Referral Management Research Articles

Gallbladder disease

Gallstone disease is a common cause for patients to present to general practice. It can lead to a range of complications, and this article aims to increase confidence in identification of the condition, as well as referral criteria and management steps. Specifically, it will focus on the care of patients presenting to primary care and recognition of features requiring prompt referral.

An evaluation of oral surgery referrals to aid development of an integrated service in South West England.

Introduction The number of oral surgery referrals from primary to secondary care has increased, resulting in longer waiting times. A study suggests two-thirds of patients referred to secondary care for oral surgery could be treated by dentists with enhanced skills.Aims To help inform the development of an integrated oral surgery service in South West England by assessing the proportion of inappropriate referrals to Bristol Dental Hospital.Methods A total of 100 non-consecutive written referrals to oral surgery were analysed. Multiple variables were collected, including the complexity of the treatment requested (Level 1, 2 or 3) and patient and referrer locations.Results In total, 94 referrals were included in the analysis: 17% were Level 1 complexity, 35% Level 2, and 48% Level 3. Additionally, 17% of referrals were inappropriate. Almost half (52%) (Levels 1 and 2) could have been treated in primary care. Many referrals had missing clinical details or unacceptable-quality radiographs.Conclusion An effective integrated oral surgery managed clinical network in South West England could reduce waiting times in secondary care and potentially improve patient experience. An electronic referral management system could also improve the quality of referral information.

Practices of disease diagnosis and patient monitoring by traditional herbalists in Mpigi district, Uganda: Implications for integration into the conventional health care system

BackgroundThe use of herbs by traditional healers plays a vital role in primary health care in rural Uganda, where most patients still prefer and use herbal medicines. However, specific literature on the traditional healing practices of herbalists is lacking. This study documented the methods traditional herbalists in Mpigi District, Uganda, employ to diagnose disease, monitor patients and handle cases of treatment failure. Materials and methodsAn exploratory study was carried out from June to November 2019 in the rural district of Mpigi in Uganda. In-depth interviews were conducted with 20 herbalists. The interviews were audiotaped, transcribed verbatim, and themes were generated using qualitative content analysis. ResultsThe methods used to diagnose disease included; prior conventional diagnosis, the patient’s description of their experience with the disease condition (including signs, symptoms, and history of disease), physical examination for signs of disease, referral for conventional diagnosis, or to another herbalist, and use of conventional tools. Herbalists use phone calls, patients’ visits, and set review dates to monitor response to therapy. Patient monitoring during therapy emphasizes the improvement or resolution of signs and symptoms of disease and does not consider adverse drug reactions to therapy. Disease conditions that do not respond to therapy are referred to conventional health centres and other traditional health practitioners. ConclusionsDiagnosis of disease and monitoring of patients depends on presenting symptomatology as observed by the herbalist or described by the patient. There is considerable dependence on the conventional health system through referral for diagnosis and management of non-responsive conditions.

Physical Therapy Management of Congenital Muscular Torticollis: A 2024 Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association Academy of Pediatric Physical Therapy.

Congenital muscular torticollis (CMT) is a postural condition evident shortly after birth. The 2013 CMT Clinical Practice Guideline (2013 CMT CPG) set standards for the identification, referral, and physical therapy management of infants with CMT, and its implementation resulted in improved clinical outcomes. It was updated in 2018 to reflect current evidence and 7 resources were developed to support implementation. Purpose: This 2024 CMT CPG is intended as a reference document to guide physical therapists, families, health care professionals, educators, and researchers to improve clinical outcomes and health services for children with CMT, as well as to inform the need for continued research. Results/Conclusions: The 2024 CMT CPG addresses: education for prevention, screening, examination and evaluation including recommended outcome measures, consultation with and referral to other health care providers, classification and prognosis, first-choice and evidence-informed supplemental interventions, discontinuation from direct intervention, reassessment and discharge, implementation and compliance recommendations, and research recommendations.

Japanese family physicians' attitudes, difficulties, and perceived significance in managing mental health problems: A qualitative study

AbstractBackgroundFamily physicians (FPs) are expected to identify, diagnose, and treat mental health problems. Despite challenges such as limited time and low confidence in their skill as mental health providers, FPs generally consider mental health as a meaningful part of their profession. However, the role of the FP in mental health services is not clearly established in Japan. Studies have not been performed in countries without an established role of FPs' in mental health care. This study investigated Japanese FP's attitudes, difficulties, and perceived significance in managing mental health problems.MethodsSemi‐structured interviews were conducted between September 2022 and February 2023. Participants were Japanese FPs involved in mental health care. Interview transcripts were subjected to thematic analysis.ResultsThirteen FPs were interviewed. The FPs approached mental health problems “as a FP who provides holistic and comprehensive care” and “practice based on experience and self‐reflection.” The difficulties faced by FPs included “time management problems” and “referral management problems and conflicts.” Regarding significance, FPs mentioned that “gaining a deeper understanding of humanity” is important for managing mental health problems.ConclusionsThe attitude of Japanese FPs toward mental health care was based on awareness of the FP's specialty. Despite difficulties such as time and referral management issues, managing mental health problems was generally considered rewarding for professional growth.

SP9.1 - Enhancing Personalised Care by Introducing Frailty Management On Lower GI 2ww Pathway

Abstract Introduction/Aim Increasing number of patients with suspected lower GI cancer are being sent Straight-To-Test to achieve the 28Day Faster Diagnosis Standards (FDS) following GP referral. This means that elderly frail patients may not get personalised care unique to their needs and undergo unnecessary investigations. Since 2022, we have piloted a frailty pathway incorporated into the protocol for management of LowerGI 2ww referrals. Aiming to provide a holistic and personalised geriatric assessment to improve outcomes and reduce health inequality. This study analyses the outcomes. Methods A prospectively maintained database of all 2ww lowerGI cancer referrals between January2022-November2023 was analysed. Patients age>75 with a frailty score>=5 or performance status>=3, dementia, poly-pharmacy or from care home were referred straight to the frailty-unit for assessment and discussion of the value of further investigation, based on a locally designed SOP. The patient journey was mapped and outcomes compared to the standard pathway. Results Over 22 months-period, 228 patients with suspected cancer were seen on the frailty pathway. The average number of investigations per referral was0.5 for frail patients compared to 1 for other patients on the standard pathway. 49.5% (113 patients) were found to be unfit for further investigations or declined/self-discharged. 5 patients required optimisation prior to investigation. Only 1patient was diagnosed with cancer. The 2ww standard was met in 80% of frail patients compared to 55% in >75s who were sent straight-to-test on the standard pathway. The 28-day FDS standard was met in 50% of frail patients compared with 18% in >75s. Conclusion The frailty pathway is an effective initiative in reducing unnecessary invasive investigations. Frail patients benefit from holistic geriatric assessment prior to invasive investigations, ensuring suitability and appropriateness.

SP9.3 - Introducing Frailty Assessment into The Suspected Lower GI Cancer Pathway – Results of a 2 Year Pilot

Abstract Introduction & Aim An Increasing number of patients with suspected lowerGI cancer are being sent Straight-To-Test to achieve the 28 Day Faster Diagnosis Standards (FDS) following GP referral. This means that elderly frail patients may not get personalised care unique to their needs and undergo unnecessary investigations. Since 2022, we have been piloting a frailty pathway incorporated into the protocol for secondary care management of LowerGI 2ww referrals. Aiming to provide a holistic and personalised geriatric assessment to improve outcomes and reduce health inequality. This study analyses the outcomes. Methods A prospectively maintained database of all 2ww lowerGI cancer referrals between January2022-January2024 was analysed. Patients aged>75 with a frailty score of >=5 or performance status>=3, dementia, poly-pharmacy or from care home were referred straight to the frailty unit for assessment and discussion of the value of further investigation, based on a locally designed SOP. The patient journey was mapped and outcomes compared to the standard-pathway. Results Over a 24-month period, 228patients with suspected cancer were seen on the frailty pathway. 49.5%(113patients) were found to be unfit for further investigations or declined/self-discharged. The 2ww standard was met in80%of frail patients compared to55% in>75s who were sent straight-to-test on the standard pathway. The 28day-FDS standard was met in50%of frail patients compared with18%in the other>75s.The average number of investigations per referral was0.5for frail patients compared to 1 for patients on the standard-pathway. 5patients required optimisation prior to investigation. Only 1patient was diagnosed with cancer. Conclusion The frailty pathway is an effective initiative in reducing unnecessary invasive investigations, whilst providing timely investigations on the suspected cancer pathway.

Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol

BackgroundOpioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study.MethodsThis is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement.DiscussionMost ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality.Trial RegistrationClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 – Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991.

Abstract P399: Defining A Negative Space: A Scoping Review of Hypertension

Study Objectives: This scoping review seeks to examine the existing body of literature to reveal consensus or absence thereof regarding the definition and management strategies for asymptomatic hypertension. Methods: The review was conducted using Joanna Briggs Institute guidelines. We searched the CINAHL (EBSCO), Scopus, Ovid EMBASE, and PubMed (MEDLINE) databases using keywords and index terms (“hypertension”, “high blood pressure”, “elevated blood pressure”, “asymptomatic”, “symptomless”, “symptom free”, “emergenc*”, “urgent”) to identify adult patients with hypertension in an emergency or outpatient setting. After review and quality assessment, we retained 35 texts for inclusion. Results: The definition of “asymptomatic hypertension” varied widely between the texts. There was significant variation in which society or academic guideline served as the reference and what the blood pressure cut offs were; all specified a lack of end-organ damage. A majority included a definition for hypertensive urgency, most commonly based on elevated blood pressure with vague symptoms. End-organ damage was poorly defined – studies instead described the absence of hypertensive emergency. The most common emergencies mentioned were myocardial infarction, renal failure, and hypertensive encephalopathy. Of the texts which provided recommendations, all recommended a thorough history and physical examination. Only one study recommended additional testing for asymptomatic patients – an ECG and creatinine test. Treatment recommendations for asymptomatic patients relied predominantly on ACEP clinical policy, with a majority of studies advocating for gradual reduction of blood pressure rather than an immediate one, as well as referral for outpatient management. Conclusion: There is a need for unified guidelines on the definition and management of asymptomatic hypertension to ensure effective and consistent patient care. Additionally, there is no consensus for further diagnostic testing in patients with a negative history and physical exam, and there is strong agreement that rapid blood pressure decrease in asymptomatic patients can be detrimental. Addressing this gap in guideline consistency and evidence base could enhance clinical outcomes and streamline healthcare processes across different settings. Future research should focus on establishing consensus and developing management strategies that are adaptable to both emergency and primary care environments.

Infective endocarditis outcomes at a tertiary hospital in Western Australia: a retrospective cohort study from 2016 to 2021.

Infective endocarditis (IE) is a severe infection with considerable mortality. It is associated with geographical variation, complicating diagnosis and treatment of patients in a standardised manner. To evaluate the characteristics and management outcomes of patients with IE in Royal Perth Hospital (RPH). A single-centre, retrospective cohort study. Data were collected from medical records of 131 patients with a diagnosis of IE admitted to RPH between 2016 and 2021. Eighty-four patients with definite IE were included for analysis. The median age of patients was 51.5 years and 77.4% were male. Compared to the general Australian population, there was disproportionately greater representation of Indigenous Australians (21.4%), those with a history of injecting drug use (IDU) (27.4%), rheumatic heart disease (14.3%) and previous IE (13.1%). The most commonly affected valve was the mitral valve in 46.4% of patients, and the most common pathogen was Staphylococcus aureus in 47.6% of patients. Twelve-month mortality was 16.7%, with significantly increased mortality in those treated non-surgically (25.6% vs 7.3%, P = 0.025). Factors associated with undergoing surgery included the presence of aortic valve disease, perivalvular extension of infection and infection with Enterococcus faecalis, whereas IDU, tricuspid valve disease and S. aureus infection were associated with non-surgical management. Adherence to multidisciplinary team review was 75.0%, and surgical management was performed in 70.7% of patients meeting an indication for surgery. IE mortality rates remain high, particularly in patients who do not undergo surgical management. Streamlined MDT assessment and referral for surgical management where appropriate is necessary to improve outcomes.

Identifying Care Gaps and Referral Patterns in Acute Dermatology at Urgent Care Centers.

Limited urgent access to board-certified dermatologists drives patients to seek dermatologic care at urgent care centers (UCC). UCC are staffed by clinicians with comparatively limited dermatology training, often resulting in lower quality care for acute dermatology conditions. This study investigates health care referral outcomes of patients seeking dermatologic care at UCC, examine the appropriateness of UCC dermatologic care, and assess the feasibility of referral management by eConsult. We utilize a retrospective cohort of 807 patients and a provider survey to examine referral outcomes of patients referred to University of Rochester Dermatology (UR-Derm), a tertiary care university-based teaching hospital, from UR UCC between January 1, 2021, and August 31, 2022. Outcomes for healthcare referrals included patient demographics, referral completion rates, UR-Derm appointment wait times, and diagnostic concordance rates between UCC and UR-Derm. Outcomes from the provider survey included appropriateness of UCC treatment plans, appropriateness of UCC referral to UR-Derm, and feasibility of referral management by eConsult. Patients who utilized UCC were predominately white (77.0%) females (53.9%) with a mean age of 37.9 years. Most patients referred by UCC did not complete an in-person UR-Derm evaluation (58.6%). Of those who did complete a UR-Derm visit, the average wait time was 38.3 days. Only 56% of UCC and UR-Derm diagnoses were concordant. Our surveyed dermatologists deemed 30% of the UCC treatment plans appropriate. The majority of referrals (83.5%) were viewed as manageable with an eConsult with only 10% of referrals requiring in-person visit. Several practice gaps exist in specialty care delivery in UCC and additional inefficiencies exist in the urgent referral process. These gaps could be addressed by targeted educational interventions and availability of dermatology consultation to support urgent care.

Patient socio-demographics and clinical factors associated with malaria mortality: a case control study in the northern region of Ghana

BackgroundGhana is a malaria-endemic country with the entire population at risk. The Northern region of the country recorded the highest malaria case fatality rate (CFR) for two consecutive years: 1.11% in 2013 and 1.07% in 2014. Even though the National Malaria Elimination Programme (NMEP) has achieved a reduction in malaria mortality, the existence of high case fatality in the Northern region was alarming. This study, therefore, aimed to determine the factors associated with malaria mortality in the northern region of Ghana to institute control measures.MethodsAn unmatched case control study was conducted from July 2015 to August 2015. The study population consisted of patients admitted to health facilities for severe malaria in the Northern region of Ghana. A case was defined as a patient diagnosed with severe malaria at an eligible health facility who died as a result of malaria. A control was a patient diagnosed with severe malaria admitted to an eligible health facility who did not die. Health facilities that recorded CFRs of 1.0% and above were randomly sampled for this study, after which, 10 cases and 20 controls were recruited from each health facility. Information on cases and controls was then abstracted from hospital records using an electronically deployed abstraction tool. Continuous variables were expressed as means and medians, and categorical variables as frequencies and proportions. Multivariable logistic regression was used to assess the strength of the association between malaria mortality and factors predictive of malaria mortality. A p-value of < 0.05 was considered statistically significant.ResultsIn all, a total of 95 cases and 190 controls participated in this study. The median ages of cases and controls were 4.1 years (IQR = 21.6) and 5.7 years (IQR = 18.2), respectively. Fifty-four (56.8%) cases were females, while 93 (49.0%) of the controls were females. Factors associated with malaria mortality included: duration of hospital stay less than 24 h [aOR: 12.0, 95% CI (5.9–24.6)], severe pallor [aOR: 2.3, 95% CI (1.1–4.6)], children under 5 years [aOR: 2.8, 95% CI (1.4–5.6)], oral Artesunate/Amodiaquine administration [aOR: 0.4, 95% CI (0.2–0.9)] and sepsis as an additional diagnosis [aOR: 4.1, 95% CI (1.8–9.5)].ConclusionPredictors of malaria mortality in the Northern region include children under 5 years, severe pallor, sepsis as an additional diagnosis, and use of oral anti-malarial. Patients with severe pallor and sepsis as co-morbidities should receive proactive management. The NMEP and its partners should implement measures to strengthen the referral system, anaemia prevention and management, and retrain health workers on malaria case management. Malaria control interventions targeted at under five children in the region should be reviewed and enhanced.

Prevalence of Amblyogenic Risk Factors Among School Children in India Using the Spot Vision Screener.

Amblyopia is a common cause of preventable visual impairment in children, affecting 1% to 6% globally. This study assesses amblyopia prevalence and risk factors among school children in rural Telangana, India, using the Spot Vision Screener (Welch Allyn, Inc., Skaneateles Falls, New York, USA), a portable, noninvasive device recommended for automated vision screening. A cross-sectional study was conducted on 714 schoolchildren aged 5-10 years. Screening was performed using the Spot Vision Screener, evaluating refractive errors, ocular alignment, and other amblyopia risk factors. Children identified with potential amblyogenic factors were referred for comprehensive ophthalmological evaluation to confirm diagnosis. Out of 714 children screened, 84 were referred by the Spot Vision Screener for further evaluation. Subsequent examination by ophthalmologists confirmed amblyopia in 65 children, resulting in a prevalence of 9.10%. Myopic refractive error was the most prevalent (69.23%), followed by astigmatism (21.53%) and hypermetropia (9.23%) among amblyopia cases. The Spot Vision Screener proved to be a reliable tool for identifying amblyopia risk factors in school children, facilitating early detection and referral for appropriate management. This study underscores the importance of implementing effective vision screening programs in rural settings to mitigate preventable childhood blindness.

Pilot Study—Gold Coast HHS Coronary Angiogram Referral Management and Triage Processes

Pilot Study—Gold Coast HHS Coronary Angiogram Referral Management and Triage Processes

Exploring ICOPE's Impact on Delaying Elderly Disability Management.

The purpose of this study was to explore the initial benefits of introducing the ICOPE (Integrated care for older people) information assessment system for the management of hospitalized elderly patients in a teaching hospital in Eastern Taiwan. The ICOPE information assessment system was set up for case screening and abnormal referral through clinical ICOPE, followed by follow-up and case management. The results showed a total of 3424 screened cases, an average of 311 ICOPE screenings per month, an average of 48 abnormal screenings per month (15%), a referral rate of 79%, a rescreening rate of 91%, and a case management completion rate of 71%. Conclusion: Introducing the ICOPE information evaluation system can quickly screen for potential abnormal disability cases in hospitalized elderly patients, timely referral case management, provide appropriate intervention measures, and improve the quality of life after returning home in old age.

Implementation of a novel computer assisted telephone follow-up model for older patients after emergency department discharge in an Asian population

BackgroundWhile the impact of telephone follow-up (TFU) for older emergency department (ED) patients is controversial, its effects on the Asian population remain uncertain. In this study, we evaluated the effectiveness of a novel computer assisted TFU model specifically for this demographic.MethodsAt a Taiwanese tertiary medical center, we developed a TFU protocol that included a referral and case management system within the ED hospital information system. We provided TFU to older discharged patients between April 1, 2021, and May 31, 2021. We compared this cohort with a non-TFU cohort of older ED patients and analyzed demographic characteristics and post-ED discharge outcomes.ResultsThe TFU model was successfully implemented, with 395 patients receiving TFU and 191 without TFU. TFU patients (median age: 76 years, male proportion: 48.9%) differed from non-TFU patients (median age: 74 years, male proportion: 43.5%). Compared with the non-TFU cohort, the multivariate logistic regression analysis revealed that the TFU cohort had a lower total medical expenditure < 1 month (adjusted odds ratio [AOR]: 0.32; 95% CI: 0.21 − 0.47 for amounts exceeding 5,000 New Taiwan Dollars), and higher satisfaction (AOR: 2.80; 95% CI: 1.46 − 5.36 for scores > 3 on a five-point Likert Scale). However, the TFU cohort also had a higher risk of hospitalization < 1 month (AOR: 2.50; 95% CI: 1.31 − 4.77) compared to the non-TFU cohort.ConclusionComputer-assisted TFU appears promising. Further research involving a larger number of patients and validation in other hospitals is necessary to bolster the evidence and extend the findings to a broader context.

Pre-referral management of preeclampsia with severity features in a low-income country—characteristics and challenges in a Sub-Saharan setting: a mixed method study

Background: Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity, globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting. ObjectiveTo determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features Study design: We conducted a mixed method study on the pre-referral management of pregnant women who complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20-30 minutes, semi-structured, qualitative face-face in depth-interview with 14 health professionals. Quantitative data were analyzed using SPSS version 23 and simple descriptive statistics was employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data. - ResultsA total of 261 pregnant women who had preeclampsia with severity features were included in the study and 14 care providers were interviewed on existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3mmHg and 100.3mmHg, respectively. The total perinatal mortality was 6.5% (17/261). Three mothers (1.1%) complicated by intra-cranial hemorrhage and other three (1.1%) other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulphate. Similarly, antihypertensive was given only to 35 patients constituting 13.4%. Eight mothers convulsed (3.1%) during referral. Two mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Likewise, another two (0.8%) women developed disseminated intravascular coagulation (DIC) by the time of arrival from referring health institution. Up on qualitative data analysis, three overarching themes were recognized: (i) challenges related Patient and family resistance, (ii) Challenges related to healthcare providers’ knowledge, skill and confidence, and (iii) health system related challenges. Low utilization of magnesium sulphate and ant-hypertensive drugs, patient misperceptions regarding reasons for referral, providers lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institution, and non-existence of uniform pre-eclampsia pre-referral and referral management protocols among the referring institutions were the identified gaps. ConclusionWe found a significant gap in pre-referral management for patients with preeclampsia with severity features. Preeclampsia management policy reforms should include introduction of adequate patients counselling platforms, increasing community awareness creation, providing in-service training on pre-referral management of preeclampsia for health personnel, ensuring constant availability of anti-convulsant and antihypertensive drugs and uniform implementation of preeclampsia pre-referral management protocols across health institutions.

Change in suicidal ideation, depression, and anxiety following collaborative care in the community

BackgroundThe Collaborative Care Model (CoCM) increases access to mental health treatment and improves outcomes among patients with mild to moderate psychopathology; however, it is unclear how effective CoCM is for patients with elevated suicide risk.MethodsWe examined data from the Penn Integrated Care program, a CoCM program including an intake and referral management center plus traditional CoCM services implemented in primary care clinics within a large, diverse academic medical system. In this community setting, we examined: (1) characteristics of patients with and without suicidal ideation who initiated CoCM, (2) changes in suicidal ideation (Patient Health Questionnaire-9 [PHQ-9] item 9), depression (PHQ-9 total scores), and anxiety (Generalized Anxiety Disorder Scale-7 scores) from the first to last CoCM visit overall and across demographic subgroups, and (3) the relationship between amount of CoCM services provided and degree of symptom reduction.ResultsFrom 2018 to 2022, 3,487 patients were referred to CoCM, initiated treatment for at least 15 days, and had completed symptom measures at the first and last visit. Patients were 74% female, 45% Black/African American, and 45% White. The percentage of patients reporting suicidal ideation declined 11%-7% from the first to last visit. Suicidal ideation severity typically improved, and very rarely worsened, during CoCM. Depression and anxiety declined significantly among patients with and without suicidal ideation and across demographic subgroups; however, the magnitude of these declines differed across race, ethnicity, and age. Patients with suicidal ideation at the start of CoCM had higher depression scores than patients without suicidal ideation at the start and end of treatment. Longer CoCM episodes were associated with greater reductions in depression severity.ConclusionsSuicidal ideation, depression, and anxiety declined following CoCM among individuals with suicidal ideation in a community setting. Findings are consistent with emerging evidence from clinical trials suggesting CoCM’s potential for increasing access to mental healthcare and improving outcomes among patients at risk for suicide.

Bilateral congenital tarsal kink syndrome with clear cornea

Congenital tarsal kink syndrome is a rare disease that causes inward rotation of the upper eyelid, leading to lacrimation, photophobia, blepharospasm, and corneal scarring. Most of the reports in the literature are unilateral cases. We report a 6-month-old male infant with bilateral tarsal kink syndrome without corneal abrasion or keratitis. The defect was corrected with transconjunctival tarsotomy with marginal rotational sutures. The postoperative outcome was satisfactory. Early diagnosis and treatment help to avoid visual complications in the long term. Increased awareness among pediatricians will help in early referral and faster management.

Referral Efficiency for Veterans with Osteoarthritis: A Quality Improvement Project.

Management of osteoarthritis, a common disease among veterans, includes referrals to orthopedic specialists. This requires an effective referral system. The aim of this study was to evaluate a quality improvement project addressing inefficiencies in the osteoarthritis referral process between primary care providers and orthopedic specialists. A pre- and post-intervention evaluation using medical record review and provider surveys was conducted to measure the process improvement of a primary care to orthopedic referral template. There was a 3.5% increase in the referral acceptance rate following the intervention. In addition, primary care providers perceived that role clarity and perception on making referrals had significantly improved. The largest perceived improved change among orthopedic specialists was in communication. A simple process change, such as improving the referral template, can help with communication, data transfer, and referral acceptance rates between primary care providers and orthopedic specialists. This in turn will benefit the large population of veterans needing orthopedic referrals for management of osteoarthritis.