Indirect Referral Research Articles

The impact of loss to follow-up in the Dutch organised HPV-based cervical cancer screening programme.

Loss to follow-up (LTFU) within cervical screening programmes can result in missed clinically relevant lesions, potentially reducing programme effectiveness. To examine the health impact of losing women during the screening process, we determined the proportion of women LTFU per step of the Dutch hrHPV-based screening programme. We then determined the probability of being LTFU by age, screening history and sampling method (self- or clinician-sampled) using logistic regression analysis. Finally, we estimated the number of missed CIN2+/3+ lesions per LTFU moment by using the CIN-risk in women compliant with follow-up. Data from the Dutch nationwide pathology databank (Palga) was used. Women eligible for screening in 2017 and 2018 were included (N = 840,428). For clinician collected (CC) samples, the highest proportion LTFU was found following 'referral advice for colposcopy' (5.5% after indirect referral; 3.8% after direct referral). For self-sampling, the highest proportions LTFU were found following the advice for repeat cytology (13.6%) and after referral advice for colposcopy (8.2% after indirect referral; 4.3% after direct referral). Self-sampling users and women with no screening history had a higher LTFU-risk (OR: 3.87, CI: 3.55-4.23; OR: 1.39, CI: 1.20-1.61) compared to women that used CC sampling and women that have been screened before, respectively. Of all women LTFU in 2017/18, the total number of potentially missed CIN2+ was 844 (21% of women LTFU). Most lesions were missed after 'direct referral for colposcopy' (N = 462, 11.5% of women LTFU). So, this indicates a gap between the screening programme and clinical care which requires further attention, by improving monitoring of patients after referral.

The Asymmetry of Embeddedness: Illegal Trade Networks and Drug Purchasing Diversity on an Online Illegal Drug Market

Abstract While economic sociology research and theory argue that excessive network embeddedness depresses competition in illegal markets, prior research does not examine how distinct types of embeddedness may have asymmetric effects on the diversity of purchasing behavior—the range of illegal goods that buyers typically purchase. This study considers how network embeddedness can positively or negatively affect drug purchasing diversity in online drug markets by referring buyers to new vendors or “locking” buyers into recurrent trade for the same products. We analyze novel network data on 16,847 illegal drug exchanges between 7205 actors on one online illegal drug market. Consistent with hypothesized network asymmetry, buyers are more likely to purchase a new type of drug when the transaction is part of an indirect network referral. Although histories of exchange increase the overall frequency of drug purchasing, they are associated with decreases in new drug-type purchases. In the aggregate, these processes either contribute to an integrated market where buyers purchase multiple drugs from multiple vendors (in the case of referrals) or a fragmented market characterized by recurrent trade from the same vendors for the same substances (in the case of repeated trade). We discuss the implications of these findings for research on embeddedness, illegal markets, risky exchange, and drug policy.

The missing voices in the conscientious objection debate: British service users’ experiences of conscientious objection to abortion

BackgroundThe fourth section of the 1967 Abortion Act states that individuals (including health care practitioners) do not have to participate in an abortion if they have a conscientious objection. A conscientious objection is a refusal to participate in abortion on the grounds of conscience. This may be informed by religious, moral, philosophical, ethical, or personal beliefs. Currently, there is very little investigation into the impact of conscientious objection on service users in Britain. The perspectives of service users are imperative in understanding the real-world consequences and potential impact of conscientious objection and should be considered when creating and reviewing policies and guidelines. This research provided a platform for women and those who can become pregnant to share their experiences and opinions at a time when these voices are largely excluded in the great tradition of Western political philosophy and law-making processes.MethodFive service users were interviewed using a narrative interview approach to uncover their abortion journeys and experiences of conscientious objection.FindingsThe findings were presented as found poems and uncovered that doctors are not always: informing service users that they have a conscientious objection to abortion, giving service users enough information to access abortion (indirect referral), treating them non-judgmentally, and providing medically correct information. Service users did not experience burdens such as long waiting times and were still able to access legal abortion. However, service users did experience negative emotional effects, as they were often left feeling scared, angry, and hopeless when they were not referred and/or were mistreated.ConclusionsFindings indicate that conscientious objection could work in practice. However, it is currently failing some individuals on an emotional level, as not all doctors are adhering to guidelines. Conscientious objection in Britain needs to be addressed, to ensure service users receive fair, impartial, non-judgmental care.

Recruiting Low-Income African American Men in Mental Health Research: A Community-Based Participatory Research Feasibility Study.

African Americans (AAs) are 20% more likely to develop serious psychological distress compared to Whites but are less likely to use mental health services. The study objective was to evaluate the effectiveness of recruitment strategies to engage AA fathers in a mental health intervention.Using the community-based participatory research (CBPR) approach, a community-academic partnership (CAP) developed and implemented direct and indirect referral strategies to engage AA fathers in a mental health intervention. Direct referral strategies focused on community partner identification of potentially eligible participants, providing information about the study (i.e., study flyer), and referring potential participants to the study. Indirect referrals included posting flyers in local businesses frequented by AA men, radio advertisements, and social media posts from community organizations.From January to October 2019, 50 direct and 1388 indirect referrals were documented, yielding 24 participants screened and 15 enrolled. Of all participants screened, 58% were referred through indirect referral, 38% were referred directly by community partners, and 4% of the participants were referred through both direct and indirect referrals. Twenty percent of those exposed to the direct referral methods and 1% of those exposed to the indirect referral methods were enrolled. The indirect referrals accounted for 60% of enrollment, whereas the direct referrals accounted for 33.3% of enrollment.Collaborating with the community partners to engage hard-to-reach populations in mental health studies allowed for broad dissemination of recruitment methods, but still resulted in low participant accrual. Additional focus on increasing direct referral methods appears to be a fruitful area of CBPR.

Abortion Referral Practices among a National Sample of Obstetrician-Gynecologists.

Obstetrician-gynecologists (ob-gyns) play a critical role in improving access to timely abortion care. This cross-sectional study estimates the proportion of ob-gyns providing abortion referral in the prior year and identifies predictors of direct (facilitated) referral compared with indirect referral (providing contact information). In 2016-2017, we invited a national sample of 2,500 ob-gyns to complete a survey. We restricted the final sample of 1,280 respondents (52% response rate) to participants who had abortion-seeking patients in the last 12months (n=868, 68% of the sample). We calculated descriptive statistics by referral type and conducted logistic regression analyses to examine associations between physician and practice setting characteristics and abortion referral type (direct vs. indirect). Eighty-eight percent of ob-gyns provided abortion referral (479 [55%] indirect referrals; 287 [33%] direct referrals). Abortion provision in the prior year (adjusted odds ratio, 2.82; 95% confidence interval, 1.80-4.42) was a significant predictor of direct referrals. Compared with ob-gyns practicing in the Northeast, ob-gyns in the South had lower odds of direct referrals (adjusted odds ratio, 0.39; 95% confidence interval, 0.24-0.62), whereas those in the West had higher odds (adjusted odds ratio, 1.91; 95% confidence interval, 1.14-3.23). Ob-gyns providing direct referrals were more likely to practice within 25 miles of an abortion facility compared with those who provided indirect referrals (25% vs. 5%, respectively; p<.001). Although the majority of ob-gyns refer patients for abortion care, most offer indirect referrals, only providing contact information for an abortion provider. Ob-gyns should facilitate referrals as access becomes more constrained, especially in regions where abortion facilities are limited.

A simulated patient study to assess referrals to abortion care by student health centers in Pennsylvania

ObjectiveTo determine college health centers’ referral patterns for students seeking induced abortion. Study designWe conducted a cross-sectional simulated patient study at 4-year colleges in Pennsylvania between June 2017 and May 2018. A researcher posing as a student seeking abortion referral contacted student health centers twice during the course of the study using a structured script, once as a minor (under 18 years), and once as an adult. The primary outcome was “direct referral”, defined as a referral to an abortion provider. We measured proportions of student health centers who provided no referral, “indirect referral” (referral to a non-specific provider), and “inappropriate referral” (referral to a non-abortion provider). We analyzed the relationship between the proportion of direct referrals and minor status of the caller as well as college characteristics (religious affiliation, location, student body mean income, and size). We included variables found to be significant as covariates in a generalized linear model that accounted for the cluster of multiple calls to each institution. ResultsWe attempted contact with 115 institutions, once as a minor and once as an adult, resulting in 202 successful contacts. Direct referral was the most common outcome (49.5%), followed by inappropriate referral (33.7%) and no referral (21.8%). The proportion of direct referrals given to minors was similar when compared to adults (48.0% vs 52.0%, OR 0.82, 95% CI 0.47–1.42). Religiously affiliated institutions were less likely to provide a direct referral than non-religiously affiliated schools (aOR 0.47, 95% CI 0.30–0.75). With each increase in students’ household income tertile, health centers were more likely to provide a direct referral (aOR 1.22, 95% CI 1.05–1.42). ConclusionsHalf of college student health centers in Pennsylvania do not provide direct abortion referrals, and many provide inappropriate referrals. Student health centers at religiously affiliated institutions and those with poorer students are less likely to provide direct abortion referrals. ImplicationsStudent health providers should inform themselves about fake health clinics and local abortion providers. Colleges should train staff, create accurate resources and define clear policies around referral. Professional and policymaking organizations should affirm the duty of all college health centers, regardless of religious affiliation, to provide abortion referrals.

The rising incidence of Acanthamoeba keratitis: A 7-year nationwide survey and clinical assessment of risk factors and functional outcomes.

PurposeTo evaluate the incidence of Acanthamoeba keratitis in the Netherlands between 2009 and 2015 and to analyse predicting factors for treatment outcome.MethodsPatient characteristics, diagnostic methods, diagnostic delay, therapy prior to and after diagnosis, and visual outcome were obtained from medical files of all patients diagnosed with Acanthamoeba keratitis in the Netherlands between 2009 and 2015. A logistic regression analysis on treatment failure, defined as a best corrected visual acuity of less than 20/40 Snellen decimals (i.e. >0.3 logMAR or an approximate loss of three lines of visual acuity) and/or the need for keratoplasty, was performed to determine predicting factors.ResultsTwo hundred and twenty-four eyes of 224 patients were included. Ninety-five percent of the patients were contact lens wearers, of whom 74% wore soft contact lenses. The number of cases increased from 16 in 2009 to 49 in 2015. This resulted in an estimated incidence of 1 in 21,000 for soft contact lens wearers in 2015. Eighty-seven eyes (39%) met the criteria for treatment failure. In a multivariable regression analysis, higher age at presentation, a higher severity stage and corticosteroid use before diagnosis were positively correlated with treatment failure. Early referral to a cornea specialist was associated with better clinical outcomes.ConclusionsAlthough Acanthamoeba keratitis is still a relatively uncommon disease, the incidence in soft contact lens wearers has increased to reach 1 in 21,000 in 2015. Treatment failure occurred in 39% of cases, with age, higher severity stage, corticosteroid use before diagnosis and indirect referral to a cornea specialist as important risks factors.

Factors Associated with Hospital Dependent Delay to Carotid Endarterectomy in the Dutch Audit for Carotid Interventions

As the risk of a recurrent neurological event in patients with symptomatic carotid stenosis requiring carotid endarterectomy (CEA) is highest in the early phase after the first neurological event, guidelines recommend operating on these patients as soon as possible or at least within 14 days of their initial event. However, in real world practice this is often not met. The aim of this study is to identify factors that cause hospital dependent delay to CEA. All consecutive patients with symptomatic carotid stenosis undergoing CEA registered in the mandatory Dutch Audit for Carotid Interventions from January 2014 up to and including December 2017 were included in the current analysis. Univariable followed by multivariable logistic regression was used to identify independent factors associated with hospital dependent waiting time, defined as time from the first consultation at any hospital to CEA of more than 14 days. A total of 8620 patients were included. The median time to CEA was 11 days (IQR 8-14). Seventy-eight per cent of patients underwent CEA within 14 days of first hospital consultation. Factors associated with a hospital dependent waiting time longer than 14 days were age (OR 0.99 per year, 95% CI 0.98-0.99), any previous CEA (OR 1.67, 95% CI 1.32-2.09), ocular symptoms as index event (OR 1.31, 95% CI 1.15-1.50), and indirect referral (OR 1.53, 95% CI 1.34-1.73). Hospital surgical volume was not identified as a factor for delay, except for the delay of indirectly referred patients where high volume hospitals reported the shortest delay. This cohort derived from a validated nationwide prospective audit identified younger age, previous CEA, ocular symptoms, and indirect referral as hospital dependent factors for delay. High volume hospitals had a similar hospital dependent waiting time to middle and low volume hospitals. However, high volume hospitals had more indirect referrals, implying that their logistics are more efficiently organised.

Referrals to Abortion Care by Student Health Centers in Pennsylvania: A “Secret Caller” Study [1F

INTRODUCTION: One in ten women between 20 and 24 years has an unintended pregnancy. For college students, student health centers play a vital role in providing reproductive health services, but their role in abortion referrals is unknown. METHODS: We conducted a “secret caller” study at 4-year colleges in Pennsylvania between June 2017 and April 2018. A female researcher posing as a student seeking abortion referral contacted student health centers using a structured script, once as a minor (under 18 years), and once as an adult (over 18). Calls were transcribed in real time. The primary outcome was “direct referral,” defined as a referral to an abortion provider; secondary outcomes were “no referral,” “indirect referral” (non-specific provider), and “inappropriate referral” (non-abortion provider). The study was approved by the University of Pennsylvania IRB. RESULTS: One hundred and fifteen institutions were contacted, resulting in 202 successful contacts. One hundred contacts (49.5%) resulted in a direct referral, which did not differ by caller age (P=0.48). Religious institutions were less likely than non-religious institutions to provide a direct referral to both minors (26.3% vs 59.4% P=0.001) and adults (36.6% vs 62.7% P=0.01). For adult callers, larger institutions (1,000+ students) as compared to smaller institutions were more likely to offer direct referral (63.0% vs. 20.0% P=0.003). Inappropriate referrals was the next most common outcome, in 68 (33.7%) contacts. CONCLUSION: Half of college health centers in Pennsylvania do not provide direct abortion referrals, and many provide inappropriate referrals. Religious institutions are less likely to provide direct abortion referrals, particularly for minors.

Indirect Referral of Orthopaedic Patients to a Safety-Net Hospital.

Patients seen in emergency departments (EDs) not requiring admission are typically discharged with appropriate follow-up. Sometimes hospitals indirectly refer, or redirect, patients to a different hospital's ED. Anecdotally, indirect referrals are commonly received in safety-net hospitals. This study characterizes the types of patients and hospitals affected and the cost of indirect referral in the orthopaedic trauma population. A retrospective cross-sectional chart review was conducted of 1,162 consecutive adult patients receiving orthopaedic care in an urban public hospital ED over a six-month period in 2011. Multivariable logistic regression analysis compared patients who were indirectly referred with those presenting primarily. One in five (N=236) patients treated for orthopaedic injury was indirectly referred from neighboring hospitals with orthopaedists available; 209 (88.6%) of these patients were uninsured (OR 3.69; CI 1.85-7.34). Nonprofit hospitals initially treated 107 (64.1%) of these patients. Costs for largely uncompensated care at the public hospital were $1.77 million.

Urologist referral delay and its impact on survival after radical cystectomy for bladder cancer.

Evidence shows that wait times before bladder cancer surgery have been increasing, and wait time can negatively affect survival. We aimed to determine if a long delay caused by an indirect referral before a first urologist visit affects the survival of patients undergoing radical cystectomy for bladder cancer. We analyzed data from 1271 patients who underwent surgery for bladder cancer during the decade 2000-2009. The cohort was obtained by linking two administrative databases in the province of Quebec. Patients were considered to have been directly referred to a urologist if they had 5 or fewer visits with a general practitioner before their first urologist visit; otherwise, they were considered to have been indirectly referred. The effect on survival after surgery of a longer delay before a first urologist visit was assessed using Cox regression models. Median referral delay for the study population was 30 days (56 days for women, 23 days for men; p < 0.0001). Indirect referral was observed for 49% of women and 33% of men. Compared with patients who were directly referred, those who were indirectly referred after first symptoms of bladder cancer experienced poorer survival (hazard ratio: 1.29; 95% confidence interval: 1.10 to 1.52). Women who were indirectly referred had a significant 47% greater risk of death after radical cystectomy. Men who were indirectly referred also experienced decreased survival (adjusted hazard ratio: 1.25; 95% confidence interval: 1.03 to 1.51). Patients indirectly referred to a urologist had an increased risk of mortality after surgery. Compared with men, women had longer wait times and poorer survival.

The role of the dental practitioner in diagnosing connective tissue and other systemic disorders: a case report of a patient diagnosed with type III Ehlers-Danlos syndrome

An adolescent patient was referred to our specialist oral surgery unit for orthodontic exposure of an ectopic upper canine. The medical history revealed a recent diagnosis of mitral valve prolapse as well as an anecdotal tendency towards regular fainting/lethargy. Examination revealed a hypermobile temporomandibular joint, and an orthopantomogram showed lower supernumerary premolar teeth. Combined, these findings indicated a likely underlying connective tissue disorder, and an indirect referral to a specialist in hypermobility syndromes confirmed a diagnosis of type III Ehlers–Danlos syndrome with postural orthostatic tachycardia syndrome. This case highlights the importance of the dental practitioner in being able to provide holistic care for their patients.

Compliance of disease awareness campaigns in printed Dutch media with national and international regulatory guidelines.

BackgroundThe European legislation prohibits prescription-only medicines' advertising but allows pharmaceutical companies to provide information to the public on health and diseases, provided there is no direct or indirect reference to a pharmaceutical product. Various forms of promotion have become increasingly common in Europe including “disease-oriented” campaigns.ObjectivesTo explore examples of disease awareness campaigns by pharmaceutical companies in the Netherlands, by assessing their compliance with the World Health Organization (WHO) Ethical Criteria for medicinal drug promotion and the Dutch guidelines for provision of information by pharmaceutical companies.MethodsMaterials referring to health/disease and treatments published in the most widely circulated newspapers and magazines were collected from March to May 2012. An evaluation tool was developed based on relevant underlying principles from the WHO ethical criteria and Dutch self-regulation guidelines. Collected disease awareness advertisements were used to pilot the evaluation tool and to explore the consistency of information provided with the WHO and Dutch criteria.FindingsEighty materials met our inclusion criteria; 71 were published in newspapers and 9 in magazines. The large majority were news items but 21 were disease awareness advertisements, of which 5 were duplicates. Fifteen out of the 16 disease awareness campaigns were non-compliant with current guidelines mainly due to lack of balance (n = 12), absence of listed author and/or sponsor (n = 8), use of misleading or incomplete information (n = 5) and use of promotional information (n = 5). None mentioned a pharmaceutical product directly.ConclusionDisease Awareness Campaigns are present in Dutch printed media. Although no brand names were mentioned, the lack of compliance of disease awareness campaigns with the current regulations is alarming. There were information deficiencies and evidence of information bias. A key concern is that the context in which the information is provided, mostly through indirect referral, is likely to support treatment with the sponsor's product.

P2.153 Delay of Entry into Care in HIV Positive Individuals

BackgroundDelay between HIV diagnosis and entry into care may have a negative impact on the individual prognosis and may enable further transmission. Insight into duration and determinants of care-delay is...

Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001–2006

In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres. We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model. After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54- 3.22) or hospital stay (RR 0.96, 95% CI 0.65-1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00-1.48). Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.

Using a simulated patient to assess referral for abortion services in the USA

BackgroundWomen seeking abortion services need to access services in a timely fashion. Quick and appropriate referrals to abortion providers are critical to this process.MethodsThe objective of this study was to...

Who goes where? A prospective study of referral patterns within a newly established primary care team

Since the introduction of primary care teams, referral patterns of General Practitioners (GPs) in Ireland have not been studied. To study the referral patterns of GPs within a primary care team (PCT) to allied health care professionals in a PCT and to secondary care. To identify indirect referral pathways. To study variation in individual GP referral patterns. Questionnaire based survey. Statistical analysis was carried out using Epi Info version 3.5.1. Of 3,166 consultations, 2,841 (89.7%) were dealt with by the GP and required no referral, 107 (3.4%) were referred within the PCT, and 218 (6.9%) were referred elsewhere. Therefore, 93.1% of consultations were managed in primary care alone. Ninety percent of GPs refer patients to the PCT. Indirect referrals constituted 17% of all outpatient referrals. Females have significantly higher referral rates than males. Referral rates of GPs in single-handed practices are higher than GPs in group practices. GPs alone can manage the vast majority of presentations in general practice. Greater GP access to diagnostic and therapeutic interventions may reduce outpatient referrals. GPs in group practices may collectively have greater experience and expertise and therefore can manage more patients in primary care. There is a significant variation in referral rates between both genders.

Derivaciones directas vs. indirectas a rehabilitación desde atención primaria

We studied the referral to rehabilitation of patients affected by joint pain and enthesophatiy directly from Primary Care or by an orthopaedist. The aim of the study is to compare waiting times following direct referral from a primary care physician to rehabilitation, with those following indirect referral, that is, arriving at Rehabilitation after orthopaedist consultation. We also studiet the orthopaedist consultation contribution apart from increased delay. The goald of this paper is to seek improved effectiveness of referral. Material and methods We selected 787 patientes referred to Rehabilitation between July 2007 and July 2008 due to musculoskeletal pathology. These were then grouped into two categories, 239 related to patients whose referral via orthopaedist is irrefutable, and 548 wich we call “Joint and Enthesophaty”. Of these 548, 66% came from orthopaedist (Indirec referral) and 34% were referred directly from Primary Care. We described the patients charactheristics and discussed the orthopaedist consultation contribution to those patients who were indirectly referred. Results and conclusion Direct referral from Primary care to Rehabilitation for Joint Pain and Enthesophaty can help avoid unnecessary delais and duplicateds consultation.

The ethics of direct and indirect referral for termination of pregnancy

Referral of pregnant patients for termination of pregnancy by physicians morally opposed to the procedure is ethically controversial, with polarized positions taken by physician organizations. Based on the ethical principles of beneficence and respect for autonomy, we establish the distinction between direct and indirect referral. Direct referral is beneficence based and requires the referring physician to ensure that the referral occurs. Indirect referral is autonomy based, with a beneficence-based component that requires that the physician provide information to the patient about health care organizations that will provide competent medical care. We show that only indirect referral is ethically required in healthy women for termination of an unwanted pregnancy or a pregnancy complicated by fetal anomalies because the indications for this procedure are solely autonomy based. Direct referral for termination of pregnancy is not ethically required but is permissible. Conscience-based objections to direct referral for termination of pregnancy have merit; conscience-based objections to indirect referral do not.