Increase In Referral Rates Research Articles

Left atrial reservoir strain differentiates cardiac amyloidosis and hypertrophic cardiomyopathy

Abstract Aims Availability of mortality-reducing therapies for cardiac amyloidosis (CA) has led to an increase in referral rates to tertiary care centers. Investigations to improve diagnosis rates are urgently needed, as diagnosis of CA requires a multimodal approach and its early diagnosis is crucial due to high mortality in untreated patients. The aim of this study is to evaluate the accuracy of the left atrial reservoir strain (LASr) in differentiating CA patients from patients with hypertrophic cardiomyopathy (HCM). Methods This is a cross-sectional analysis from the Graz HCM Registry, a prospective single-center cohort study enrolling consecutive patients with a HCM phenotype. This analysis included HCM and CA patients with valid standardized transthoracic echocardiographic examinations. Blinded investigators performed post-processing echocardiographic analyses in 100 HCM and 95 CA patients. Results Compared to HCM patients, CA patients were more frequently male [79 (83%) vs. 54 (54%); p<0.001] and older [78 (73-81) vs. 58 (47-70) years; p<0.001]. Moreover, CA patients had a lower BMI [25.0 (22.8-26.9) vs. 26.5 (24.3-29.7) kg/m²; p=0.002] as well as lower systolic [134±20 vs. 142±25 mmHg; p=0.018] and diastolic blood pressure [78±12 vs. 84±12 mmHg; p<0.001]. Additionally, CA patients had higher NT-proBNP [2533.0 (1146.0-5016.0) vs. 543.0 (195.0-1381.0) pg/ml; p<0.001] and lower eGFR [58.4±19.1 vs. 80.1±22.2 ml/min/1.73m²; p<0.001]. LASr was significantly worse in CA patients compared to HCM patients [9.2 (5.6-13.0) vs. 21.7 (14.8-27.6) %; p<0.001]. Multivariable logistic regression analysis revealed LASr as an independent predictor of CA [OR=0.936 (95% CI 0.877-0.998)], adjusting for covariates. ROC analysis showed an AUC of 0.80 (95% CI 0.73-0.86) for LASr to discriminate CA from HCM. LASr ≤14.3% demonstrated a 80% sensitivity and 79% specificity for the identification of CA patients. Sensitivity analyses involving 74 sex- and age-matched patients yielded materially unchanged results. Conclusion Compared to HCM patients, LASr was diminished in CA patients and an independent predictor of CA. Moreover, LASr showed high diagnostic accuracy in differentiating CA and HCM patients. Prospective studies are needed to evaluate the added value of left atrial strain in the diagnostic work-up of CA patients.ROC curve of LASr

Effect of COVID-19 lockdowns on maxillofacial fractures in New Zealand: a retrospective study

Introduction: The New Zealand Accidents Compensation Corporation received 28,901 new claims for maxillofacial fractures between January 2018 and December 2021, at an annual cost of NZ$70–80 million. We have previously reported interpersonal violence as the most common cause of maxillofacial fractures disproportionately affecting young Māori males. This study provides an update on the incidence and cause of maxillofacial fractures with a specific review of the impact of COVID-19 lockdowns. Methods: Patients referred to the Wellington Regional Plastic, Maxillofacial and Burns Unit from 1 January 2018 to 31 December 2021 were identified from our maxillofacial fracture database. Age, ethnicity, gender, cause of injury, risk factors, and fracture pattern and management were analysed. Results: Out of 1281 patients identified, 75.2 per cent were male, most commonly (38.7%) aged 16–30 years. Interpersonal violence, falls and sports accounted for 37.6 per cent, 24.9 per cent, and 24.0 per cent of all maxillofacial fractures, respectively. Māori (22.0%) and New Zealand Europeans (55.7%) were the two largest groups, most commonly affected by interpersonal violence and falls, respectively. There was a relative increase in referral rates for females and for those older than 60 years (1.78 per 10 person-days versus 0.014 per 10 person-days and 4.2 per 10 person-days versus 1.8 per 10 person-days, respectively) and a decrease in the rates of interpersonal violence and sports related referrals (1.2 per 10 person-days versus 3.4 per 10 person-days and 0.41 per 10 person-days versus 2.19 per 10 person-days, respectively) during COVID-19 lockdowns, compared with outside lockdown. Conclusions: Interpersonal violence remains the main cause of maxillofacial fractures. There is a need for a national prevention strategy to reduce this. During COVID-19 lockdowns, there was a relative increase in the referral rates of females aged 60 years and over. Both sports and interpersonal violence showed significantly reduced referral rates during lockdowns, while falls, road traffic accidents and other were referred at a similar rate as out of lockdown.

Analysis of Factors Related to Referral Cases in Childbirth

Various factors can affect the number of referrals and the quality of referrals. This increase in referral rate can be an indication that the implementation of the referral system has not gone well. These indicators can be divided into indicators from the midwife's side, namely education and length of work, and indicators from the family in the form of support provided and speed of decision making. The purpose of this study was to analyze the effect of midwife education, midwives' tenure, and family support on referral success. This study is a type of intervention research with a cross sectional design. The location used for this study is at the Cikande Health Center in November-December 2023. The samples used in this study, using total sampling with samples were 30 obstetric referral cases. The data was collected by questionnaire. The independent variables were midwives' education, midwives' length of service, and family support. The dependent variable is referral success. The test used is the Chi Square test. The results of p value 0.007 < 0.05 which indicate that education has a significant relationship with referral success, p value 0.023 < 0.05 which indicates that midwives' tenure has a significant relationship with referral success, and p value 0.001 < 0.05 which indicates that the support provided by family has a very significant relationship with referral success.

Effectiveness of immediate appointment scheduling in smoking cessation clinics for patients with chronic airway diseases: Preliminary results from a randomized trial.

Patients with airway diseases who bear the burden of smoking need access to smoking cessation support. We aimed to investigate the impact of immediately scheduled appointments on access to smoking cessation clinics compared with usual care in this patient group. This multicenter, prospective, randomized, open-label study was conducted between November 2022 and June 2023 at pulmonary outpatient clinics. The study included adult patients who were current smokers and had a diagnosis of asthma, COPD, or bronchiectasis for at least six months. Sequentially randomization was used for the allocation of patients in a 1:1 ratio to two study arms: the usual support arm (representing the current standard care procedure) and the immediate support arm (involving intensive brief cessation advice followed by the immediate arrangement of an appointment at the same clinic's smoking cessation service). After one week, both patient groups were contacted by phone to assess their quit attempts and whether they had sought assistance from smoking cessation outpatient clinics (SCCs). A total of 397 patients were enrolled in the study, with 199 allocated to the usual support arm and 198 allocated to the immediate support arm. Within the first week, 18.1% of patients in the usual support arm and 77.3% of patients in the immediate support arm sought assistance from the smoking cessation clinic (p<0.001). The rate of smokers without an intention to quit was 56.7% in the usual support arm and 27.7% in the immediate support arm in the first week of follow-up. Immediate appointment scheduling was significantly associated with a 13-fold (OR=13.38; 95% CI: 8.00-22.38) increase in referral rates in the multivariate logistic regression model. Arranging instant appointments has increased access to SCCs by 13 times compared to the usual care, this group of patients should be given an immediate appointment to SCCs.

Utilisation of physician reminders about smoking cessation improves patient outcome

Background: Smoking is a major risk factor for cardiovascular disease and is prevalent amongst 18-64-year-olds (31.9%) in Qatar. Disease prevention through health promotion remains the cornerstone of physicians workload in primary care. Physician reminders (PR) be it electronic or physical can prompt doctors to offer smoking cessation services, hopefully reducing disease burden. The objective was to improve the identification of smokers and provision of smoking cessation services using a PR system in primary care. Methods: A prospective quality improvement project in a primary care health centre focusing on physician practices towards smokers. We analyzed physicians’ documentation post consultation looking for specific end points like use of the code “smoker” and referral rates to the smoking cessation clinic (SCC). Data was collected with and without use of a PR (used to identify smoker) and then compared for the difference in documentation and services offered. Results: The use of a physician reminder vastly improved the identification of smokers. This led to an increase in the use of the code ‘smoker’ by physicians by 43.5%. Documentation of smoking status and the provision of smoking cessation counselling both improved by 32.8%. There was an increase in referral rates (18.8%) to the SCC due to use of the physician reminder. There was a 7.9% rise in smokers attending the SCC. Conclusions: Using a physician reminder helped to improve the identification of smokers and patient provision of smoking cessation services such as referral to the SCC. Repeating the study using an electronic physician reminder incorporated within the EMR system would be beneficial given the findings from this study.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Improving referrals to survivorship: A patient-driven initiative.

44 Background: Patients often feel lost in the transition from cancer patient to survivor. As cancer treatment improves, the number of survivors in the US is expected to approach 22 million by the year 2029. Smaller increases in the MD workforce coupled with long-term effects of new treatments necessitate the creation survivorship clinics led by advanced practice providers (APP) who are disease-specialized and specifically trained to manage unique survivor needs. Although the institutions Survivorship program was established more than a decade ago, the average referral rate to the program is only 30%. Given the high levels of patient satisfaction with the program, we sought to understand and address clinician awareness and referral obstacles. Methods: Based on patient input, members of our Patient &amp; Family Advisory Council for Quality (PFACQ) put forth a proposal aimed at increasing referrals to the Survivorship program. A multidisciplinary working group comprising patients, clinicians, administrators and process engineers was assembled. Process Improvement training was conducted, and a primary goal was developed: increase Survivorship referrals by 25%. Central to the approach was engagement with referring physicians and APPs on a service-by-service basis. A four-question survey was developed to address timing of initial discussion, challenges to referring, knowledge of visit elements, and materials needed to support referrals. A customized ‘roadshow’ presentation was created and delivered by a PFACQ member at a faculty meeting. Highlights included: the importance of Survivorship care to patients and details of the visit, survey responses, and additional faculty discussion and input. Results: Four roadshows were completed from August 2020-June 2021: Gynecologic Surgery, Endocrine, Breast Medicine and Lymphoma. Based on survey responses and dialogue with providers, new material to support patient discussions and education have been developed: a patient-facing brochure, clinician- &amp; patient-facing video, and clinician talking points. Methods to facilitate identifying eligible patients were also discussed, as well as automatic referrals to Survivorship for selected services. Data reveal a significant increase in referral rates from GYN and Endocrine services (follow up &gt; 6 months) of 63% and 228%, respectively. (Breast Medicine and Lymphoma with shorter follow up will be reported.) Engagement with other services is underway. Conclusions: Results have exceeded the goal of increasing referral rates to the program. This process suggests that ongoing engagement with referring clinicians is essential to achieving and maintaining higher referral rates. The patient voice throughout this process has been a powerful tool in raising clinician awareness of their experiences and expectations for comprehensive follow up care, which can be delivered on a greater scale by survivorship providers.

S246 Colorectal Cancer Screening: Quality Improvement and Education at a Resident-Led Clinic

Introduction: Colorectal cancer (CRC) is a leading cause of cancer-related death, yet only ∼65% of age-eligible adults receive appropriate screening. In a resident-led primary care clinic, lack of provider recommendation presents a barrier to screening. This quality improvement project aimed to improve resident confidence in recommending various CRC screening modalities and increase the number of age-appropriate screening referrals made. Methods: A CRC educational module and decision algorithm were designed and presented to internal medicine residents at a single primary care clinic. Each resident was provided a list of patients due for CRC screening. Resident knowledge of and confidence in recommending various CRC screening modalities were assessed on a 5-point Likert scale and with questionnaires via pre- and post-intervention surveys. CRC screening referral rates from 30 months before and 6 months after the intervention were evaluated. Statistical process control (SPC) charts were created to determine if CRC screening referrals significantly increased following the intervention. Results: Of the 60 residents, 59 participated in the pre-survey and 41 in the post-survey. After the educational intervention, residents reported significantly increased confidence in obtaining a list of patients on their panel not up to date on screening (P < 0.05), identifying screening options available at their practice (P < 0.001), and discussing options for CRC screening with patients (P < 0.05). Confidence in recommending guideline-based screening, follow-up, and assisting patients in overcoming barriers for Cologuard (P < 0.001) and FOBT (P < 0.05) also increased. Residents identified inadequate provider training, lower prioritization, and financial limitations as major barriers to successful screening. There was a significant increase in Cologuard referrals and decrease in FOBT (P < 0.01), but there was no significant change in total CRC screening or colonoscopy referrals after the intervention. Conclusion: This study demonstrates that a resident-led curriculum on CRC screening can improve provider confidence in counseling patients on CRC screening modalities and follow-up. Our intervention resulted in a statistically significant increase in referral rates for Cologuard, but did not show an increase in the number of total CRC screening or colonoscopy referrals. Ongoing data collection will evaluate for trends that may suggest a delayed improvement in CRC screening referrals with additional educational interventions.Figure 1.: Monthly CRC Screening Referrals by Modality Legend: Screening Method Blue - Colonoscopy Orange - Cologuard Yellow - Fecal Occult Blood Test Dashed - Intervention Start DateTable 1.: Pre- and Post-Intervention Survey Responses *Significance calculated using the Mann-Whitney U test

Early help and children’s services: exploring provision and practice across English local authoritiesIntroduction

PurposeThe purpose of this study was to explore early help provision to children and families not reaching the Children Act (1989) child in need threshold, across all 152 English local authorities in 2017.Design/methodology/approachA freedom of information request was used, in September 2017, to obtain information regarding recorded numbers, attributes and referral reasons for Early Help cases, case categorisation, professional groups involved in this provision and models of practice.FindingsResponses revealed there are no common protocols categorising referrals and identified needs of children and young people. Child behavioural issues were the most frequently occurring category followed by parenting issues and child emotional well-being. The numbers of children engaged by Early Help services varied with a range between Barnsley with 7.8% of children under 18 years old and Richmond on Thames with 0.33% and only exceeded children in need in a 7 out of 71 reporting authorities. Models of practice used were most commonly based on the assessment framework, which operates at all social work thresholds including child protection. The enquiry found a diverse workforce involved in Early Help and sets it within a context of local thresholds for dealing with large increases in referral rates to children’s services departments in recent years.Originality/valueThe study provides a unique insight into the nature and scope of Early Help provision across England. The relationship between existing thresholds of intervention in the child welfare system is underexplored in the social work literature.

Evaluating specialist autism teams’ provision of care and support for autistic adults without learning disabilities: the SHAPE mixed-methods study

Background The National Institute for Health and Care Excellence recommends that every locality has a ‘Specialist Autism Team’: an specialist autism, community-based, multidisciplinary service that is responsible for developing, co-ordinating and delivering care and support. The National Institute for Health and Care Excellence recommended that this novel delivery model was evaluated. Objectives The objectives were to identify services fulfilling the National Institute for Health and Care Excellence’s description of a Specialist Autism Team; to describe practitioner and user experiences; to investigate outcomes; to identify factors associated with these outcomes; and to estimate costs and investigate cost-effectiveness of these services. Design During stage 1, desk-based research and a survey to identify Specialist Autism Teams were carried out. Stage 2 comprised a mixed-methods observational study of a cohort of Specialist Autism Team users, which was followed for up to 2 years from the assessment appointment. The cohort comprised users of a Specialist Autism Team not previously diagnosed with autism (the ‘Diagnosis and Support’ group) and those already diagnosed (the ‘Support-Only’ group). Stage 2 also involved a nested qualitative study of senior practitioners and an exploratory comparison of the Diagnosis and Support group with a cohort who accessed a service which only provided autism diagnostic assessments (‘Diagnosis-Only’ cohort). Setting The setting in stage 2 was nine Specialist Autism Teams; three also provided a regional diagnostic assessment service (used to recruit the Diagnosis-Only cohort). Participants There were 252 participants in the Specialist Autism Team cohort (Diagnosis and Support, n = 164; Support Only, n = 88) and 56 participants in the Diagnosis-Only cohort. Thirty-eight participants (across both cohorts) were recruited to the qualitative evaluation and 11 practitioners to the nested qualitative study. Main outcome measures The World Health Organization Quality of Life assessment, abbreviated version (psychological domain) and the General Health Questionnaire (12-item version). Data sources Self-reported outcomes, qualitative interviews with users and focus groups with practitioners. Results A total of 18 Specialist Autism Teams were identified, all for autistic adults without learning disabilities. Services varied in their characteristics. The resources available, commissioner specifications and clinical opinion determined service design. Practitioners working in Specialist Autism Teams recruited to stage 2 reported year-on-year increases in referral rates without commensurate increases in funding. They called for an expansion of Specialist Autism Teams’ consultation/supervision function and resources for low-intensity, ongoing support. For the Specialist Autism Team cohort, there was evidence of prevention of deterioration in outcomes and positive benefit for the Diagnosis and Support group at the 1-year follow-up (T3). Users of services with more professions involved were likely to experience better outcomes; however, such services may not be considered cost-effective. Some service characteristics were not associated with outcomes, suggesting that different structural/organisational models are acceptable. Findings suggest that one-to-one work for mental health problems was cost-effective and an episodic approach to delivering care plans was more cost-effective than managed care. Qualitative findings generally align with quantitative findings; however, users consistently connected a managed-care approach to supporting improvement in outcomes. Among the Diagnosis-Only cohort, no changes in mental health outcomes at T3 were observed. Findings from the interviews with individuals in the Diagnosis and Support group and Diagnosis-Only cohort suggest that extended psychoeducation post diagnosis has an impact on immediate and longer-term adjustment. Limitations Sample size prohibited an investigation of the associations between some service characteristics and outcomes. Comparison of the Diagnosis-Only cohort and the Diagnosis and Support group was underpowered. The economic evaluation was limited by incomplete costs data. Conclusions The study provides first evidence on the implementation of Specialist Autism Teams. There is some evidence of benefit for this model of care. Service characteristics that may affect outcomes, costs and cost-effectiveness were identified. Finding suggest that extended psychoeducation post diagnosis is a critical element of Specialist Autism Team provision. Future work We recommend a comparative evaluation of Specialist Autism Teams with diagnosis-only provision, and an evaluation of models of providing consultation/supervision and low-intensity support. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 48. See the NIHR Journals Library website for further project information.

Referral rates for children with acute gastroenteritis: a retrospective cohort study.

BackgroundHospital admission rates are increasing for children with acute gastroenteritis. However, it is unknown whether this increase is accompanied by an increase in referral rates from GPs due to increased workloads in primary care out-of-hours (OOH) services.AimTo assess trends in referral rates from primary care OOH services to specialist emergency care for children presenting with acute gastroenteritis.Design & settingThis retrospective cohort study covered a period from September 2007–September 2014. Children aged 6 months to 6 years presenting with acute gastroenteritis to a primary care OOH service were included.MethodPseudonymised data were obtained, and children were analysed overall and by age category. Χ2 trend tests were used to assess rates of acute gastroenteritis, referrals, face-to-face contacts, and oral rehydration therapy (ORT) prescriptions.ResultsThe data included 12 455 children (6517 boys), with a median age of 20.2 months (interquartile range [IQR] 11.6 to 36.0 months). Over 7 years, incidence rates of acute gastroenteritis decreased significantly, and face-to-face contact rates increased significantly (both, P<0.01). However, there was no significant trend for referral rates (P = 0.87) or prescription rates for ORT (P = 0.82). Subgroup analyses produced comparable results, although there was an increase in face-to-face contact rates for the older children.ConclusionIncidence rates for childhood acute gastroenteritis presenting in OOH services decreased and referral rates did not increase significantly. These findings may be useful as a reference for the impact of new interventions for childhood acute gastroenteritis.

Time trends in referrals to child and adolescent gender identity services: a study in four Nordic countries and in the UK

Purpose: To explore whether the increase observed in referrals to child and adolescent gender identity services (GIDSs) has been similar in four Nordic countries and in the UK.Materials and methods: Numbers of referrals per year in 2011–2017 were obtained from all GIDS in Denmark, Finland, Norway, Sweden and the UK and related to population aged <18.Results: A similar pattern of increase in referral rates was observed across countries, resulting in comparable population adjusted rates in 2017. In children, male:female birth sex ratio was even; in adolescents, a preponderance of females (birth sex) was observed, particularly in Finland.Conclusions: The demand for GIDSs has evolved similarly across Nordic countries and the UK. The reasons for the increase are not known but increased awareness of gender identity issues, service availability, destigmatization as well as social and media influences may play a role.

Action plan for improving cardiac rehabilitation-related outcomes in a university hospital based on a review of previous interventions.

Although referral to cardiac rehabilitation (CR) is considered the standard of care and demonstrably reduces both mortality rates and hospital admissions after cardiac events, rates of referral continue to be suboptimal. In fact, national reports reveal rates ranging from approximately 60% to 85% depending on the type of cardiac event. At an urban teaching hospital in Tennessee, efforts to increase referral rates were launched during the first quarter of 2018 as part of the Define, Measure, Analyze, Improve, Control (DMAIC) Project: Acute Myocardial Infarction (AMI) Transition of Care. The goal of this Action Plan is to review the interventions taken and the outcomes data from this project in order to propose future deliverables that can address areas of improvement within the DMAIC project. A list of the DMAIC project's interventions, which were varied and multidisciplinary, were obtained from the university hospital as well as the project's data. Data from the National Cardiovascular Data Registry (NCDR)-ACTION Registry show that referral rates at this hospital have been on the rise since the initiation of the DMAIC project. Peak referral rates in the year before the interventions were implemented were approximately 39%; whereas, the peak referral rate in the year these interventions were launched rose to 86.4%. While the interventions of the DMAIC project are hypothesized to have contributed to this increase in referral rates, based on their collaborative nature and the types of referral strategies employed, there are still opportunities for improvement and growth. Thus, this Action Plan proposes future projects to increase inclusivity of CR referral pathways, improve physician education, and establish support for outpatient CR programs.

Impact of China's referral reform on the equity and spatial accessibility of healthcare resources: A case study of Beijing

In 2015, the Chinese government implemented referral reform in its hierarchical medical system by adjusting the reimbursement rules of medical insurance, in order to guide patients' hospital preference. This reform has impacted the equity and spatial accessibility of healthcare resources in different regions. Taking Beijing as a case study, we calculated and compared the equity and accessibility of healthcare resources before and after referral reform with a three-stage two-step floating catchment area method. We set different referral rates and explored their effects on medical service accessibility and equity. The results showed that the referral reform improved total accessibility of public hospitals in Beijing, but at the same time aggravated the inequality of healthcare resource accessibility among towns and streets. Healthcare accessibility demonstrated a U shape with an increase in referral rates. After testing five scenarios, we conclude that a 90% referral rate from the secondary hospitals to tertiary hospitals could be a trade-off when the government strikes a balance between equal chance of access to health services and high accessibility.

Using Clinical Decision Support to Improve Referral Rates in Severe Symptomatic Aortic Stenosis: A Quality Improvement Initiative.

Clinical decision support systems are used to ensure compliance with guidelines and can assist providers in improving quality of care. This quality improvement initiative was designed to evaluate the use of a clinical decision support system to improve specialist referral rate for patients with severe aortic stenosis. A clinical decision support system for cardiology and primary care providers was implemented to improve diagnosis of severe aortic stenosis. The ordering provider received an electronic medical record in-basket alert providing feedback and recommendations for referral to specialist for evaluation. The echocardiogram data were evaluated for change in specialist referral rate. Before clinical decision support system implementation, the referral rate was 72% for a 3-month period. All providers ordering echocardiograms received clinical decision support system notification if patient results met criteria based on valve severity (aortic valve area < 1.0 cm, mean gradient ≥ 40 mm Hg, peak velocity ≥ 4.0 m/s). After implementation, clinical decision support system referral rate was 97.5%, a 24.6% increase in referral rates (P < .001). Low referral rates for patients with severe aortic stenosis are a recognized challenge. Utilizing the clinical decision support system to improve awareness of quality guidelines and recommendations was associated with increased adherence to referral guidelines by providers. This innovation is pertinent to practice and enhances the functionality of the electronic medical record by providing real-time feedback to providers to improve practice. Referral rates for patients with severe aortic stenosis can be improved with use of provider clinical decision support system.

An Australian hospital's training program and referral pathway within a multi‐disciplinary health–justice partnership addressing family violence

ObjectiveAn innovative health–justice partnership was established to deliver legal assistance to women experiencing family violence who attended an Australian hospital. This paper reports on a multifaceted response to build capacity and willingness of health professionals to identify signs of family violence and engage with referral pathways to on‐site legal assistance. MethodsA Realistic Evaluation analysed health professionals’ knowledge and attitudes towards identification, response and referral for family violence before and after training; and use of referral pathways. ResultsOf 123 health professionals participating in training, 67 completed baseline and follow‐up surveys. Training improved health professionals’ self‐reported knowledge of, and confidence in, responding to family violence and understanding of lawyers’ roles in hospitals. Belief that patients should be referred to on‐site legal services increased. Training did not correspond to actual increased referrals to legal assistance. ConclusionThe program built capacity and willingness of health professionals to identify signs of, and respond to, family violence. Increase in referral rates to legal assistance was not shown. Potential improvements include better data capture and greater availability of legal services. Implications for public healthStrong hospital system supports and reliable recording of family violence referrals need to be in place before introducing such partnerships to other hospitals.

The relationship between indicators of drug users detection and the population referral to drug treatment services

To examine the relationship between the results of drug users' identification through medical examination for drug intoxication and the rates of primary population' referral for drug treatment. The data of the state federal statistical observation for period of 2009-2013 were used. Methods of descriptive statistics and regression analysis were applied. It has been established that the identification of drug users during medical examination of citizens for the state of drug intoxication has a statistically significant effect on the population' drug treatment referral rates. According to linear regression equations, out of each 100 cases identified through medical examination, only 15 patients referred to drug treatment services. From practical point of view, the influence of the first indicator on the second one is not high: an increase in the number of identified drug users for each 100 cases leads to an increase in referral rate of patients with drug dependence syndrome for 2 cases, while the referral rate of drug users with established diagnosis of the harmful use of drugs increases for 10 patients. The results of the study highlight the urgent need for developing secondary prevention programs for those diagnosed with the harmful use of drugs. There is also a question of further improvement of legislation in the field of law-governed motivation of exposed drug users to seek drug treatment.

Epidemiology of gender dysphoria and transgender identity.

This review provides an update on the epidemiology of gender dysphoria and transgender identity in children, adolescents and adults. Although the prevalence of gender dysphoria, as it is operationalised in the fifth edtion of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), remains a relatively 'rare' or 'uncommon' diagnosis, there is evidence that it has increased in the past couple of decades, perhaps reflected in the large increase in referral rates to specialised gender identity clinics. In childhood, the sex ratio continues to favour birth-assigned males, but in adolescents, there has been a recent inversion in the sex ratio from one favouring birth-assigned males to one favouring birth-assigned females. In both adolescents and adults, patterns of sexual orientation vary as a function of birth-assigned sex. Recent studies suggest that the prevalence of a self-reported transgender identity in children, adolescents and adults ranges from 0.5 to 1.3%, markedly higher than prevalence rates based on clinic-referred samples of adults. The stability of a self-reported transgender identity or a gender identity that departs from the traditional male-female binary among non-clinic-based populations remains unknown and requires further study.

Assessing guideline impact on referral patterns of postprostatectomy patients to radiation oncologists

Adjuvant radiotherapy (aRT) can improve biochemical progression-free survival in patients with high-risk features (HRF) after radical prostatectomy (RP). Guidelines from Alberta and the Genitourinary Radiation Oncologists of Canada (GUROC) recommend that patients with HRF be referred to radiation oncologists (RO) based on the findings from three randomized, controlled trials (RCT). Our study examines the impact of these recommendations both pre- (2005) and post- (2012) publication of RCT and GUROC guideline establishment. Patients undergoing RP during 2005 and 2012 were identified from the provincial cancer registry. Charts were retrospectively reviewed and variables of interest were linked to the registry data. RO referral patterns for each year were determined and variables influencing referral (extracapsular extension, positive margin, seminal vesicle invasion, and post-RP prostate-specific antigen [PSA]) were compared. Median time to referral was 26.4 months in 2005 compared to 3.7 months 2012 (p<0.001). Among patients referred post-RP, a higher proportion was referred within six months in 2012 (21%) as compared to 2005 (13%) (p=0.003). Among eligible patients in 2012, 30% were referred for discussion of aRT compared to 24% in 2005 (p=0.003). There was a marked drop in patients referred for salvage radiation therapy beyond six months and a rise in the number of patients who are never referred. Despite an increase in referral rates to RO post-RP from 2005-2012, more than 50% of those patients with HRF did not receive a referral. Initiatives aimed at improving multidisciplinary care and guideline adherence should be undertaken.

Effective management of attention-deficit/hyperactivity disorder (ADHD) through structured re-assessment: the Dundee ADHD Clinical Care Pathway

Attention-deficit/hyperactivity disorder (ADHD) has become a major aspect of the work of child and adolescent psychiatrists and paediatricians in the UK. In Scotland, Child and Adolescent Mental Health Services were required to address an increase in referral rates and changes in evidence-based medicine and guidelines without additional funding. In response to this, clinicians in Dundee have, over the past 15 years, pioneered the use of integrated psychiatric, paediatric, nursing, occupational therapy, dietetic and psychological care with the development of a clearly structured, evidence-based assessment and treatment pathway to provide effective therapy for children and adolescents with ADHD. The Dundee ADHD Clinical Care Pathway (DACCP) uses standard protocols for assessment, titration and routine monitoring of clinical care and treatment outcomes, with much of the clinical work being nurse led. The DACCP has received international attention and has been used as a template for service development in many countries. This review describes the four key stages of the clinical care pathway (referral and pre-assessment; assessment, diagnosis and treatment planning; initiating treatment; and continuing care) and discusses translation of the DACCP into other healthcare systems. Tools for healthcare professionals to use or adapt according to their own clinical settings are also provided.Electronic supplementary materialThe online version of this article (doi:10.1186/s13034-015-0083-2) contains supplementary material, which is available to authorized users.