Incorrect Referrals Research Articles

Joint pain - a rheumatic disease?

Pain in the musculoskeletal system and therefore joint pain is one of the most common reasons for consulting a general practitioner (GP). Inflammatory rheumatic diseases are among the important differential diagnoses. However, the prevalence of rheumatological diseases is significantly lower than that of degenerative causes of pain. Incorrect referrals can be avoided if the causes of pain are better differentiated in GP practices. This article presents the first differential diagnostic steps that make it easier for the GP to make further treatment decisions. Physical examination, laboratory diagnostics and imaging are discussed, and the concept of "clinically suspect arthralgia" as well as the possible effects of treatment trials with glucocorticoids are presented.

An economic impact of incorrect referrals for MRI and CT scans: A retrospective analysis.

Up to date, no research on the economic efficacy of diagnostic modalities, such as magnetic resonance imaging (MRI) and computerized tomography (CT), has been done in Central Asia. The aim of this study was to analyse the inappropriate appointments of MRI and CT scanning procedures in Kazakhstan. We used the imaging diagnostic reports and medical records from 9725 planned outpatient CT and MRI exams performed in two major hospitals in Almaty. The study period was for the period 2014-2019. The independent experts-radiologists evaluated the MRI and CT exams for validity using the ACR® compliance standards and RCR recommendations. The results showed that the combined costs of MRI and CT scans increased by $17.982 between 2014 ($22.537) and 2019 ($40.519), p = 0.002. The highest rate of MRI examinations was observed in 2019, with a rate of 6.9 per 10,000 people. It was determined that in 2019 the highest rate for men who undertook CT was equal to 12.4 per 10,000 people, while for women it was equivalent to 5.7 per 10,000 patients. The majority of non-corresponding imaging examinations (n = 1304) were referred for MRI and CT scans by general practitioners. We detected the irrational referrals for head and neck radiological examinations in n = 178 (13.7%) cases, and the abdominal cavity checks in n = 249 (19.1%) cases (p = 0.001). The main portion of erroneously unreasonable referrals for examination of the abdominal organs was made by surgeons in n = 43 (3.3%) cases. The findings indicated an increase in the number of referrals for unnecessary CT and MRI tests over the research period (2014-2019). It had a substantial impact on the rise in healthcare system expenses. The results demonstrate the need for the education of GPs and improving the approaches for diagnostics.

Mapping of referral patterns for undescended testes – Risk factors for referral of children with normal testes

Accurate referral of boys with suspected undescended testes (UDT) is of importance to preserve fertility and reduce risk of future testicular cancer. While late referral is well studied, there is less knowledge about incorrect referrals, hence, referral of boys with normal testes. To evaluate the proportion of UDT referrals that did not lead to surgery or follow-up, and to assess risk factors for referral of boys with normal testes. All UDT referrals to a tertiary center of pediatric surgery during 2019-2020 were retrospectively assessed. Only children with suspected UDT in the referral (not suspected retractile testicles) were included. Primary outcome was normal testes at examination by a pediatric urologist. Independent variables were age, season, region of residence, referring care unit, referrer's educational level, referrer's findings, and ultrasound result. Risk factors for not needing surgery/follow-up were assessed with logistic regression and presented as adjusted odds ratios with a 95% confidence interval (aOR, [95% CI]). A total of 378 out of 740 included boys (51.1%) had normal testes. Patients >4 years (aOR 0,53, 95% CI [0,30-0,94]), referrals from pediatric clinics (aOR 0.27, 95% CI [0.14-0.51]) or surgery clinics (aOR 0.06, 95% CI [0.01-0.38]) had lower risk of normal testes. Boys referred during spring (aOR 1.80, 95% CI [1.06-3.05]), by a non-specialist physician (aOR 1.58, 95% CI [1.01-2.48]) or referrer's description of bilateral UDT (aOR 2.34, 95% CI [1.58-3.45]), or retractile testes (aOR 6.99, 95% CI [3.61-13.55]) had higher risk of not needing surgery/follow-up. None of the referred boys that had normal testes had been re-admitted at the end of this study (October 2022). Over 50% of boys referred for UDT had normal testes. This is higher or equal to previous reports. Efforts to reduce this rate should in our setting probably be directed towards well-child centers and training in examination of testicles. The main limitation of this study is the retrospective design and the rather short follow-up time, which however should have very modest effect on the main findings. Over 50% of boys referred for UDT have normal testes. A national survey regarding the management and examination of boys testicles has been launched and directed at well-child centers to further evaluate the findings of the current study.

A simple, automated, speech‐based and AI‐enhanced screener for mild cognitive impairment and amyloid beta positivity

AbstractBackgroundVocal and linguistic changes in Alzheimer’s dementia have been documented. The current study assesses whether a fully automated speech‐based artificial intelligence (AI) system can detect early clinical impairment and amyloid positivity, which characterise the earliest stages of Alzheimer’s disease (AD).MethodTwo studies were completed in the UK and USA: AMYPRED‐UK (NCT04828122) and AMYPRED‐US (NCT04928976). 200 participants with established amyloid beta (Aβ) and clinical diagnostic status (97 Aβ+, 103 Aβ‐ from prior PET scan or CSF tests; 94 cognitively unimpaired (CU), 106 with mild cognitive impairment (MCI) or mild AD) were recruited and completed automated assessments with the Automatic Story Recall Task (ASRT) either in‐clinic or via telemedicine appointment. The AI text‐pair evaluation model ParaBLEU produced vector‐based representations of the abstract, generalized patterns that differed between the original story text and transcribed retellings. These were fed into logistic regression models trained with tournament leave‐pair‐out cross‐validation analysis to predict Aβ status and MCI/mild AD. Potential benefits of screening using the ASRT system were examined via simulation, including: (1) identifying MCI in primary care, and (2) reducing the number of PET scans required in clinical research studies and trials.ResultUsing an average of only 6.56 minutes of speech per participant, the ASRT system predicted Aβ positivity in the full sample (area under the receiver operating characteristic curve (AUC) = 0.77) and in diagnostic subsamples (MCI/mild AD: AUC = 0.82; CU: AUC = 0.71), as well as MCI/mild AD (AUC = 0.83) in the full sample. Simulation indicated that screening with the ASRT system could: (1) increase correct (+8.5%) and reduce incorrect referrals (‐59.1%) compared with the Mini‐Mental State Exam; and (2) enrich samples for Aβ positivity prior to PET scan (‐35.3% and ‐35.5% fewer scans required in MCI and CU individuals, respectively).ConclusionWith the first disease‐modifying treatment for AD now available, there is an urgent need for improved screening to identify individuals at risk for AD dementia. The ASRT system is a brief, effective, automated, speech‐based cognitive assessment offering scalable screening for MCI/mild AD and amyloid beta biomarker positivity.

Point-of-care ultrasound of abdominal as an useful diagnostic tool for the general practitioner

Introduction and purpose
 Ultrasonography (US) is a safe, non-invasive and widespread diagnostic tool. Point-of-care ultrasound (POCUS) is more and more often used in a general practitioner’s (GP) office as an element complementing the medical and physical examination. The aim of the study is to present ultrasonography as a useful diagnostic tool in the practice of a general practitioner (GP).
 Description of the state of knowledge
 Abdominal pain and gastrointestinal infections are among the most common reasons for patients visiting their GPs. A point-of-care ultrasound examination enable the shortening of the time necessary to make a diagnosis as well as the fastest possible implementation of appropriate treatment. This is especially important in acute conditions such as cholecystitis, cholelithiasis, appendicitis or renal colic.Patients who underwent ultrasound examination during their GP visit gave them a better understanding of their health problem, increased their sense of securityand confidence in the diagnosis made by the doctor.
 Summary
 Point-of-care ultrasound is an examination that is increasingly used by doctors working in primary care as a diagnostic tool ensuring earlier and more precise diagnosis. GP familiarization with ultrasound could reduce the number of incorrect referrals as well as improve the interpretation of the results. Performing the POCUS examination during a visit to the primary care physician allows GP to make a quick diagnosis and make a decision about conservative treatment, referral to the appropriate specialist or hospitalization.

Adherence to the American Society for Colposcopy and Cervical Pathology guidelines: an observational study.

ObjectiveThe 2012 American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines were developed to provide guidance regarding cervical pathology and to minimize overtreatment of lesions that may resolve spontaneously. We aimed to evaluate the adherence to these guidelines with referrals for colposcopy at a large academic center and to understand the factors associated with incorrect referrals.MethodsThis retrospective observational study involved women referred to the Virginia Commonwealth University for colposcopy or loop electrosurgical excision procedure from January 2015 to December 2016.ResultsReferral requests from 430 women were reviewed. Among these, 17.4% were discordant with the ASCCP guidelines. The most common discordant colposcopy referrals were low-grade squamous intraepithelial lesions (48%) and atypical squamous cells of undetermined significance (29%). The possibility of incorrect referrals was decreased among high-grade lesions (odds ratio [OR], 0.03), while it was increased in women aged <25 years (OR, 31.6) and in those referred by family medicine (OR, 3.6) or internal medicine (OR, 4.4). Ten patients were referred for cervical cytology results of samples collected from the vaginal cuffs despite hysterectomies performed for benign lesions.ConclusionPatients referred outside of the guidelines were most often women aged <25 years with low-grade lesions. Referrals outside evidence-based guidelines may lead to unnecessary procedures and additional healthcare expenses. Our results help identify the areas for provider education and potential areas of concern regarding the implementation of the 2019 ASCCP guideline updates.

Evaluation of the blinq vision scanner for detection of amblyopia and strabismus

To report the results of a clinical study designed to evaluate the accuracy of the blinq pediatric vision scanner, which detects amblyopia and strabismus directly by means of retinal polarization scanning, unlike other vision screening devices, which infer possible disease based on detection of refractive risk factors. Subjects 1-20years of age were prospectively enrolled in this cross-sectional diagnostic accuracy study with planned enrollment of 200. All enrolled subjects were tested by individuals masked to the diagnosis, followed by complete ophthalmologic examination by pediatric ophthalmologists masked to the screening result. Patients previously treated for amblyopia or strabismus were analyzed separately. The study cohort comprised 193 subjects, 53 of whom had been previously treated, leaving 140 treatment-naïve subjects, including 65 (46%) with amblyopia or strabismus, 11 (8%) with risk factors/suspected binocular vision deficit without amblyopia/strabismus, and 64 (46%) controls. Sensitivity was 100%, with all 66 patients with referral-warranted ocular disease referred. Five patients with intermittent strabismus receiving pass results were deemed "acceptable pass" when considering patient risk factors and amblyogenic potential. Specificity was 91%, with 7 incorrect referrals. Subanalysis of children aged 2-8years (n=92) provided similar results (sensitivity 100%; specificity 89%). In this study cohort, the blinq showed very high sensitivity and specificity for detecting referral-warranted unilateral amblyopia and strabismus. Implementation of the device in vision screening programs could lead to improved rates of disease detection and reduction in false referrals.

328 Community Clinic Report Card on Utilization of Screening Colonoscopies: How Well Are We Doing?

INTRODUCTION: Screening colonoscopy is an integral but underutilized diagnostic tool in preventing colorectal cancer (CRC). Reasons for delays in CRC screening include incorrect referrals, shortage of physician availability and endoscopy capacity, and limited access to care for uninsured and minority patients. The aims of our study were to measure the time from referral to screening colonoscopy and to define predictors of noncompliance to CRC screening. METHODS: A retrospective chart review of patients referred to our clinic for screening colonoscopy was conducted from 7/2017 to 9/2018. Inclusion criteria were age appropriate CRC screening; patients with positive FOBT/FIT for purely screening reasons were also included. Patients younger than 45 or older than 85 years, or those referred for a diagnostic (evaluation of anemia, hematochezia, weight loss) or surveillance colonoscopy (prior adenomatous polyps or adenocarcinoma) were excluded. Patient demographics, referral data, and medical histories were reviewed. RESULTS: 180 patients met inclusion criteria. Follow-up throughput is shown in Figure 1. 63% patients were deemed non-compliant (not making an appointment, missing scheduled appointment, or not completing recommended colonoscopy). Appointments for 60% of patients were canceled because of missed pre-GI visit registration or patient no showed. 52% of referrals came from outside the health system. 53% of all patients referred were never seen by GI. 71% of patients ordered to have a screening colonoscopy completed their procedure. A final total of 28% of all patients referred eventually underwent colonoscopy.Non-compliant patients were more likely to be uninsured (P-value = 0.04), come from outside referral (P-value = 0.014), have more days from referral reviewed to appointment (81.8 vs 71 days, P value = 0.01), and have less medical problems (1.2 vs 1.5, P value = 0.04). There was no statistical difference between gender, age, race, Hispanic, language, marital status, tobacco use, Charlson Comorbidity Score, or days from clinic appointment to colonoscopy. CONCLUSION: Our study identified outside referrals, lack of insurance, and more days from referral received to appointment as predictors of non-compliance to screening colonoscopy.Further interventions should address optimization of utilization of screening colonoscopies, such as targeted navigational resources for uninsured patients from outside referrals, minimizing steps to GI clinic visit, and educating patients on the value of CRC screening.

Clinical evaluation of the use of an mhealth intervention on quality of care provided by Community Health Workers in southwest Niger.

BackgroundUnder the World Health Organization’s (WHO) integrated community case management (iCCM) Rapid Access Expansion Program (RAcE), World Vision Niger and Canada supported the Niger Ministry of Public Health to implement iCCM in four health districts in Niger in 2013. Community health workers (CHWs), known as Relais Communautaire (RCom), were deployed in their communities to diagnose and treat children under five years of age presenting with diarrhea, malaria and pneumonia and refer children with severe illness to the higher-level facilities. Two of the districts in southwest Niger piloted RCom using smartphones equipped with an application to support quality case management and provide good timely clinical data. A two-arm cluster randomized trial assessed the impact of use of the mHealth application mainly on quality of care (QoC), but also on motivation, retention and supervision.MethodsA two-arm cluster randomized trial was conducted from March to October 2016 in Dosso and Doutchi districts. The intervention arm comprised 66 RCom equipped with a smartphone and 64 in the paper-based control arm. Trained expert clinicians observed each RCom assessing sick children presenting to them (264 in intervention group; 256 in control group), re-assessed each child on the same set of parameters, and made further observations regarding perceptions of motivation, retention, supervision, drug management and caregiver satisfaction. The primary outcome was a QoC score composed of diagnostic and treatment variables. Other factors were assessed by questionnaires.ResultsOn average, the mHealth equipped RCom showed a 3.4% higher QoC score (mean difference of 0.83 points). They were more likely to ask about the main danger signs: convulsions (69.7% vs 50.4%, P < 0.001); incapacity to drink or eat (79.2% vs 59.4%, P < 0.001); vomiting (81.4% vs 69.9%, P < 0.01); and lethargy or unconsciousness (92.4% vs 84.8%, P < 0.01). Specifically, they consistently asked one more screening question. They were also significantly better at examining for swelling feet (40.2% vs 13.3%, P < 0.01) and advising caretakers on diarrhea, drug dosage and administration, and performed (though non-significantly) better when examining cough and breathing rates, referring all conditions, getting children to take prescribed treatments immediately and having caregivers understand treatment continuation. The control group was significantly better at diagnosing fast breathing, bloody diarrhea and severe acute malnutrition; and was somewhat better (non-significant) at treating fever and malaria. With treatment in general of the three diseases, there was no significant difference between the groups. On further inspection, 83% of the intervention group had a QoC score greater than 80% (25 out of 31), whereas only 67% of the control group had comparable performance. With respect to referrals, the intervention group performed better, mostly based on their better assessment of danger signs, with more correct (85% vs 29%) and fewer missed, plus a lower proportion of incorrect referrals, with the reverse being true for the controls (P = 0.012). There were no statistically significant differences in motivation, retention and supervision between the two groups, yet intervention RCom reported double the rate of no supervision in the last three months (31.8% vs 15.6%).ConclusionsResults suggest that use of the mHealth application led to modestly improved QoC through better assessment of the sick children and better referral decisions by RCom, but not to improvement in the actual treatment of malaria, pneumonia and diarrhea. Considering mHealth’s additional costs and logistics, questions around its viability remain. Further implementation could be improved by investing in RCom capacity building, building organization culture and strengthened supervision, all essential areas for improving any CHW program. In this real-world setting, in poor and remote communities in rural Niger, this study did not support the overall value of the mHealth intervention. Much was learned for any future mHealth interventions and scale-up.

Faecal immunochemical testing (FIT)

Aim: Faecal immunochemical testing (FIT) is simple, noninvasive and accessible test widely used in screening programmes for colorectal cancer. Though the use of FIT in detecting positive pathology has been a topic of contention, there is a strong body of evidence demonstrating FITs high negative predictive value (96100%), namely its strength in ruling out sinister disease. Recently recommendations in NICE guidelines on suspected cancer in symptomatic patients suggests its use to triage the need for referral to secondary care in patients of low risk; namely those with iron deficiency anaemia under 60 and those with anaemia (all types) over 60. The data from these recommendations are based on are from 10 cohort studies, 5 of which were deemed to have high risk of bias by the guideline authors, only 4 examine colorectal cancer alongside faecal occult blood testing, none of which examine cohorts with more than 80 colorectal cancers detected and none reporting results specific to this low risk symptomatic group that is being described. This leaves a grey area whereby management is left to the digression of primary care practitioners. Patients: With more than 40,000 new cases of colorectal cancer being detected every year and the growing burden on secondary care, there is an urgent need to define management for this large pool of patients with anaemia and suspected colorectal cancer. More rigorous data is needed to direct referral guidelines, delineate influential factors including age, sex and medication, and stratify risk factors and pretest probability. Intervention/Comparator: Can FIT triage and rule out sinister pathology in patients presenting with suspicious symptoms of bowel cancer who belong to a low risk demographic Study design: We propose a multicentre diagnostic cohort study recruiting patients with anaemia and suspected colorectal cancer, who have been referred to secondary care. All patients will have a faecal occult blood test done a full blood count, urea and electrolytes and CRP and a complete drug history recorded prior to further investigation (colonoscopy/CT colonography). Data will be collected on positive pathological findings including colorectal cancer, advanced adenomas, and other causes of occult bleeding including inflammatory bowel disease and polyps. Plus, data for cancers that went onto resection will be followed up including staging and metastases. We aim to recruit 25003000 patients with the primary goal to detect 150 300 cancers and gather demographic information sufficient to analyse gender disparity, impact of medications and if detection thresholds should be altered and potentially produce a system to score and stratify this group of patients. In cost effectiveness analysis, FIT is better than both guaiacbased faecal occult blood testing and no triage and in analysis models the use of FIT could save 77% incorrect referrals to colonoscopy (true negatives), and missed only 0.2% of cancers (false negatives). This has the potential to have a significant impact on both the economic and logistical management of colorectal cancer services nationwide.

RETROSPECTIVE ANALYSIS OF PATIENT REFERRALS FOR COMPUTED TOMOGRAPHY

To conduct a retrospective analysis of patient referrals for computed tomography to identify the main problems, both in writing the direction itself and in its validity. Materials and methods: The patient referrals for computed tomography (CT) were analyzed at the Radiology Department of the National Scientific Center named after AN Syzganov - outpatients for 3 months. Results and discussions: it has been established that, in the main, clinicians, when issuing a referral for a study, ignore such item as a diagnosis, or replace it with the word — examination. There is also the groundlessness and incorrectness of the referrals for the studies, considering their variability and insufficient awareness of doctors both in the indications and the need for a particular study. Conclusion: Clinicians are not sufficiently aware of the correctness of referrals for computed tomography and, as a result, write out incorrect referrals.

The role of guideline reinforcement in improving quality of referrals to a specialist breast clinic

The role of guideline reinforcement in improving quality of referrals to a specialist breast clinic

Experiences of general practitioners, practice nurses, psychologists and patients with stepped collaborative care for depression: a focus group study in a large primary healthcare organization

Rationale, aims and objectives: Depression is a major and complex problem in primary care. Stepped Collaborative Care (SCC) models for depression have been developed to support primary care in diagnostic and therapeutic procedures. This study aimed to compare barriers and facilitators experienced by general practitioners (GPs), practice nurses for psychosocial care, primary care psychologists and patients working with SCC for depression and to discuss possible solutions for barriers in daily practice.Method: Conventional content analysis of focus group data. Nine mono-disciplinary focus groups including 16 general practitioners (GPs), 4 practice nurses, 6 psychologists and 23 patients.Results: All 4 participant groups appeared to perceive a need for more skills, support and time for GPs to adequately assess symptoms and initiate psychosocial management accordingly. Psychologists often ignore a GP’s diagnosis. The GPs’ diagnostic uncertainty and their unfamiliarity with psychological therapies can result in inappropriate treatments, incorrect referrals and long waiting lists. To improve stepped collaborative care programs for psychosocial symptoms, improving initial symptom assessment by the GP, seems the most important aspect. All participants agreed that diagnostic tools/questionnaires should be used in primary care, but such activities should not be complicated and should not add to the GPs’ workload. Patients need more information to share decisions with their care providers.Conclusion: There is a need for a diagnostic-therapeutic tool to support GPs in regulating the influx of patients in SCC models and enhancing the effect of SCC in daily practice in order to improve the person-centeredness and efficiency of primary healthcare.

School Referrals of Children and Adolescents to CAPSi – the Burden of Incorrect Referrals

School Referrals of Children and Adolescents to CAPSi – the Burden of Incorrect Referrals

Accuracy of referrals from an orthoptic vision screening program for 3- to 4-year-old preschool children

To determine the accuracy of orthoptist referrals from a preschool-based vision screening program for children 3-4 years of age and to report the outcomes of referred children. This was a retrospective review of records of participants in the preschool vision screening program in the Walsall, United Kingdom, area for the 2006-2007 school year. Screening examinations were performed by orthoptists and included assessment of visual acuity, ocular alignment, ocular motility, and stereoacuity. For the 2006-2007 school year, 2,830 of 3,623 children (78%) were screened, Of these, 413 were referred to the Hospital Eye Service. Comparison of the screening results and the Hospital Eye Service examination revealed that recorded visual acuities were similar in 81% of subjects and ocular alignment in 94%. Visual acuity was 6/9 or better at the hospital examination in 87% of referred children, with 46% requiring spectacle use only; 17% of referrals were diagnosed with amblyopia. Although the Walsall vision screening program diverged from UK national guidelines by testing at an earlier age, there was no evidence that earlier screening led to a large number of incorrect referrals, and early screening may allow for better outcomes. Sensitivity of screening was not tested, and orthoptist screening in the United Kingdom is likely to be more accurate in this age group than nonspecialist or lay screening that is performed in many other areas.

Análisis etiológico de 425 pacientes remitidos a una consulta extrahospitalaria de neurología por temblor o parkinsonismo

Movement disorders are a common reason for visits to outpatient neurology departments. This study has two objectives. The first is to analyse the diagnoses of patients referred to the neurology service due to tremor or Parkinsonism. The second aim is to analyse whether such patients are referred from primary care correctly or incorrectly. The study examines patients referred from primary care to the neurology service in a medical specialty centre because of tremor or Parkinsonism. The final diagnoses established by the neurologist were analysed and patient referral was also analysed using a set of previously agreed criteria. The sample consisted of 425 consecutive patients who were referred from primary care due to tremor (n = 294) or Parkinsonism (n = 131). The most common diagnoses were Parkinson's disease (n = 211; 50%), essential tremor (n = 157; 37%) and pharmacological Parkinsonism (n = 23; 5%). Referral was considered to be incorrect in 39 patients and correct in 388 cases (91%). The causes of incorrect referrals were: pharmacological Parkinsonism (n = 23), anxiety that was not treated in primary care (n = 12) and hypothyroidism that went undiagnosed in primary care (n = 4). Parkinson's disease, essential tremor and pharmacological Parkinsonism are the most frequent diagnoses in patients who are referred from primary care because of tremor and Parkinsonism. Referral to a neurology service is correct in most cases, but there is still room for improvement.