Higher Referral Rates Research Articles

The Effect of Mental Comorbidity on Service Delivery Planning in Primary Care

In their everyday practice, primary-care physicians are often asked to refer patients to a specialist without a prior appointment in primary care. Such referrals are problematic, and one might suspect that patients who make such requests are more likely to have mental comorbidities predisposing them toward higher utilization of health-care services. In a cross-sectional study, 307 patients of 13 primary-care practices who requested referral to a specialist without a prior appointment in primary care were given a Patient Health Questionnaire (PHQ) containing questions that related to depression, anxiety, panic disorder, and somatoform disorder (independent variables). Further information was obtained about these patients' primary-care contacts, referrals, and days taken off from work with a medical excuse over the course of one year (dependent variables). A regression model was used to compare these patients with 977 other primary-care patients. The groups of patients who did and did not request specialist referral without a primary-care appointment did not differ to any statistically significant extent with respect to mental comorbidity. In the overall group, somatoform disorder was found to be associated with a high rate of primary-care contacts (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.4-4.3). High rates of referral were strongly correlated (percentage of variance explained, R²) with depression (OR 2.1, 95% CI 1.1-4.0; R² = 35.3%), anxiety (OR 4.1, 95% CI 1.8-9.6; R² = 34.5%), panic disorder (OR 5.9, 95% CI 2.1-16.4; R² = 34.3%), and somatoform disorder (OR 2.2, 95% CI 1.2-4.0; R² = 34.6%). Taking a long time off from work with a medical excuse was correlated with depression (OR 2.5, 95% CI 1.2-4.8), anxiety (OR 4.2, 95% CI 1.7-10.5), and somatoform disorder (OR 2.2, 95% CI 1.2-4.2). Mental comorbidity contributes to the increased utilization of health-care services. This should be borne in mind whenever a patient requests many referrals to specialists (either with or without a prior appointment in primary care). It is important to identify "doctor-hopping" patients so that the causes of their behavior can be recognized, discussed, and properly treated.

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks

Injury/Illness Physician Referral Profile From a Youth University-Sponsored Summer Sport Camp Program

Participation at university-sponsored summer sport camps is popular among youth athletes; however, there is a dearth of information to describe the injuries/illnesses experienced by camp participants. Data from a university-sponsored sport camp program from 2008 to 2011 were accessed retrospectively. The sport camp program had approximately 80 camps for 28 sports over 12 weeks annually. Male and female participants were 10 to 17 years old. Athletic trainers maintained medical documentation and provided medical referrals. Referrals were made for 9.9% (n=478) of all injuries/illnesses. Emergency department referrals were made for 2.9% of injuries/illnesses. University health services received 42.5% of referrals. There were 1.1 referrals per 100 participants. Boys comprised 60.7% of referrals. Rugby had the highest referral rate--5.0 per 100 participants. These data help increase physician preparedness and guide the delivery of sports medicine services for related sport camp programs as a means to improve quality of care delivered to participants.

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks

High referral rates to secondary care by general practitioners in Norway are associated with GPs’ gender and specialist qualifications in family medicine, a study of 4350 consultations

BackgroundReferral rates of general practitioners (GPs) are an important determinant of secondary care utilization. The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The main objective of this study was to assess the GPs’ referral rate to secondary care in Norway, any associations between the referral decision and patient, GP, health care characteristics and who initiated the referring issue in the consultation.MethodsThe probabilities of referral to secondary care and/or radiological examination were examined in 100 consecutive consultations of 44 randomly chosen Norwegian GPs. The GPs recorded whether the issue of referral was introduced, who introduced it and if the patient was referred. Multilevel and naive multivariable logistic regression analyses were performed to explore associations between the probability of referral and patient, GP and health care characteristics.ResultsOf the 4350 consultations included, 13.7% (GP range 4.0%-28.0%) of patients were referred to secondary somatic and psychiatric care. Female GPs referred significantly more frequently than male GPs (16.0% versus 12.6%, adjusted odds ratio, AOR, 1.25), specialists in family medicine less frequently than their counterparts (12.5% versus 14.9%, AOR 0.76) and salaried GPs more frequently than private practitioners (16.2% versus 12.1%, AOR 1.36).In 4.2% (GP range 0%-12.9%) of the consultations, patients were referred to radiological examination. Specialists in family medicine, salaried GPs and GPs with a Norwegian medical degree referred significantly more frequently to radiological examination than their counterparts (AOR 1.93, 2.00 and 1.73, respectively).The issue of referral was introduced in 23% of the consultations, and in 70.6% of these cases by the GP. The high referrers introduced the referral issue significantly more frequently and also referred a significantly larger proportion when the issue was introduced.ConclusionsThe main finding of the present study was a high overall referral rate, and a striking range among the GPs. Male GPs and specialists in family medicine referred significantly less frequently to secondary care, but the latter referred more frequently to radiological examination. Our findings indicate that intervention on high referrers is a potential area for quality improvement, and there is a need to explore the referral decision process itself.

Implementation of routine biochemical validation and an ‘opt out’ referral pathway for smoking cessation in pregnancy

To introduce an 'opt out' referral pathway for smoking cessation in pregnancy and to compare different methods for identifying pregnant smokers in maternity care. Pilot study that analysed routine data from maternity and smoking cessation services with biochemical validation of smoking status. Dudley and South Birmingham, England. A total of 3712 women who entered the referral pathway-1498 in Dudley and 2214 in South Birmingham. Routine monitoring data on smoking at maternity booking, referral to smoking cessation services, number of women who set quit dates set and short-term (4-week) self-report smoking status. Comparison of self-report, carbon monoxide (CO)-validated and urinary cotinine-validated smoking status for a subsample (n = 1492) of women at maternity booking. In Dudley 27% of women who entered the opt out referral pathway were identified as smokers following CO testing. Of those referred to the smoking cessation services, 19% reported stopping smoking at 4-week follow-up. In South Birmingham 17% were smokers at booking, with 5% of those referred recorded as non-smokers at 4 weeks. The number of women quitting did not increase during the study when compared with the previous year, despite higher referral rates in both areas. An optimum cut-off CO measurement of 4 parts per million (p.p.m.) was identified for sensitivity and specificity. The introduction of an opt out referral pathway between maternity and stop smoking services resulted in more women being referred for support to quit but not higher numbers of quitters, suggesting that automatic referral may include women who are not motivated to stop and who may not engage with services. Routine carbon monoxide monitoring introduced as part of a referral pathway should involve a cut-off of 4 p.p.m. to identify smoking in pregnancy.

How do surgeons decide to refer patients for adjuvant cancer treatment? Protocol for a qualitative study.

BackgroundNon-small cell lung cancer, breast cancer, and colorectal cancer are commonly diagnosed cancers in Canada. Patients diagnosed with early-stage non-small cell lung, breast, or colorectal cancer represent potentially curable populations. For these patients, surgery is the primary mode of treatment, with (neo)adjuvant therapies (e.g., chemotherapy, radiotherapy) recommended according to disease stage. Data from our research in Nova Scotia, as well as others’, demonstrate that a substantial proportion of non-small cell lung cancer and colorectal cancer patients, for whom practice guidelines recommend (neo)adjuvant therapy, are not referred for an oncologist consultation. Conversely, surveillance data and clinical experience suggest that breast cancer patients have much higher referral rates. Since surgery is the primary treatment, the surgeon plays a major role in referring patients to oncologists. Thus, an improved understanding of how surgeons make decisions related to oncology services is important to developing strategies to optimize referral rates. Few studies have examined decision making for (neo)adjuvant therapy from the perspective of the cancer surgeon. This study will use qualitative methods to examine decision-making processes related to referral to oncology services for individuals diagnosed with potentially curable non-small cell lung, breast, or colorectal cancer.MethodsA qualitative study will be conducted, guided by the principles of grounded theory. The study design is informed by our ongoing research, as well as a model of access to health services. The method of data collection will be in-depth, semi structured interviews. We will attempt to recruit all lung, breast, and/or colorectal cancer surgeons in Nova Scotia (n ≈ 42), with the aim of interviewing a minimum of 34 surgeons. Interviews will be audiotaped and transcribed verbatim. Data will be collected and analyzed concurrently, with two investigators independently coding and analyzing the data. Analysis will involve an inductive, grounded approach using constant comparative analysis.DiscussionThe primary outcomes will be (1) identification of the patient, surgeon, institutional, and health-system factors that influence surgeons’ decisions to refer non-small cell lung, breast, and colorectal cancer patients to oncology services when consideration for (neo)adjuvant therapy is recommended and (2) identification of potential strategies that could optimize referral to oncology for appropriate individuals.

099 Lack of Impact of Automated Referral on Attendance At Cardiac Rehabilitation Among Coronary Artery Bypass Grafting Patients: The Calgary Experience

Cardiac Rehabilitation (CR) is a guideline indicated modality for reducing residual cardiovascular risk among patients after they undergo Coronary Artery Bypass Grafting (CABG). However, many patients do not attend - further, some patients are not given the opportunity to attend as they are never referred. The objective of this study was to assess rates of referral to CR and the impact of an automated referral system. All subjects who underwent CABG surgery in Calgary, Canada between 1996 and 2010 were included. Data was obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart disease (APPROACH) and CR databases. Automated referral to CR was instituted in July 2007. Baseline characteristics were compared between those who were referred to CR and those who were not pre- and post-automated referral. Predictors of referral and attendance rates were also assessed pre- and post-automation. A total of 5256 subjects (mean age 65.6 (+/− 10.1) years, 80.7% male) underwent CABG during the study period; 4700 prior to automation, 556 post. Subjects pre- and post- automation were similar in terms of mean age, proportion female, heart failure, and diabetes (all p>0.05). Rates of referral increased from 41.9% prior to automated referral to 75.7% post-automation (p<0.0001). Of the 2390 subjects referred to CR, 1497 (62.6%) attended - however, attendance rates were significantly lower after automation than before, 48.2 vs 65.7% (p<0.0001). Referral to CR, regardless of attendance status, was associated with reduced mortality (unadjusted hazard ratio, 0.54, 95%CI 0.48, 0.61; adjusted for all clinical comorbidities, 0.74, 95% CI 0.66, 0.84). Automated referral to CR in CABG patients results in higher rates of referral. However, there is a commensurate decline in CR attendance. Automated referral to CR is insufficient to increase attendance; when CR referral is automated, care must still be made to emphasize the benefits of CR to patients.

100 Comparison of the Aristotle and RACHS Scores to Predict Morbidity in Congenital Cardiac Surgery

automation were similar in terms of mean age, proportion female, heart failure, and diabetes (all p 0.05). Rates of referral increased from 41.9% prior to automated referral to 75.7% post-automation (p 0.0001). Of the 2390 subjects referred to CR, 1497 (62.6%) attended however, attendance rates were significantly lower after automation than before, 48.2 vs 65.7% (p 0.0001). Referral to CR, regardless of attendance status, was associated with reduced mortality (unadjusted hazard ratio, 0.54, 95%CI 0.48, 0.61; adjusted for all clinical comorbidities, 0.74, 95% CI 0.66, 0.84). CONCLUSION: Automated referral to CR in CABG patients results in higher rates of referral. However, there is a commensurate decline in CR attendance. Automated referral to CR is insufficient to increase attendance; when CR referral is automated, care must still be made to emphasize the benefits of CR to patients.

Simple Guidelines for Efficient Referral of Soft-Tissue Sarcomas

Optimal treatment of soft-tissue sarcoma requires multidisciplinary management at a sarcoma center. However, these rare tumors are often misinterpreted as benign and many are inadequately treated outside a sarcoma center, with an increased risk of local recurrence that often requires further extensive surgical treatment. To improve referral and centralization of soft-tissue sarcoma management in the southern Sweden health care region, an open-access outpatient clinic at our sarcoma center and simple referral guidelines have been established for the past thirty years. The guidelines call for referral of all deep-seated soft-tissue tumors and of all ≥5-cm superficial tumors before open biopsy or surgery. We evaluated adherence to these guidelines and characterized referral patterns. We also studied the consequences of our strategy with regard to the relative numbers of benign and malignant diagnoses among referred patients. Adherence to guidelines, referral pathways, and time to referral to the sarcoma center were analyzed in a population-based series of 100 consecutive patients with soft-tissue sarcoma in the extremities or trunk wall. We also analyzed diagnosis and management of benign and malignant tumors in a second cohort consisting of 464 consecutive patients referred to the sarcoma center because of a soft-tissue tumor. Ninety-seven of the 100 patients with soft-tissue sarcoma were referred to the sarcoma center. All fifty-eight of the deep-seated soft-tissue sarcomas and twenty-eight of the forty-two superficial tumors were referred before open biopsy or surgery. Three-quarters of the patients with soft-tissue sarcoma first presented to a general practitioner. One-quarter of these patients were directly referred to the sarcoma center, which cut the referral time in half compared with patients initially referred to a local hospital. One-quarter of all patients referred to the outpatient clinic were diagnosed with a malignancy, with the majority of the malignancies being soft-tissue sarcoma. Our simple referral guidelines and open-access outpatient clinic resulted in nearly complete referral of patients with soft-tissue sarcoma to the sarcoma center. The "excess work" associated with referral of benign tumors according to our strategy was limited to the diagnosis of three benign tumors for each malignant tumor. We consider this surplus evaluation of benign tumors acceptable and probably necessary to achieve a high referral rate of soft-tissue sarcoma before initial surgery. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Quality of cancer family history and referral for genetic counseling and testing among oncology practices: A pilot test of quality measures as part of the ASCO Quality Oncology Practice Initiative (QOPI).

CRA1505 Background: The cancer family history (CFH) is an important tool for identification of individuals for genetic counseling/testing (GC/GT). Prior studies demonstrate a low rate of family history documentation and low referral rates for genetic counseling and genetic testing. Methods: In 2011ASCO began pilot testing new measures in QOPI to evaluate the practice of family history taking and referral for genetic counseling/testing in patients with either breast cancer (BC) or colorectal cancer (CRC). The measures assessed the presence or absence of CFH in 1st/2nd degree relatives, age at cancer diagnosis, referral for GC/GT and outcomes of referral. Results: Between September and October 2011 272 practices pilot tested these measures and reported on 10,466 patients (BC 6569, CRC 3897). 77.4% of all charts reviewed documented presence or absence of CFH in 1st degree relatives (BC 81.2% (CI 80-82%), CRC 77.4% (CI 76-79%), p= &lt;0.001) and 61.5% of charts documented presence or absence of CFH in 2nd degree relatives (BC 68.9% (CI 68-70%), CRC 57.3% (CI 56-59%) p=&lt;0.001). Age at diagnosis was documented for all relatives with cancer in 30.7% of charts (BC 45.2% (CI 44-47%), CRC 35.4% (CI 34-37%) p=&lt;0.001). Patients were referred for GC/GT in 22.1% of all charts reviewed (BC 29.1% (CI 28-30%), CRC 19.6% (CI, 18-21%) p=&lt;0.001). Of patients with hereditary risk (defined by selected risk guidelines) 52.2% of BC and 26.4% CRC were referred for GC/GT. When genetic testing was performed by the practice consent was documented 77.7% of the time and discussion of results was documented 78.8% of the time. Conclusions: Appropriate referral for GC/GT requires a complete and accurate CFH. In this pilot testing of QOPI measures we identified a higher quality of CFH information than expected though with room for improvement. Significant differences were seen between BC and CRC charts with greater accuracy of CFH and higher referral rates among BC patients. To obtain improvement in the identification and management of patients at high risk, significant improvements are needed. Education is part of the answer.

Physical Function in Hospice Patients and Physiotherapy Interventions: A Profile of Hospice Physiotherapy

There is a dearth of international research on hospice physiotherapy. This study aims to profile hospice physiotherapy in an Irish setting in order to inform practice internationally. The study design consisted of a retrospective chart audit over 6 months. The study took place at a specialist palliative care inpatient unit (hospice) in Limerick, Ireland. All patients were discharged (through death or discharge onwards) from January to June 2010. The Edmonton Functional Assessment Tool (EFAT-2) was used as an outcome measure. Sixty-five percent were referred for physiotherapy; 58% (n=144) were assessed and treated. A wide range of patients was referred (mean functional score 11, range 1-23, SD 5). Rehabilitation activities were widespread: 48% with more than one functional score recorded made improvements; 53% of physiotherapy patients were eventually discharged home; 47% of physiotherapy patients died, of whom 52% received physiotherapy in the last week of life. The median physiotherapy program lasted 11 days (range 1-186, SD 22) whereas the median number of treatments was four (range 1-99, SD 10). The most common interventions were gait re-education (67%), transfer training (58%), and exercises (53%). One third of treatment attempts were unsuccessful because of the unavailability/unsuitability of patients. Challenges for physiotherapists included frequent suspension of treatment and large functional fluctuations in patients. There was a high referral rate to physiotherapy in this hospice. Functional changes in hospice patients were mapped, showing that physiotherapy involved both rehabilitative and quality of life/supportive measures. The most common treatments were physical activity interventions.

UK building surveying education: the graduates' view

PurposeMany facilities management professionals originally graduated from a building surveying course. The high referral rate of the professional body pre‐qualification assessment process for building surveyors and other criticisms of graduates have led many to question whether building surveying education is fit for purpose. This paper seeks to address these issues.Design/methodology/approachPrevious research on this subject has concentrated on obtaining the views of course providers and employers. The approach adopted for this study has been an on‐line survey of recent UK building surveying graduates. A 30 per cent response rate resulted in 806 graduates undertaking the survey.FindingsMost graduates had studied a full‐time undergraduate course, three‐quarters had gained some form of placement or work‐experience during their studies, the mode of the year of graduation was 2004 and 65 per cent of the sample work in private practice. The survey reveals concerns over non‐coverage of some of the professional body's pre‐qualification competencies. The most useful subjects studied by graduates were construction technology and building pathology and the least useful was economics. The top two omitted subjects from courses were contract administration and dilapidations – both core areas of work. Skills development was weaker on postgraduate than undergraduate courses.Practical implicationsThose designing HE building surveying courses can refer to the results of this study to ensure that their curricula remain relevant and current to the needs of industry.Originality/valueThis study into building surveying education has been undertaken at a time when many UK universities are reviewing their course provision to ensure that they are well placed to survive the massive upheaval imposed by government funding cuts and changes in student finance. This study with its large sample size will be of assistance to those reviewing building surveying courses.

A primary care specialist genetics service: a cluster-randomised factorial trial.

GPs do not have the confidence to identify patients at increased genetic risk. A specialist primary care clinical genetics service could support GPs with referral and provide local clinics for their patients. To test whether primary care genetic-led genetics education improves both non-cancer and cancer referral rates, and primary care-led genetics clinics improve the patient pathway. Cluster-randomised factorial trial in 73 general practices in the south of England. Practices randomised to receive case scenario based seminar (intervention) or not (control), and referred patients a primary (intervention) or secondary (control) care genetic counsellor (GC)-led appointment. GP referral and clinic attendance rates (primary), appropriate cancer and case scenario referral rates, patient satisfaction, clinic costs, and case management (secondary). Eighty-nine and 68 referrals made by 36 intervention and 37 control practices respectively. There was a trend towards an overall higher referral rate among educated GPs (referral rate ratio [RRR] 1.34, 95% confidence interval [CI] = 0.89 to 2.02; P = 0.161), and they made more appropriate cancer referrals (RRR 2.36, 95% CI = 1.07 to 5.24; P = 0.035). No indication of difference in clinic attendance rates (odds ratio 0.91, 95% CI = 0.43 to 1.95; P = 0.802) or patient satisfaction (P = 0.189). Patients spent 49% less travelling (£3.60 versus £6.62; P<0.001) and took 33% less time (39.7 versus 57.7 minutes; P<0.001) to attend a primary than secondary care appointment; 83% of GC-managed appointments met the 18-week referral to treatment, NHS target. An integrated primary care genetics service both supports GPs in appropriate cancer referral and provides care in the right place by the right person.

Human papillomavirus viral load expressed as relative light units (RLU) correlates with the presence and grade of preneoplastic lesions of the uterine cervix in atypical squamous cells of undetermined significance (ASCUS) cytology

Human papillomavirus (HPV) testing is more sensitive and has higher negative predictive value (NPV) than the Pap test for the detection of cervical intraepithelial neoplasia (CIN) in patients with atypical squamous cells of undetermined significance (ASCUS) cytology, but has low specificity, leading to high referral rates to second-level triage. Our goal was to identify the prognostic significance of HPV viral load figures. We evaluated whether a correlation between viral load, expressed as relative light units/cutoff (RLU/CO), and the severity of cervical lesions existed in 614 ASCUS cases. Hybrid Capture 2 (HC2®) RLU/CO values, categorised into five classes, were correlated to clinical outcomes and statistically analysed. A significant correlation (p < 0.0001) was observed between increasing RLU values and the prevalence of high-grade CIN (CIN2/CIN3). The mean RLU values for negative, low-grade and high-grade lesions were 68.1, 172.5 and 1,020.0 RLU/CO, respectively (p < 0.0001). CIN2/CIN3 ranged from 4% for 0 < RLU/CO values ≤ 1, to 5% for 1 < RLU/CO values ≤ 10, to 9% for 10 < RLU/CO values ≤ 100, to 23% for 100 < RLU/CO values ≤ 1,000 and to 48% when RLU/CO values were >1,000 (p < 0.05). The HPV viral load in ASCUS cases significantly correlates with the severity of cervical cancer precursors. These data may have prognostic value, as they significantly correlate with the probability of a CIN2+ .

Newborn hearing screening: importance and characteristics of a high-risk register in a neonatal intensive care unit

EnAbstract Background Hearing loss is one of the most common congenital anomalies, occurring in approximately two to four infants per 1000. Children whose hearing loss is identified, and who receive appropriate intervention before 6 months of age, develop significantly better language ability than those who are identified later. Objectives To assess the failure rate of neonatal hearing screening in a high-risk register group of neonates and the relative importance of these risk factors in hearing impairment in the neonatal ICU (NICU) of the El-Mounira Children Hospital and identify the incidence of hearing loss. Patients and methods The study was carried out on 100 neonates in El-Mounira Children Hospital (NICU) and on 30 control neonates (15 boys and 15girls) chosen from Kasr El-Eini Maternity Hospital. All control cases aged 1–4 days had normal birth weight (2000–4000 g) and gestational age (35–40 weeks) and were delivered normally or by cesarean section without complications. The children in the study group were 3–23 days old (53 boys and 47 girls) and had birth weight ranging from 900 to 4000 g and gestational age ranging from 28 to 41 weeks. All the cases were screened for hearing loss using the transient evoked otoacoustic emission device (Echo-Screen), followed by a second-stage screening for those who failed the test with the transient evoked otoacoustic emission device. Those cases given a Refer were then made to undergo an Automated Auditory Brainstem Response test after 3–4 weeks. Results In the NICU group, 55% had hyperbilirubinemia, requiring exchange transfusion, 13% were of low birth weight (&lt;1500 g), and 13% were on mechanical ventilation. Other risk factors such as cranio-facial anomalies showed a combined effect. In the first screening phase, 71% were given a Pass response and 29% were given a Refer response. In the second screening phase, 28% were given a Pass, 31% were given a Refer, and 41% were dropouts, as they had passed their critical stage and had been discharged. The highest referral rates were in neonates with multiple risk factors. Conclusion A comprehensive intervention and management program must be an integral part of the screening program in the postnatal period. Public awareness about the value of hearing screening is important for follow-up to be more effective. Monitoring of ototoxic drug administration and further assessment of the high prevalence of hyperbilirubinemia are needed. A team of obstetricians, pediatricians, and audiologists is needed to identify and assess risk factors.

Acceptability and cost-effectiveness of military telehealth mental health screening.

Telehealth has been touted as one solution to the shortage of mental health providers within the military. Despite developing evidence for the equivalence of telehealth mental health care, there is no research that covers the use of telehealth for population mental health screening, a standard component of postdeployment medical screening. This paper summarizes soldier perceptions of three separate screening events in which telehealth was used and the cost-effectiveness of telehealth versus in-person implementations of the same screening. Soldiers who have not been through telehealth screening report a strong preference for in-person screening. Soldiers who have been through telehealth screening still report preference for in-person screening, but they express more ambivalence about the screening method. Using telehealth-only mental health screening for large numbers of soldiers within a compressed time frame is more expensive than in-person screening. Telehealth resulted in higher referral rates than in-person screening. Government and military leaders should use care when making decisions about telehealth implementation. Although telehealth for small numbers may be sufficiently equivalent and economical, there is no evidence of cost savings or improved acceptability for telehealth mental health post-deployment screening.

Investigation of a significant increase in referrals during neonatal hearing screening: A comparison of Natus ALGO Portable and ALGO 3i

Objective: Neonatal hearing screening programs in Flanders and the Netherlands use Natus ALGO screening devices. Since 2006 in Flanders and 2009 in the Netherlands, both programs have replaced the older ALGO Portable devices with the newer ALGO 3i devices. However, in both countries, ALGO 3i devices have a significantly higher rate of referrals than ALGO Portable devices. In Flanders, the refer rate has more than doubled with the switch to ALGO 3i devices. In the Netherlands, screening centers which used ALGO 3i devices also showed a significant increase in referrals. In both countries, the percentage of children diagnosed with permanent hearing loss remained approximately the same. Design: A technical comparison of both device types was carried out to identify possible causes for the increase in referrals. The stimulus output of two ALGO Portable and three ALGO 3i devices was recorded and analysed for stimulus level, spectral properties, and stimulus irregularities. Results: ALGO 3i devices stimulate at a peak level 4.6 dB lower than ALGO Portable devices, have a different stimulus spectrum and show unexplained stimulus irregularities during 4% of the stimulation time. Conclusions: A number of technical differences were found between both device types which could explain the increase in referrals.

Problematic 'low grade' lesions in lymphoproliferative pathology

Pathological diagnosis of lymphoproliferative processes has been associated with a high error rate of 1735%, compared to a low diagnostic error incidence of 1-3% in general histopathology. In lymphoma diagnosis, one half of the diagnostic errors result in significant clinical consequences such as delayed or inappropriate therapy, unnecessary treatment, avoidable morbidity and compromised survival.1 Inherent pathological ambiguity of lymphoproliferative processes, interpretational subjectivity, unfamiliarity with diagnostic criteria and novel entities, lack of expert opinion, inappropriate laboratory support and poor clinico-pathological correlation are the main reasons behind most pitfalls in this subspecialty. Over the past 20 years, advances in classification have aided pathologists to better characterise lymphoid proliferation. The WHO lymphoma classification has imposed additional requirements for genetic and molecular interrogations. as a result, it has now been widely advocated that diagnosis of lymphoproliferative processes is centralised and conducted in dedicated, highly specialised laboratories.2 However, even in the context of central pathology review of lymphoid proliferations, the initial steps in selecting cases for referral depend on the diagnostic skills of generalist pathologists. Their familiarity with reactive conditions many of which closely mimic neoplasms, is essential. reactive lymphoproliferations represent 10-20% of the cases referred to subspecialist diagnostic services. This high referral rate outlines the pathological ambiguity of these conditions and their difficult differential diagnosis with lymphoma. In many instances, this is complicated by a dramatic clinical presentation resulting in high concern and “pressure” from clinicians, which may further compromise diagnostic confidence. such conditions comprise a variety of morphological patterns including follicular proliferations, paracortical expansions, intrasinusoidal and necrotizing processes. In the recent update of the WHO lymphoma classification there is a “plethora” of new entities which further widen the differential diagnosis of reactive lesions and “low grade” lymphomas. This particularly refers to a spectrum of early lesions which sit at the interface between the reactive and neoplastic. In the context of this review, “low grade” lesions are not considered to represent a homogeneous group of entities. This colloquial term is here used for diverse both reactive and neoplastic processes the clinical course of which is mostly non-aggressive, even though the morphological features may sometimes imply otherwise. Examples of difficult differential diagnoses and newly recognised entities with their clinical implications are discussed with emphasis on the importance of clinico-pathological correlation. Reactive lymphoproliferations with nodular architecture may mimic lymphoma (and vice versa): Progressive transformation of germinal centres is a rare reactive process of uncertain aetiology which may result in bulky lymphadenopathy. The morphological features mimic nodular lymphocyte predominant Hodgkin lymphoma or follicular lymphoma. diagnosis relies on the identification of disrupted but retained components of the lymphoid follicles, without L&H cells. Other nodular/follicular proliferations including florid non-specific follicular hyperplasia and hyaline vascular variant of Castleman’s disease pose a differential diagnosis with lymphomas exerting a nodular growth pattern. This relates primarily to variants of follicular lymphoma (FL)(Grade 3a/B, “floral variant”, FL with hyaline vascular changes). appreciation of retained lymph node architecture is essential for diagnosis. difficult cases may need clonality and genetic studies.3 “In situ” and early neoplastic lesions in lymphoproliferative pathology do exist: Follicular lymphoma in situ is a recently recognised entity representing an early phase of neoplastic transformation with uncertain HEMaTOPaTOLGIjakratki kurs 2/HEMaTHOPaTOLOGY short Course 2

Market conditions and general practitioners’ referrals

We study how market conditions influence referrals of patients by general practitioners (GPs). We set up a model of GP referral for the Norwegian health care system, where a GP receives capitation payment based on the number of patients in his practice, as well as fee-for-service reimbursements. A GP may accept new patients or close the practice to new patients. We model GPs as partially altruistic, and compete for patients. We show that a GP operating in a more competitive market has a higher referral rate. To compete for patients and to retain them, a GP satisfies patients' requests for referrals. Furthermore, a GP who faces a patient shortage will refer more often than a GP who does not. Tests with Norwegian GP radiology referral data support our theory.