted to risk factors and poor healthcare coordination were frequent suboptimal factors. Possibly preventable deaths were higher (P < .05) for women with gestational diabetes or hypertension (44.6%) than women without (29.0%). Preventive actions to improve healthcare referral and coordination, especially for overweight and obese women and women with medical and obstetrical risk factors, could reduce perinatal mortality in disadvantaged areas.

Hospital referral and capacity strategies in the two-tier healthcare systems

Healthcare referral has been widely advocated and adopted through the implementation of the two-tier healthcare systems whereby patients are transferred from a comprehensive hospital provider (CHP) to a primary hospital provider (PHP). However, operationally, exactly how to implement the healthcare referral program remains a challenging research question, especially when considering the possibility of patient revisits and the coordination needed between the CHP and PHP. To address such a challenge, this paper considers the two-tier healthcare systems consisting of a CHP and a PHP. By establishing a three-stage Stackelberg game within a queuing framework among the CHP, the PHP, and their patients, we first investigate the equilibrium strategy in terms of the CHP's referral rate and the PHP's capacity level, and then examine the impact of revisit rates and referral payments (RP) on the healthcare system and the equilibrium outcomes (e.g., expected utility, social welfare, and waiting times). Two major findings of our study are: (1) both the equilibrium referral rate and the equilibrium capacity first increase and then decrease according to the revisit rate; in addition, the patient referral process always improves the PHP's performance but is likely to sacrifice the social welfare of the CHP. (2) There exists an RP threshold value such that if the RP is below the threshold, then all the permitted patients should be referred and the system performance will be enhanced, in which case a win-win situation in terms of expected utilities can be attained that benefits all the stakeholders, i.e., the CHP, the PHP, and the patients. Otherwise, only a portion of the permitted patients can be referred, and an increase in RP always reduces the efficiency of the healthcare delivery system, i.e., a higher RP mitigates the operational performance of the healthcare system. Our analysis sheds light on how to implement a healthcare referral scheme.

Weak smoking cessation awareness in primary health care before surgery: a real-world, retrospective cohort study

Objective: Tobacco smoking is a well-established risk factor for postoperative complications. Research on preoperative smoking cessation in primary health care is scarce.Design: This was a retrospective cohort study.Setting: The Stop Smoking before Surgery Project (SSSP) started in Porvoo, Finland, in May of 2016, involving both primary health care and specialized health care. The goals of the project were smoking awareness and preoperative smoking cessation.Subjects: Our study involved 1482 surgical patients operated at Porvoo Hospital between May and December of 2016.Main outcome measures: We studied the recording of smoking status in all patients, and ICD-10 diagnosis of nicotine dependency and the initiation of preoperative smoking cessation in current smokers. Variables were studied from electronic patient records, comparing primary health care referrals and surgical outpatient clinic records.Results: Smoking status was visible in 14.2% of primary health care referrals, and in 18.4% of outpatient clinic records. Corresponding rates for current smokers (n = 275) were 0.0 and 8.7% for ICD-10 diagnosis of nicotine dependence, and 2.2 and 15.3% for initiation of preoperative smoking cessation. The differences between primary health care referrals and outpatient clinic records were statistically significant for all three variables (p ≤ .001).Conclusion: In primary health care, very little attention was paid to preoperative smoking cessation. Rates were significantly better at the surgical outpatient clinic, but still low. We could not demonstrate any certain effect of the intervention. Our results call for future research on ways to improve smoking cessation rates.Key pointsTobacco smoking is a well-established risk factor for postoperative complications. Research on preoperative smoking cessation in primary health care is scarce.We found weak smoking awareness and weak smoking cessation intervention numbers among both primary and specialized health care doctors. Our results indicate an urgent need for an efficient preoperative smoking cessation model involving both primary and specialized health care.

Awareness among pediatricians regarding oral health care in children including those with special health care needs: A cross- sectional survey.

Background:Pediatricians are the custodians of the overall health of children and are the ideal healthcare personnel to impart information and instruction about oral health care. The aim of this survey was to evaluate awareness of pediatricians regarding oral health care and prevention of oral diseases in children.Methodology:The study participants consist of 102 young pediatricians working as Junior and Senior Residents. A questionnaire was formulated to evaluate their knowledge about oral diseases and their prevention. The questionnaire also tested the attitude and practices of pediatricians towards oral health of children with special health care needs.Results:Majority of the pediatricians had correct knowledge about dental caries (60%), bottle feeding (88.2%), tongue cleaning (83.3%) and medication causing gum enlargement (92.2%). Few had correct knowledge about recommended age to start tooth brushing (35.3%) and maximum recommended sugar exposures per day (35.3%). Although, majority (62.7%) had correct knowledge about fluoride and its role caries prevention, very few (2.9%) knew about recommended fluoride concentration in toothpaste for children.Conclusion:There was a lack of knowledge amongst pediatrician about oral health care, prevention, and appropriate referral. The study result necessitates the emphasis of improving oral health related knowledge among pediatrician.

Effect of interprofessional education on oral assessment performance of nursing students.

ObjectivesThe purpose of this study was to investigate the effect of interprofessional educational programmes on the improvement of nursing students' oral assessment performances by comparing their attitudes, confidence, abilities, and self‐performance before and after the education.Materials and methodsThe subjects included 112 first‐year nursing students in a Japanese nursing school. They participated in the oral assessment educational programmes, which were supported by dentists and introduced into the 1‐year curriculum. The first programme was a 1.5‐hr lecture with a self‐oral assessment training in May 2018, and the second was a 1‐hr oral assessment training in October 2018. The questionnaire surveys investigating nursing students' attitudes, confidence, and self‐performance regarding oral assessment and the tests measuring their oral assessment abilities were conducted before and after the programmes. The total scores on the tests were 0–9 points.ResultsA total of 101 (90.2%) nursing students responded to all the questionnaires and tests. Their attitudes and confidence regarding oral assessment were significantly improved after the programmes. The total average scores on the tests were significantly increased from 6.8 points at baseline to 7.9 points after the programmes. The percentage of their performance of self‐oral assessment every day significantly increased from 15.8% at baseline to 32.7% after the programmes.ConclusionsThese results suggested that the educational programme might be effective in improving not only the students' attitudes and confidence regarding oral assessment but also their oral assessment abilities and self‐oral assessment performance. Therefore, future programmes must focus on training them to improve oral health care referrals.

Acute Rehabilitation of a 27-Year-Old Man With Failure to Thrive

Background and Purpose: Failure to thrive is a complex medical diagnosis that does not describe a single disease process, but rather a variety of symptoms associated with one or more possible underlying diseases or conditions. It is a diagnosis that is not well-documented outside pediatric or geriatric populations. The purpose of this case report is to present the physical therapy examination and treatment of a 27-year-old Hispanic man with a diagnosis of failure to thrive, a history of superior mesenteric artery syndrome, chronic malnutrition, type 1 diabetes mellitus, and osteopenia. Case Description: A 27-year-old Hispanic man, BMI of 12, admitted to the hospital for acute hypothermia, urinary tract infection, generalized weakness, hypotension, and failure to thrive. The complexity of his medical condition required nearly 2 weeks to stabilize general health prior to initiating physical therapy services. Personal and environmental factors contributed to progressive decline in physical activity prior to this hospital admission and led to increased dependence and support. Outcomes: Blood pressure increased by 18 mm Hg systolic and 20 mm Hg diastolic and stabilized within normal range; 5 repetitions in the 30-second sit-to-stand; functional balance composite score of 35 seconds; 20% reduction in subjective Numeric Pain Rating Scale; supervised bed mobility; maximum assistance stand-pivot transfer; and family to support caregiver needs upon return home. The patient was discharged home with recommendation for continued services through home health care referral. Discussion: Evidence-based literature regarding failure to thrive in the young adult or middle-aged adult population is limited. Therefore, the physical therapy plan of care necessitates the application of interventions shown to be effective in addressing the physical structure and function limitation upon examination generally applied to the geriatric and/or pediatric population. Clinical decision-making focused on improving physical activity and participation are imperative across clinical settings. Manual therapy interventions applied in this case may prove beneficial in the acute care setting to maximize muscle activation within available range of motion elicited through patterns of functional movements emphasizing existing abilities.

Hospital Referral and Capacity Strategies in a Two-Tier Healthcare System

Healthcare referral has been widely advocated and adopted through the implementation of a two-tier healthcare system whereby patients are transferred from a comprehensive hospital provider (CHP) to a primary hospital provider (PHP). However, operationally, exactly how to implement the healthcare referral program remains a challenging research question, especially when considering the possibility of patient revisits and the coordination needed between the CHP and PHP. To address such a challenge, this paper considers a two-tier healthcare system consisting of a CHP and a PHP. By establishing a three-stage Stackelberg game within a queuing framework among the CHP, the PHP and their patients, we first investigate the equilibrium strategy in terms of the CHP’s referral rate and the PHP’s capacity level, and then examine the impact of revisit rates and referral payments (RP) on the healthcare system and the equilibrium outcomes (e.g., expected utility, social welfare, and waiting times). Two major findings of our study are: (1) Both the equilibrium referral rate and the equilibrium capacity first increase and then decrease according to the revisit rate; in addition, the patient referral process always improves the PHP's performance but is likely to sacrifice the social welfare of the CHP. (2) There exists an RP threshold value such that if the RP is below the threshold, then all the permitted patients should be referred and the system performance will be enhanced, in which case a win-win-win situation in terms of expected utilities can be attained that benefits all the stakeholders, i.e., the CHP, the PHP, and the patients. Otherwise, only a portion of the permitted patients can be referred, and an increase in RP always reduces the efficiency of the healthcare delivery system, i.e., a higher RP mitigates the operational performance of the healthcare system. Our analysis sheds light on how to implement a healthcare referral scheme.

Physician referral to a psychologist: Testing alternative behavioral healthcare seeking models.

Primary care physicians (PCPs) often refer patients to psychological services, but help-seeking factors in the context of behavioral healthcare referral are understudied. This study examined perceptions of seeking psychological help for depression by comparing alternative structural equation models derived from the Theory of Reasoned Action (TRA). Internet survey participants (N = 685 US adults, 77% female, M age = 45) imagined themselves in a vignette scenario in which they are experiencing depression symptoms and encouraged by a PCP to see a psychologist. Results supported the indirect model, in which the links between distal help-seeking factors (i.e., self-stigma, symptom recognition, perceived effectiveness of treatment) and intention to follow through on the referral to the psychologist were fully mediated by the more proximal TRA factors (i.e., attitudes, subjective norms, etc). Our findings supported the use of TRA in understanding peoples' intention to seek psychological help for depression when referred by their PCP.

Assessing the Quality of the Saudi Healthcare Referral System: Potential Improvements Implemented by Other Systems

INTRODUCTION: The referral system authorizes and transfers the responsibility for healthcare services from one provider to another. A key component of the system is the communication between primary-care and specialist providers. Poor communication between them is detrimental to and can cause significant issues with coordination of effective care.&#x0D; &#x0D; OBJECTIVE: The purpose of this review was to evaluate current healthcare referral systems, focusing on the communication among providers, and to suggest practices that could make the Saudi healthcare referral system more effective.&#x0D; &#x0D; DESIGN: This systematic review identified published studies of the quality of the healthcare referral system in Saudi Arabia and other countries using two databases, Medline and PubMed. Data were summarized and extracted into two tables.&#x0D; &#x0D; RESULTS: The review included 12 studies that met its selection criteria. These studies were conducted in various regions of Saudi Arabia, but mostly the west and north. The 12 studies included 181,192 participants, with numbers of participants ranging from 21 to 138,484. The present review found that more than 50% of the referral documents and feedback reports in these studies had incomplete patient information. Implementation of electronic referrals (e-referrals) in several countries, including Australia, New Zealand and the United States, improved their referral systems, particularly by solving the problem of incomplete referral documents. In addition, the present review found that in some specialist clinics, referral cases contributed to increased workloads. One study reported on implementation of Lean Six Sigma principles in a military hospital in western Saudi Arabia, which reduced the number of referrals delayed, inappropriate referrals and the response time to referrals (7%). E-referrals and Lean Six Sigma principles may be applicable in Saudi Arabia as solutions to referral and response-time problems.&#x0D; &#x0D; CONCLUSIONS: An increase in healthcare referrals in Saudi Arabia has caused an increase in missing essential information in referral letters and feedback reports as well as overcrowding in specialist clinics. The results of the present review suggested that implementing e-referral and Lean Six Sigma principles may improve the quality of Saudi Arabia&amp;rsquo;s healthcare referral system.

Comprehensive Diabetes Self-Management Support From Food Banks: A Randomized Controlled Trial.

To determine whether food bank provision of self-management support and diabetes-appropriate food improves glycemic control among clients with diabetes. We screened 5329 adults for diabetes at food pantries (n = 27) affiliated with food banks in Oakland, California; Detroit, Michigan; and Houston, Texas, between October 2015 and September 2016. We individually randomized 568 participants with hemoglobin A1c (HbA1c) 7.5% or greater to waitlist control or 6-month intervention including food, diabetes education, health care referral, and glucose monitoring. The primary outcome was HbA1c at 6 months. Food security (relative risk [RR] = 0.85; 95% confidence interval [CI] = 0.73, 0.98), food stability (RR = 0.77; 95% CI = 0.64, 0.93), and fruit and vegetable intake (risk difference [RD] = 0.34; 95% CI = 0.34, 0.34) significantly improved among intervention participants. There were no differences in self-management (depressive symptoms, diabetes distress, self-care, hypoglycemia, self-efficacy) or HbA1c (RD = 0.24; 95% CI = -0.09, 0.58). Food banks are ideally situated to provide diabetes-appropriate food to food-insecure households. Effective strategies for food banks to support improvements in diabetes clinical outcomes require additional study. Public Health Implications. Moving chronic disease support from clinics into communities expands reach into vulnerable populations. However, it is unclear how community interventions should be integrated with clinical care to improve disease outcomes. NCT02569060.

Contracts for Healthcare Referral Services: Coordination via Outcome-Based Penalty Contracts

This work focuses on the business-to-business interaction between a service requester and a service provider in a healthcare environment. The requester is the primary caregiver responsible for managing the health of a population of patients. When a patient requires advanced care outside of the requester’s expertise, the requester refers the patient to a provider and pays for the referral services. Treatment may succeed or fail, and in the case of failure, the requester incurs further follow-up costs. The requester may exert preventive effort to reduce the volume of referrals. The provider may exert nonreimbursable effort to reduce the chance of treatment failure. We analyze payment contracts between the two firms. We find that fee-for-service (FFS) induces neither system nor social optimum effort outcomes. However, a penalty contract can generally coordinate the effort decisions with either the system optimum or the social optimum. Furthermore, we find that patients may benefit from having a coordinating contract replace FFS. However, the types of procedures that make a coordinating contract most advantageous for the requester and provider are not necessarily the same as those that make the patients better off than under FFS. Yet, in most cases, the coordinating contract improves social welfare, as compared to FFS, and brings it close to the social optimum. Hence, the requester–provider coordinating contract can be considered as an improvement over FFS for the entire system. The online appendix is available at https://doi.org/10.1287/mnsc.2017.3000 . This paper was accepted by Serguei Netessine, operations management.

Prevalence of breast-related symptoms, health care seeking behaviour and diagnostic needs among women in Burkina Faso

BackgroundThe prevalence of breast cancer has been increasing in sub-Saharan Africa over the last few years. Patients often present with late stage disease, resulting in a high mortality rate. This study aims to estimate the prevalence of breast -related symptoms in the female population of Burkina Faso. The findings can be used to advise on adequate diagnostic health services for breast symptoms to ensure early detection and down-staging of breast cancer.MethodsA cross-sectional, population based study of 996 women was conducted to investigate the proportion of women with breast-related symptoms. A semi-structured questionnaire was used to collect sociodemographic data, information about breast cancer knowledge and details about breast-related symptoms, health care seeking and medical care. Breast-related symptoms were categorised as currently present/not currently present to estimate the current prevalence of women requiring a diagnostic service.ResultsAmong the 996 women, 120 reported having had a breast-related symptom in their life. Only 36 women sought medical advice and eight women had diagnostic confirmation by histological or imaging techniques. Current breast-related symptoms were reported by 33 women (3.3% of the sample). An extrapolation to Burkina Faso’s female population suggests that 184,562 women are in current need of diagnostic services due to any breast-related symptoms.ConclusionsImaging techniques at the community and referral level are needed in order to triage women with breast-related symptoms. Specialised services need to be strengthened to ensure appropriate diagnosis and treatment of breast diseases. Education campaigns among the general population and among health care professionals are required to increase awareness of breast cancer and improve prompt health care seeking and referral.

Barriers in treating patients with acute coronary syndrome in Indonesia Primary Health Care: A phenomenological study

Introduction: Acute Coronary Syndrome (ACS) is the leading cause of mortality in the world. Primary prevention strategy focuses on reducing the risk of disease spread. At the same time, curative strategy aims at reducing the risk of disability and mortality. Initial therapy should be considering early stabilization and immediate advanced care to reduce the risk of complication. Therefore, it is important to improve guidelines, the medical referral system, and family consent procedure to save patients with ACS. Aim: This research aimed at exploring the barriers faced by nurses in treating patients with ACS in Primary Health Care (PHC). Method: This research employed a qualitative research method using descriptive phenomenology.This study involving 16 subjects of nurses working in PHC with indepth interview . The data analysis procedure proposed by Clark and Brown 2013. Result: Three main themes were pointed out by 16 participants; 1) Update Guidlines, 2) Inefficient referral process to other health centers, 3) Consent making process by the family. Dicussion: Barriers in performing health care for patients with ACS in the emergency unit of PHC needs updating guidline to be enhanced by engaging the advancement of technology and communication using electronic medical record system, family education, and fulfillment of better medical facilities to make the process more efficient. At the same time, also improves the management service for patients with ACS and making it possible for PHC to provide reliable health care as the first health care provider for the society. Keywords: Barriers to care, Health Care Referral, Acute Coronary Syndrome, Emergency Nursing, Primary Health Care

Improving Healthcare Referral System Using Lean Six Sigma

The World Health Organization considers the referral system, begun in 1978, to be one of the primary components of any medical system. Referral is the procedure of directing a patient to an appropriate specialist or agency. This research uses King Abdullah Medical City in Makkah, Saudi Arabia as a case study to explore using Lean Six Sigma as a way to improve healthcare referral system. King Abdullah Medical City received 16,807 referral requests in 2015, a 13.6% increase compared with 2014. Over time, the process of referral unwieldy, making the process less efficient and effective. By addressing the application of Lean principles and Six Sigma methodology to improve the referral process, this study reveals implications for their use in the healthcare industry. Then DMAIC methodology was utilized to decrease the delay in physicians’ response time to the referral system. After the Lean Six Sigma project was completed, a noticeable improvement in compliance to response times was achieved and sigma improved from 2.05 to 2.2; even greater improvement is expected after all of the long term recommendations have been applied.

Predictive values of referrals for transient ischaemic attack from first-contact health care: a systematic review.

Over 150 000 cases of suspected transient ischaemic attack (TIA) are referred to outpatient clinics in England each year. The majority of referrals are made by GPs. This study aimed to identify how many patients referred to a TIA clinic actually have TIA (that is, calculate the positive predictive value [PPV] of first-contact healthcare referral) and to record the alternative diagnoses in patients without TIA, in order to determine the optimal service model for patients with suspected TIA. A systematic review of TIA clinic referrals from first-contact health professionals (GPs and emergency department [ED] doctors) was undertaken. Four databases were searched using terms for TIA and diagnostic accuracy. Data on the number of patients referred to a TIA clinic who actually had a TIA (PPVs) were extracted. Frequencies of differential diagnoses were recorded, where reported. Study quality was assessed using the QUADAS-2 tool. Nineteen studies were included and reported sufficient information on referrals from GPs and ED doctors to derive PPVs (n = 15 935 referrals). PPVs for TIA ranged from 12.9% to 72.5%. A formal meta-analysis was not conducted due to heterogeneity across studies. Of those not diagnosed with TIA, approximately half of the final diagnoses were of neurological or cardiovascular conditions. This study highlights the variation in prevalence of true vascular events in patients referred to TIA clinics. For patients without a cerebrovascular diagnosis, the high prevalence of conditions that also require specialist investigations and management are an additional burden on a care pathway that is primarily designed to prevent recurrent stroke. Service commissioners need to assess whether the existing outpatient provision is optimal for people with pathologies other than cerebrovascular disease.

Indian Medical Mission at Hajj-2016: Mass-Gathering Medicine Perspectives, Challenges, and Opportunities in a Mission Posture

Introduction: Hajj is an annual mass gathering of over 3.5 million pilgrims congregating from 200 countries in the desert climate of Saudi Arabia. Mass gathering medicine at Hajj is challenged by issues of healthcare accessibility, infection control, on-site treatment, referral, evacuation, and response to disasters and public health emergencies. The Indian Medical Mission at Hajj 2016 established, operated, and coordinated a strategic network of mass gathering medical operations, the proceeds of which are discussed herein. Methods: The mission was designed to provide holistic health security through health intelligence for pre-existing chronic diseases, epidemic intelligence for endemic and exotic diseases, public-health and disaster-health preparedness, and tiered healthcare through mobile medical task forces, static clinics, tent clinics, secondary care hospitals, and evacuation capabilities. Results: Primary care, secondary care, and tertiary care treated 374 475, 930, and 523 patients, respectively. Patients exhibited limited compliance with pre-instituted treatments and precautionary protocols. Respiratory and gastrointestinal infections, cardiorespiratory, trauma, and heat illnesses were seen. Epidemic intelligence revealed an outbreak of food poisoning. Respiratory infections were reported by 90% of the healthcare personnel. Surge capacity was overwhelmed with patient throughput and ambulance transfers. Crude unadjusted mortality was 11.99/10 000. Conclusion: The Indian Medical Mission at Hajj 2016 yielded solutions to the challenges faced during the 2016 Hajj pilgrimage. The mission posture of the Indian Medical Mission in Hajj presents a modus operandi for handling crisis scenarios in mass gathering. The situational analysis of the Hajj health mission calls for dynamic interventions in preparedness, clientele, and health systems.

Design of an mHealth System for Maternal and Children HIV care.

While progress has been made to slow down its spread and increase uptake of treatment, human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is still a highly significant health problem for many low- and middle-income countries (LMICs). Specifically, almost half of new HIV patients in Asia Pacific were children. The prevention of mother-to-child transmission faces complex socioeconomic and other problems. With the increasing growth of mobile technologies in LMICs, especially in Asia Pacific, mHealth, the application of mobile technology for health applications, has a significant potential to help alleviate these problems. In this paper, we propose the design of an mHealth System for Maternal and Children HIV care. It includes specialized portals for patients, family/community members, healthcare providers, healthcare referral system, payers and drug supply chain. While each portal is customized towards the needs of a particular actor, such as treatment scheduling and education for patients, and epidemiological data management for healthcare referrals, all the different elements are integrated through a central server to form an integrated system with a secured data exchange environment. This proposed integrative design is aimed to facilitate efficient, timely and coordinated information dissemination, analysis, and care across the healthcare system, and is intended for application in developing countries, especially in the Asia Pacific region.

Analysis and Dynamic Routing Implementation of Hierarcical Healthcare Referral System

Abstract—Hierarchical Healthcare Referral System (HHRS) is implemented by National Insurance Providing Agency (BPJS) as part of the healthcare insurance policies. Patients who want to get health insurance in a hospital should get a referral from the community health center in which they are registered. Congestion of patients happens in certain hospital as there is no policy implemented to govern the referral system. In this paper, HHRS is modeled as a network of queuing system and is analyzed for its queue performances. Analysis of queuing network performances shows the influence patient preferences to buildup congestion of patients in hospitals. Referral is then controlled by means of dynamic routing with considering patient preferences. Estimation of arrival rate is done with hypercube queuing theory which concerns user preference. Simulation shows that patient preferences affect the arrival rate at each hospital, the application of dynamic routing can reduce the maximum utility and reduce the average waiting time, prioritization of patients improve dynamic routing performance on systems with a high workload.Keywords—dynamic routing; hierarchical healthcare referral system; patient priority; queueing networks;

Adherence to geriatric assessment (GA)-based recommendations in older patients (pts) with cancer.

10010 Background: In the general older population, GA-guided treatment plans improve overall survival, quality of life and functional status. In geriatric oncology, studies mainly focused on screening and assessment but not on geriatric interventions and follow-up. The aim of this study was to investigate the adherence to recommendations and subsequent interventions based on GA results in older pts with cancer. Methods: A prospective Belgian multicenter (n = 22) cohort study included pts ≥70 years with a malignant tumor when an oncological treatment decision had to be made. Pts with an abnormal G8 (≤14/17) underwent GA and were included in this study. Recommendations for interventions were formulated based on GA results. At follow-up adherence to GA-based recommendations was documented. Results: From 11-2012 till 2-2015, G8 screening was performed in 8451 pts. 5838 pts with an abnormal G8 were included in the study. Geriatric recommendations were given in 79.2% of pts with a median of 2/pt (range 0-10), most frequently consultation of a dietician (73%) for malnutrition, a social worker (54.8%) for social and functional status problems and a geriatrician (42.1%) for general geriatric problems. Follow-up data were available for 4167 pts. In the group of pts where recommendations were given, at least one intervention was performed in 69% with a median of 1/pt (range 0-6), most frequently dietician (43.4%), social worker (26.1%) and geriatrician (22.6%). A total of 7569 actions were undertaken for a total of 5725 geriatric recommendations. Recommendations were most frequently adhered to for malnutrition, social status and functional status problems. The most frequent actions undertaken were nutritional support and supplements, extended home care and psychological support. Conclusions: This large scale Belgian study focusses on the adherence to GA based interventions in older pts with cancer and contributes to the optimization of care for these pts. We identified the domains for which geriatric interventions are most frequently recommended and adhered to and which health care professionals and referrals are essential in the multidisciplinary approach of older pts with cancer.

Factors associated with access to physical rehabilitation for victims of traffic accidents.

ABSTRACTOBJECTIVE Evaluate the level of access to physical rehabilitation for survivors of traffic accidents and the associated factors.METHODS A cross-sectional study performed in Natal, Northeastern Brazil, through a telephone survey of 155 victims of traffic accidents admitted to an emergency hospital between January and August of 2013, with a diagnosis of fracture, traumatic brain injury or amputation. Participants were identified in the database of the reference hospital for care of traffic accident victims. We calculated point estimates and confidence interval (95%CI) for the frequency of subjects who had access, in addition to multivariate analysis (logistic regression) between access (dependent variable) and sociodemographic, clinical, and assistance variables.RESULTS Among the 155 respondents, the majority were adolescents and adults between 15–29 years of age (47.7%), men (82.6%), education up to high school (92.3%), income of up to two minimum wages (78.0%) and bikers (75.5%). Although 85.8% of traffic accident survivors reported the need for physical rehabilitation, there was little access (51.6%; 95%CI 43.7–59.4) and a delay to start the physical rehabilitation (average = 67 days). We classified factors associated with access to physical rehabilitation as: (i) unmodifiable individuals in the short term – family income greater than two minimum wages (OR = 3.7), informal worker (OR = 0.11) or unemployed (OR = 0.15) and possession of a private health care plan (OR = 0.07); and (ii) assistance modifiable by service management – written referral for physical rehabilitation (OR = 27.5) and perceived need of physical rehabilitation (OR = 10).CONCLUSIONS This study found a low and slow access to physical rehabilitation for individuals potentially in need. The associated factors were the organizational processes of health care (health information and referral) and social determinants (income, occupation and private health care plan).