Indirect Referrals Research Articles

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.

Factors associated with diagnostic delay in children with Wilms’ tumor

Background: In Wilms’ tumor, the time elapsed between clinical diagnosis and the start of treatment is clearly associated with morbidity and mortality. As treatment delay can influence patient survival, identification of possible causes can mitigate the consequences arising from prolonged diagnostic uncertainty. Objective: To ascertain whether an initial diagnosis of Wilms’ tumor in the emergency department influences patient prognosis depending on the type of referral for definitive treatment. Patients and methods: Retrospective chart review of 98 children receiving treatment for Wilms’ tumor at the Brazilian National Cancer Institute (INCA) between April 2003 and December 2016. Patients were categorized into two groups: those referred directly from an emergency public department to INCA and those first transferred to another hospital before being referred to INCA. Results: Of the 98 cases included in the study, 42.9% were direct referrals and 57.1% were indirect referrals. Presence of an abdominal mass was the most common presenting complaint, followed by abdominal pain. In cases with larger tumors, the mean tumor volume was greater than reported elsewhere in the literature, suggesting longer disease duration. Significantly higher tumor volumes were observed in patients with a palpable abdominal mass as compared to those with the second most frequent complaint (abdominal pain). Conclusion: The findings of this study support the hypothesis that patients diagnosed with kidney masses in the emergency department are at greater risk of delayed diagnosis when they are referred first to a non-specialized outside hospital than when referred directly to a specialized cancer treatment unit.

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.

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.

Management and treatment of cervical intraepithelial neoplasia in the Netherlands after referral for colposcopy

IntroductionThe aim of this study was to describe trends in the diagnosis and treatment of women referred from the national screening program with cervical intraepithelial neoplasia (CIN) in the Netherlands, and to compare these trends with national guidelines and identify potential areas for improvement for the new primary high‐risk HPV screening program.Material and methodsWe conducted a population‐based cohort study using data from the Dutch pathology archive. Women aged 29‐63 years who took part in the Dutch cervical screening program between 1 January 2005 and 31 December 2014 were selected. Three referral groups were identified: direct referrals and those referred after either one (first indirect referrals) or two (second indirect referrals) repeat cytology tests, totaling 85 239 referrals for colposcopy. The most invasive management technique and the most severe diagnosis of each screening episode was identified. Rates of management techniques were calculated separately by referral type, highest CIN diagnosis and age group.ResultsIn all, 85.1% of CIN 3 lesions were treated with excision (either large excision or hysterectomy) and 26.4% of CIN 1 lesions were treated with large excision. Rates of overtreatment (CIN 1 or less) in see‐and‐treat management were higher for indirect referrals than for direct referrals and increased with age. Large excision rates increased with CIN diagnosis severity.ConclusionsDespite guideline recommendations not to treat, CIN 1 lesions were treated in just over 25% of cases and approximately 15% of CIN 3 lesions were possibly undertreated. Given the expected increase in CIN detection in the new primary high‐risk HPV screening program, reduction in CIN 1 treatment and CIN 2 treatment in younger women is needed to avoid an increase in potential harm.

Practitioners’ opinions on traumatic brain injury care pathways in Finland and France: different organizations, common issues

ABSTRACTObjective: In traumatic brain injury (TBI), differences in health-care contexts have profound effects on care pathways. Objectives were to compare TBI pathways of care and practitioners’ views on quality of care issues in two large European areas: Varsinais-Suomi, Finland and Ile-de-France, France.Methods: Thematic analysis of semi-structured interviews was conducted with TBI practitioners (n = 10) from all stages of TBI care. Interviews addressed organization and financing of care, decision-making on care transitions, and perceived issues. The structure–process–outcome model of Donabedian was used to classify findings related to quality of care issues.Results: Main differences in organization of care pathways for people with TBI were related to financing modalities, number of pathway alternatives, inpatient versus outpatient rehabilitation, and indirect versus direct referrals to rehabilitation. Similar categories of issues were raised in the two settings. Issues in structures involved availability of services, financial access, and heterogeneity of expertise. Issues in processes involved diagnosis and follow-up, training regarding cognitive impairments, decision-making for referrals, transition delays, and care pathways of very severely affected patients.Conclusions: These findings provide clues to address care pathways in further comparative studies. Determinants of care pathway quality could be classified as direct or indirect, binding or adaptive organizational factors.

The impact of centralization of services on treatment delay in ovarian cancer: A study on process quality.

Emphasis on improving healthcare quality has led to centralization of services for patients suspected of ovarian cancer. As centralization of services may induce treatment delays, we aimed to assess compliance with health system interval guidelines in patients suspected of ovarian cancer. Evaluation of health system intervals, comparison between direct and indirect referrals and between 2013 and 2014. A managed clinical network (MCN) comprising 11 hospitals in the Netherlands. Patients that were treated for ovarian cancer within the University Medical Center Groningen in 2013 and 2014. Introduction of an MCN to centralize services for patients suspected of ovarian cancer. Compliance with national guidelines regarding health system intervals. Between 2013 and 2014 a clinically relevant improvement in compliance with guidelines was demonstrated. Within this period, median treatment intervals decreased from 34 to 29 days, and the percentage of patients in which treatment interval guidelines were met increased from 63.5 to 72.2%. New regulations and increased awareness of health system intervals inspired changes in local practice leading to improved compliance with guidelines. Compliance was highest in patients that were directly referred to our academic hospital. Evaluation of health system intervals in patients suspected of ovarian cancer was feasible and may be applicable to other MCNs. Though compliance with guidelines improved within the study period, there is potential for improvement. To facilitate real-time evaluation of compliance with national guidelines establishing uniformity of electronic patient files in the MCN is deemed essential.

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.

Referral Incentives in Crowdfunding

Word-of-mouth, referral, or viral marketing is a highly sought-after way of advertising. In this paper, we investigate whether such marketing can be encouraged through incentive mechanisms, thus allowing an organisation to effectively crowdsource their marketing. Specifically, we undertake a field experiment that compares several mechanisms for incentivising social media shares in support of a charitable cause. Our experiment takes place on a website promoting a fundraising drive by a large cancer research charity. Site visitors who sign up to support the cause are asked to spread the word about it on Facebook, Twitter or other channels. They are randomly assigned to one of four treatments that differ in the way social sharing activities are incentivised. Under the control treatment, no extra incentive is provided. Under two of the other mechanisms, the sharers are offered a fixed number of points that help take the campaign further. We compare low and high levels of such incentives for direct referrals. In the final treatment, we adopt a multi-level incentive mechanism that rewards direct as well as indirect referrals (where referred contacts refer others). We find that providing a high level of incentives results in a statistically significant increase in sharing behaviour and resulting signups. Our data does not indicate a statistically significant increase for the low and multi-level incentive mechanisms.

Referral Incentives in Crowdfunding

Word-of-mouth, referral, or viral marketing is a highly sought-after way of advertising. We undertake a field experiment that compares incentive mechanisms for encouraging social media shares to support a given cause. Our experiment takes place on a website set up to promote a fundraising drive by a large cancer research charity. Site visitors who choose to sign up to support the cause are then asked to spread the word about the cause on Facebook, Twitter or other channels. Visitors are randomly assigned to one of four treatments that differ in the way social sharing activities are incentivised. Under the control treatment, no extra incentive is provided. Under two of the other mechanisms, the sharers are offered a fixed number of points that help take the campaign further.We compare low and high levels of such incentives for direct referrals. In the final treatment, we adopt a multi-level incentive mechanism that rewards direct as well as indirect referrals (where referred contacts refer others). We find that providing high level of incentives results in a statistically significant increase in sharing behaviour and resulting signups. Our data does not indicate a statistically significant increase for the low and recursive incentive mechanisms.

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.

Achieving 18-week waiting times in elective hand surgery

ObjectiveThe Department of Health proposed an 18-week referral-to-treatment time (RTT) as a measure of high quality healthcare, to be achieved by December 2008. In 2007, referrals for elective hand surgery, to the Plastic Surgery Hand Service, were either direct or indirect. Direct referrals were from the general practitioner (GP). Indirect referrals were from other specialties, to which patients had been initially referred. We audited the RTT in elective hand surgery patients to see if 18-week waiting times could be achieved.DesignThe RTT for 152 patients who had elective hand surgery in 2007 were audited prospectively and retrospectively. After the initial audit, managers responsible for the ‘Choose & Book’ (CAB) GP referral system, managers responsible for ‘Action on Orthopaedics’ and colleagues who referred, were contacted, to explain the difficulties in meeting the 18-week wait target. The audit cycle was repeated prospectively in 2008 with the audit of a further 94 patients.SettingThis audit took place in a district general hospital, in the United Kingdom.Main outcome measureThe main outcome measure was referral-to-treatment time.ResultsThe mean RTT for direct referrals decreased from 15 to 12 weeks and that for indirect referrals decreased from 43 to 24 weeks (p < 0.0001). The difference in the average RTT for direct and indirect referrals remained statistically significant (p < 0.0001), in both audit cycles.ConclusionsThe attempts to reduce the RTT, in both groups of patients, did not decrease the average RTT for indirect referrals, to within government targets. Increase in GP awareness of the limitations of the CAB system and availability of local hand surgery services, may help to reduce inappropriate referrals. However we are aware that a multispecialty approach is required to ensure that hand surgery referrals are passed on to plastic surgery as soon as possible.

A sybil-proof referral system based on multiplicative reputation chains

Transactions between peers in social networks generate direct reputation (social capital) information. This can be augmented with indirect referrals, on demand or continually, thus giving peers additional information prior to engaging in transactions with others. Despite proposed deterrents such as identity acquisition costs, false referrals through sybil identities pose a significant threat. In this note, we show how a reputation system which multiplicatively chains referrals, and adds referrals from different referral paths/chains, is sybil-proof.

A study on the routes of referral for patients with colorectal cancer and its affect on the time to surgery and pathological stage

Firstly, to determine the proportion of colorectal cancer (CRC) patients seen within an established two week rule (TWR) system and to observe other routes of referral for CRC patients. Secondly to determine if referral route affects the interval to, and cancer stage at, definitive treatment.GP referrals of patients with CRC were divided into direct surgical outpatient referrals (group 1) and indirect referrals to accident and emergency and medical outpatients (group 2). Data were recorded on the time to definitive treatment and the location and stage of tumour.There were 78 patients in group 1. Thirty (20%) patients were referred by their GP under the TWR, 31 (21%) as urgent and 17 (12%) as nonurgent referrals, to surgical outpatients. There were 69 patients in group 2. Forty-two (29%) were referred initially to the accident and emergency department and 27 (18%) to general medical outpatients. Group 1 patients were treated within a median of 70.5 days and group 2 patients within 14 days of referral (P < 0.0005). Group 2 contained tumours of a significantly more advanced pathological stage (P = 0.015) and more proximal colonic cancers (P < 0.005).Fifty-three percent of patients with CRC were referred directly to surgical outpatients, 20% under the TWR guidelines. Despite having this system in place direct referrals were slower to treatment but the tumours were still of a less advanced pathological stage. Compliance with the TWR should not be used as a means of assessing a colorectal unit's treatment of CRC.

A study on the routes of referral for patients with colorectal cancer and its affect on the time to surgery and pathological stage

Firstly, to determine the proportion of colorectal cancer (CRC) patients seen within an established two week rule (TWR) system and to observe other routes of referral for CRC patients. Secondly to determine if referral route affects the interval to, and cancer stage at, definitive treatment. GP referrals of patients with CRC were divided into direct surgical outpatient referrals (group 1) and indirect referrals to accident and emergency and medical outpatients (group 2). Data were recorded on the time to definitive treatment and the location and stage of tumour. There were 78 patients in group 1. Thirty (20%) patients were referred by their GP under the TWR, 31 (21%) as urgent and 17 (12%) as nonurgent referrals, to surgical outpatients. There were 69 patients in group 2. Forty-two (29%) were referred initially to the accident and emergency department and 27 (18%) to general medical outpatients. Group 1 patients were treated within a median of 70.5 days and group 2 patients within 14 days of referral (P < 0.0005). Group 2 contained tumours of a significantly more advanced pathological stage (P = 0.015) and more proximal colonic cancers (P < 0.005). Fifty-three percent of patients with CRC were referred directly to surgical outpatients, 20% under the TWR guidelines. Despite having this system in place direct referrals were slower to treatment but the tumours were still of a less advanced pathological stage. Compliance with the TWR should not be used as a means of assessing a colorectal unit's treatment of CRC.

Delays in the referral and treatment of oral squamous cell carcinoma.

To investigate the delays in referral and treatment of patients with oral cancer. A retrospective study. District General Hospital Maxillofacial Unit (MFU). 100 consecutive patients with invasive squamous cell carcinoma of the oral cavity referred to Rotherham District General Hospital Maxillofacial Unit (RDGH MFU) between 15th March 1993 and 16th January 1998. Information collected at the time of referral and treatment was examined retrospectively. In the patients studied 72% were male, mean age 61.2 years (sd = 11.2, range 37 to 88) and 28% female, mean age 65.6 years (sd = 16.7, range 29 to 90). The majority of referrals were from medical practitioners (56%) and most of the remainder being referred by dental practitioners (36%). The patient delay was found to be the most significant with only 39% presenting within 4 weeks, 29% delayed more than 3 months. There was no statistical correlation between T-stage, alcohol or cigarette use and the patient delay in presentation. Having presented to a medical or dental practitioner 69% were referred within 1 week. There were no significant differences between the T-stages presenting to either medical or dental practitioners or in their delay in referral for each stage. There was no significant difference in age or sex distribution between the populations presenting to general medical or general dental practitioners. General medical practitioners were more likely to refer a patient urgently. Patients referred directly to the MFU were seen quickly but those referred via an indirect route were delayed. 95% of patients were treated within 6 weeks of first consultation. The majority of practitioners refer patients with oral cancer within 1 week. The most significant delay is that caused by the patient. Some practitioners referred patients to inappropriate specialties, leading to indirect referrals. This results in additional delay in the referral and treatment pathway. Education of the public and primary health care workers should continue. Opportunistic screening of the oral mucosa should be part of the dental check up, with possible targeting of patients at greatest risk, particularly heavy drinkers and smokers.

Delays in referral and treatment of oral cancer

Objective To investigate the delays in referral and treatment of patients with oral cancer. Design A retrospective study. Setting District General Hospital Maxillofacial Unit (MFU). Subjects 100 consecutive patients with invasive squamous cell carcinoma of the oral cavity referred to Rotherham District General Hospital Maxillofacial Unit (RDGH MFU) between 15th March 1993 and 16th January 1998. Method Information collected at the time of referral and treatment was examined retrospectively. Results In the patients studied 72% were male, mean age 61.2 years (sd = 11.2, range 37 to 88) and 28% female, mean age 65.6 years (sd = 16.7, range 29 to 90). The majority of referrals were from medical practitioners (56%) and most of the remainder being referred by dental practitioners (36%). The patient delay was found to be the most significant with only 39% presenting within 4 weeks, 29% delayed more than 3 months. There was no statistical correlation between T-stage, alcohol or cigarette use and the patient delay in presentation. Having presented to a medical or dental practitioner 69% were referred within 1 week. There were no significant differences between the T-stages presenting to either medical or dental practitioners or in their delay in referral for each stage. There was no significant difference in age or sex distribution between the populations presenting to general medical or general dental practitioners. General medical practitioners were more likely to refer a patient urgently. Patients referred directly to the MFU were seen quickly but those referred via an indirect route were delayed. 95% of patients were treated within 6 weeks of first consultation. Conclusion The majority of practitioners refer patients with oral cancer within 1 week. The most significant delay is that caused by the patient. Some practitioners referred patients to inappropriate specialities, leading to indirect referrals. This results in additional delay in the referral and treatment pathway. Education of the public and primary health care workers should continue. Opportunistic screening of the oral mucosa should be part of the dental check up, with possible targeting of patients at greatest risk, particularly heavy drinkers and smokers.