Barriers To Referral Research Articles

Dementia Rehabilitation Training for General Practitioners and Practice Nurses: Does It Make a Difference?

Rehabilitation helps reduce disability in dementia. The Australian National Dementia Action Plan identifies a gap in clear treatment pathways post-diagnosis, affecting the quality of life for those with dementia. This study assessed the impact of a one-day dementia training course and follow-up on GPs' and practice nurses' knowledge, attitudes, and confidence regarding dementia rehabilitation. The training, led by two experienced GPs and an academic physiotherapist, covered dementia diagnosis, allied health roles, care planning, and referrals. The follow-up involved applying the learnt material and completing a reflective task. Three longitudinal surveys (Dementia Knowledge Assessment Scale-DKAS, General Practitioners' Attitudes and Confidence towards Dementia Survey-GPACS-D, and Dementia Rehabilitation Scale) and Likert-scale statements were conducted pre-course, post-course, and at four-month follow-up, alongside a focus group. Descriptive and regression analyses were applied to survey data, and content analysis was used for focus group data. Seventeen participants (14 GPs, 3 nurses) completed the pre-post-course survey, with eight (6 GPs, 2 nurses) participating in follow-up and focus group discussions. Post-course, DKAS scores increased by 12.1%, GPACS-D by 10.1%, and the dementia rehabilitation scale by 9.4%. Likert-scale statements improved by 8-79%. At the four-month follow-up, there was a slight, non-significant decline in most measures. Focus groups highlighted the training's impacts, useful components, barriers, and suggestions for improvement. Training GPs and practice nurses in dementia rehabilitation enhances knowledge, awareness, and confidence. Ongoing efforts are needed to sustain benefits and address referral barriers for better access to dementia rehabilitation services.

Barriers to Cardiac Rehabilitation Enrollment and Secondary Prevention Adherence in Patients with Coronary Heart Disease Following Percutaneous Coronary Intervention: A Cross-sectional Survey.

This study aimed to evaluate adherence to secondary prevention measures and to identify barriers to cardiac rehabilitation enrolment among patients with coronary heart disease after percutaneous coronary intervention. An observational cross-sectional survey was conducted through computer-assisted telephone interviews to assess recently treated percutaneous coronary intervention patients at the Prince Sultan Cardiac Center in Saudi Arabia. Out of 104 surveyed patients with coronary heart disease, 85 (82%) were male, with an average age of 59.5 years. The obesity rate was 28% (n = 29), with a high prevalence of comorbidities: 82 (79%), 63 (61%), and 62 (60%) patients had hyperlipidemia, diabetes, and hypertension, respectively. Despite high medication compliance (97%), adherence to secondary prevention measures was low (21%). Adherence to physical exercise and weight monitoring for fluid body build-up was notably poor at 35% and 9%, respectively. Only 11 (10.6%) patients were referred for cardiac rehabilitation, of whom only four (36.4%) attended. Significant barriers such as a lack of staff contact, insufficient physician support, and distance to cardiac rehabilitation facilities were particularly noted by 69% of rural patients. This study underscores the significant cardiac risk factors and low adherence to secondary prevention measures among post revascularization patients with coronary heart disease in Saudi Arabia. Low referral and other organizational barriers, as well as the travel distance to hospital-based cardiac rehabilitation, hinder program enrolment. To improve cardiac rehabilitation accessibility, it is crucial to revise the discharge plans, implement automated referral systems, expand the services across all regions, and utilize alternative delivery models.

Key steps and barriers in the journey of patients with epilepsy through the National Healthcare System in Spain: The EPIPASS qualitative study.

Epilepsy requires continuous medical attention from multiple healthcare specialists, specialized facilities, and community-based care. In Spain, there is no standardized approach to epilepsy care. The aim of this study was to identify the factors impacting on the delivery of high-quality care by exploring key steps and barriers along the patient journey through the Spanish National Healthcare System (NHS). A qualitative study was conducted using opinions and experiences of neurologists, nurses, patients, and caregivers shared in discussion meetings. Using thematic content analyses, relevant aim-focused statements were coded according to prespecified issues in a discussion map (i.e., key steps and barriers), and sub-coded according to emerging issues. Thematic saturation and co-occurrence of key steps/barriers were evaluated to identify the most relevant factors impacting on the delivery of high-quality care. Sixty-five stakeholders took part in discussion meetings (36 neurologists, 10 nurses, 10 patients, and nine caregivers). Six key steps on the patient journey were identified: emergency care, diagnosis, drug therapy, follow-up, referral, and interventional treatment. Of these, follow-up was the most relevant step impacting on the delivery of high-quality patient care, followed by drug therapy and diagnosis. Emergency care was considered a hot-spot step with impact throughout the patient journey. Communication (among HCPs and between HCPs and patients) was a barrier to the delivery of high-quality care at several stages of the patient journey, including drug therapy, follow-up, referral, and interventional treatment. Resource availability was a barrier for diagnosis (especially for confirmation), drug therapy (drug availability), and referral (lack of professionals and specialized centers, and long waiting lists). This is the first study capturing perspectives of four key stakeholders involved in epilepsy care in Spain. We provide an overview of the patient journey through the Spanish NHS and highlight opportunities to improve the delivery of patient-centered care with a chronicity perspective. Patients with epilepsy may require prolonged medical care. In Spain, care is provided by a range of specialist and non-specialist centers. In this study, a team of Spanish neurologists, nurses, patients and caregivers identified barriers that affect the delivery of high-quality care for patients with epilepsy at each stage of their journey through the Spanish NHS. Specific epilepsy training for healthcare providers, appropriate resources for diagnosing and treating patients, and good communication between healthcare workers and patients were identified as important factors in providing high-quality care for patients with epilepsy.

S14-3: The adoption and implementation of a physical activity referral pathway integrated into a major U.S. health system

Abstract Background Regular physical activity (PA) is highly effective in improving mental, physical, and emotional health; yet, health systems experience challenges integrating PA referral pathways connecting eligible patients to health-enhancing PA resources and programs. Purpose To examine the adoption of a clinic-to-community PA referral pathway in primary care clinics in a major U.S. health system and identify provider- and patient-level barriers and facilitators associated with its implementation. Methods Exercise is Medicine Greenville® (EIMG®) is a clinic-to-community model that connects primary care patients to a 12-week, evidence-informed, PA program in community PA facilities. Resumption of EIMG® in March 2021 after COVID-19 closures provided a unique opportunity to comprehensively evaluate the PA referral pathway from inception. Referral provision, utilization, and program enrollment were tracked from reopening through September 2022 in twelve primary care clinics. Semi-structured interviews were conducted with providers (informed by the i-PARIHS framework) and referred patients who declined enrollment (informed by the COM-B model). Interviews were recorded, transcribed, and themes identified. Results Twenty-six providers completed interviews. Referral barriers included a lack of knowledge about EIMG®, a perceived time-consuming referral process, and placing incomplete referrals. Facilitators included acknowledgment of a high value for PA in healthcare, desire to incorporate EIMG® into patient visits, and the work of the EIMG® nurse navigator. Twenty-eight patients completed interviews. Enrollment barriers included time, financial constraints, inconvenient locations, disruptions due to COVID-19, and suboptimal communication. Facilitators included aligning EIMG® with patients’ health goals, enhanced trust due to provider referral, group-based format of the PA program, and friendly staff. Conclusions Improving communication, conducting refresher trainings, simplifying the referral process, and providing more resources (for providers), along with providing more program details, and offering more program times, locations, and financial support (for patients), may increase success of PA referral pathways implemented in primary care settings. Practical implications This work identifies modifiable factors that can guide improvements in the adoption and implementation of PA referral models in health settings. Funding The Duke Endowment and the National Heart, Lung, and Blood Institute (NHLBI)

Experiences and barriers in downward referral decision-making for palliative care patient caregivers under China's three-tiered linkage model: A qualitative study

ObjectiveThis study aimed to explore hospice caregivers’ downward referral decision-making experiences and barriers under the triadic linkage model in China and to analyze the deeper social dynamics of hospice referral choices. MethodsSemi-structured interviews were conducted with caregivers handling hospice referrals from two primary hospice agencies in Nanjing, China. The themes were analyzed and summarized using the Colaizzi 7-step analysis. ResultsFour themes and nine subthemes were extracted: multidimensional caregiver psychological experience (Dilemma and Guilt, Emotional Support and Psychological Adaptation), perceived disparities between referral organizations (convenience and affordability in the home community, perceived lack of primary health care resources), limitations of caregiver decision-making (cognitive comprehension bias, difficulty in information seeking, and passive acceptance of decision making), and limitations of health care referral support (lack of health care referral guidance, inadequate referral handoffs). ConclusionsFeedback from caregivers of hospice-referred patients reveals many barriers to hospice referral decision making and referral implementation. Overcoming these barriers entails efforts to change the cognitive misunderstandings regarding hospice referrals from patients' perspective, clarify the distribution of responsibilities among hospice agencies, and provide information support and decision-making assistance. These measures must be employed to improve the implementation of hospice referral, realize the multiple benefits of hierarchical diagnosis and treatment, boost patients’ satisfaction with the referrals, and ensure the rational and efficient distribution of hospice resources.

RADT-11. PROTON BEAM THERAPY (PBT) FOR CENTRAL NERVOUS SYSTEM (CNS) TUMOURS IN CHILDREN: A CANADIAN PEDIATRIC BRAIN TUMOUR CONSORTIUM STUDY

Abstract BACKGROUND Radiotherapy is important for treating pediatric CNS tumours. The main modalities include photon therapy and PBT. PBT offers potential advantages over photon therapy in children since its precise dose control can limit long-term side effects. However, Canadian patients needing PBT are referred to the United States (US) because PBT is unavailable in Canada. We aimed to describe PBT use and outcomes over time for Canadian pediatric patients with CNS tumours. METHODS Patient demographics, treatment characteristics, and outcomes were extracted from medical records of patients from 10/13 Canadian provinces/territories. Patients diagnosed with a CNS tumour at ≤20 years old between 2001-2021 who received curative-intent PBT were included. PBT plans were compared using Fisher’s exact or Kruskal-Wallis rank sum tests. Overall survival (OS) was estimated using the Kaplan-Meier method. RESULTS Of 195 patients (59.0% male) included in the study, majority were from Alberta (28.7%), Quebec (26.7%), British Columbia (22.6%), and Ontario (20.5%). Median age at diagnosis was 8.0 years. Most tumours (77.9%) were non-metastatic. Medulloblastoma was the most common diagnosis (30.8%). Provinces/territories referred patients to proton centres in the same geographical regions, except Alberta (74.5% referred to Florida). Referral numbers have increased ~180%/year since 2011. Median time from diagnosis to PBT was 126 days [11-5236] for all patients, and 36 days [21-1313] for medulloblastoma. Radiation doses, irradiation site, therapy duration, and time to treatment were not different (p≥0.2) across all PBT facilities for medulloblastoma. 5-year OS were 86.8% and 73.0% for the PBT study population and the Cancer in Young People-Canada reference population, respectively, in those aged <15 years. CONCLUSIONS Given the unavailability of PBT in Canada, pediatric CNS tumour patients were referred to US PBT facilities close in proximity. Further studies are needed to better understand provincial referral patterns and barriers to equitable PBT access across Canada.

Hematopoietic Cell Transplant (HCT) Referral Barriers for Patients with Hematologic Malignancies: A Retrospective Study at the National Institutes of Health (NIH)

Hematopoietic Cell Transplant (HCT) Referral Barriers for Patients with Hematologic Malignancies: A Retrospective Study at the National Institutes of Health (NIH)

Abstract PO4-10-11: Needs of oncology nurse navigators serving young or metastatic breast cancer patients

Abstract Oncology nurse navigators (ONN) facilitate breast cancer patients' care via information, resources, and referral services. Two important groups of breast cancer patients served by ONN are young women with breast cancer (yBC), defined as women diagnosed at age 45 or younger, and metastatic breast cancer (mBC) patients. These two groups of patients have distinct needs for clinical care and services. To better understand the needs and experiences of ONN serving these patients, we surveyed 52 active ONN in the United States via an online needs assessment survey about their familiarity with topics relevant for breast cancer patients, referral patterns, and perception of educational needs. As expected, most ONNs saw more yBC than mBC patients. Familiarity of ONN with topics relevant for yBC and mBC differed based on their work experience. For some topics, earlier-career ONN (<5 years of work experience) reported distinct experiences from later-career ONN (more than 5 years of work experience). Earlier-career ONN were less familiar than later-career ONN with clinical trial participation (45% vs 79%; p=0.0315) and genetic counseling and testing (73% vs 96%; p=0.0431). Most ONN referred yBC and mBC patients for financial, mental health, or genetic testing services. For many other services, referral patterns of yBC and mBC patients differed. Earlier-career ONN referred patients less often than later-career ONN to clinical trials (35% vs 89%; p=.0014 for yBC, and 36% vs 89%, p=.0028 for mBC). Earlier-career ONN tended to refer mBC patients less often than yBC for genetic counseling and testing, healthy lifestyles, menopause management, and sexual health or intimacy services. In contrast, later-career ONN referred yBC and mBC patients at similar rates. ONN reported substantial barriers to many services (but not to fatigue, menopause management, and pain management). The services for which ONN most frequently reported barriers were fertility preservation (predominantly financial and lack of programs/providers) and clinical trial services (patient understanding of value and medical jargon/health literacy barriers). ONN referred patients infrequently to some services despite reporting few barriers in contrast to prior reports of breast cancer patients' needs. Most ONN were interested in continuing education for sexual health and intimacy but not clinical trials, treatment side effects, or pain management. Most ONN cited a need for patient materials about sexual health and intimacy and mental health issues. While most ONN were confident in their ability to address questions about breast cancer in the media, they indicated additional resources would be useful. Understanding barriers to information and referrals is necessary to develop approaches to reduce educational gaps and lower referral barriers. Adapting efforts according to ONN career stage may be an important component for continuing education. For clinical trial participation, patient-friendly materials may help reduce barriers to referral and participation. Citation Format: Kelly Owens, Marleah Dean, Elizabeth Bourquardez Clark, Piri Welcsh, Diane Rose, Erica Kuhn, Jessica Conaty, Robin Pugh-Yi, Susan Friedman. Needs of oncology nurse navigators serving young or metastatic breast cancer patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-10-11.

Unlocking timely palliative care: assessing referral practices and barriers at a ghanaian teaching hospital

BackgroundThe need for primary care physicians to be heavily involved in the provision of palliative care is growing. International agencies and practice standards advocate for early palliative care and the use of specialized palliative care services for patients with life-threatening illnesses. This study was conducted to investigate physicians’ referral practices and perceived barriers to timely referral at the Korle Bu Teaching Hospital.MethodsA cross-sectional study design was employed using a convenience sampling technique to recruit 153 physicians for the study. Data on socio-demography, referral practices, timing and perceived barriers were collected using a structured questionnaire. Binary Logistic regression using crude and adjusted odds was performed to determine the factors associated with late referral. Significance was set at p < 0.05.ResultsThe prevalence of late referral was reported to be 68.0%. There were poor referral practices among physicians to palliative care services, and the major barriers to late referral were attributed to the perception that referring to a palliative care specialist means that the physician has abandoned his patient and family members’ decisions and physicians’ personnel choices or opinions on palliative care.ConclusionThe healthcare system needs tailored interventions targeted at improving physicians’ knowledge and communication strategies, as well as tackling systemic deficiencies to facilitate early and appropriate palliative care referrals. It is recommended that educational programs be implemented, palliative care training be integrated into medical curricula and culturally sensitive approaches be developed to address misconceptions surrounding end-of-life care.

Clinician perspectives on integrating neuro-oncology and palliative care for patients with high-grade glioma.

Patients with high-grade glioma have high palliative care needs, yet few receive palliative care consultation. This study aims to explore themes on (1) benefits of primary (delivered by neuro-oncologists) and specialty palliative care (SPC) and (2) barriers to SPC referral, according to a diverse sample of clinicians. From September 2021 to May 2023, 10 palliative physicians and 10 neuro-oncologists were recruited via purposive sampling for diversity in geographic setting, seniority, and practice structure. Semistructured, 45-minute interviews were audio-recorded, professionally transcribed, and coded by 2 investigators. A qualitative, phenomenological approach to thematic analysis was used. Regarding primary palliative care, (1) neuro-oncologists have primary ownership of cancer-directed treatment and palliative management and (2) the neuro-oncology clinic is glioma patients' medical home. Regarding SPC, (1) palliative specialists' approach is beneficial even without disease-specific expertise; (2) palliative specialists have time to comprehensively address palliative needs; and (3) earlier SPC enhances its benefits. For referral barriers, (1) appointment burden can be mitigated with telehealth, home-based, and embedded palliative care; (2) heightened stigma associating SPC with hospice in a population with high death anxiety can be mitigated with earlier referral to promote rapport-building; and (3) lack of neuro-oncologic expertise among palliative specialists can be mitigated by emphasizing their role in managing nonneurologic symptoms, coping support, and anticipatory guidance. These themes emphasize the central role of neuro-oncologists in addressing palliative care needs in glioma, without obviating the need for or benefits of SPC. Tailored models may be needed to optimize the balance of primary and specialty palliative care in glioma.

“I Wasn't Expecting That Question”: Responses to Requests for Abortion Referral at College Student Health Centers

BackgroundWomen 18–24 years of age have the highest proportion of unintended pregnancies of any age group, and thus represent a significant population in need of abortion services. Prior research indicated that only half of college student health centers provide appropriate abortion referrals. Our objective was to better understand the referral experience and barriers to abortion referral at college student health centers. ProceduresWe conducted a “secret caller” study at all 4-year colleges in Pennsylvania between June 2017 and April 2018, using a structured script requesting abortion referral. Calls were transcribed, coded using an iteratively developed codebook, and analyzed for themes related to barriers and facilitators of abortion referral. Main FindingsA total of 202 completed transcripts were reviewed. Themes that emerged were knowledge, experience, and comfort with abortion referral; support, empathy, and reassurance; coercion; misleading language; questioning the caller's autonomy; and institutional policy against referral. Most staff lacked knowledge and comfort with abortion referral. Although some staff members made supportive statements toward the caller, others used coercive language to try to dissuade the caller from an abortion. Many staff cited religious institutional policies against abortion referral and expressed a range of feelings about such policies. ConclusionsAbortion referrals at student health centers lack consistency. Staff members frequently did not have the knowledge needed to provide appropriate abortion referrals, used coercive language in responding to requests for referrals, and perpetuated abortion stigma. Some health staff used coercive or evasive language that further stigmatized the caller's request for an abortion referral. College health centers should improve training and resources around abortion referral to ensure they are delivering appropriate, high-quality care.

Referral rates and barriers to lung transplantation based on pulmonary function criteria in interstitial lung diseases: a retrospective cohort study.

Interstitial lung diseases (ILD) unresponsive to medical therapy often require lung transplantation (LTx), which prolongs quality of life and survival. Ideal timing for referral for LTx remains challenging, with late referral associated with significant morbidity and mortality. Among other criteria, patients with ILD should be considered for LTx if forced vital capacity (FVC) is less than 80% or diffusion capacity for carbon monoxide (DLCO) is less than 40%. However, data on referral rates are lacking. To evaluate referral rates for LTx based on pulmonary function tests (PFTs) and identify barriers associated with non-referral. A single-center retrospective cohort study. The study consisted of ILD patients who performed PFT between 2014 and 2020. Patients with FVC < 80% or a DLCO < 40% were included in the study. Patients with absolute contraindications to LTx were excluded. Referral rates were computed, and a comparison was made between referred and non-referred subjects. Out of 114 ILD patients meeting criteria for referral to LTx, 35 were referred (30.7%), and 7 proceeded to undergo LTx. Median time from PFT to referral for assessment was 255 days [interquartile range (IQR) 35-1077]. Median time from referral to LTx was 89 days (IQR 59-143). Referred patients were younger (p = 0.003), had lower FVC (p < 0.001), DLCO (p < 0.001), and a higher rate of pulmonary hypertension (p = 0.04). Relatively better PFT, and older age, were significantly associated with non-referral of patients. There is under-referral of ILD patients who are eligible for LTx, which is associated with severe disease and missed opportunities for LTx. Further research is required to validate these findings.

A qualitative exploration of interprofessional collaborative practice between genetic counselors and mental health providers.

Genetic counselors (GCs) typically provide short-term counseling and assess patient needs, including the need for ongoing psychosocial support. While some patients may benefit from a referral to a mental health provider (MHP), previous research identified barriers to this process due to patient characteristics, the GC work environment, and MHP availability. Adoption of interprofessional collaborative practice (IPCP), a model where multiple healthcare professionals from diverse training disciplines collaborate to deliver patient care, may mitigate these barriers. Evidence suggests that IPCP both increases patient satisfaction and reduces healthcare spending. Anecdotal evidence suggests that GCs and MHPs may use IPCP in select institutions, but there is limited research examining these relationships. This study aims to characterize the benefits, barriers, and limitations of current IPCP practice between GCs and MHPs. Six semi-structured interviews with GCs and MHPs were completed and analyzed thematically. Four themes emerged: (1) mental health concerns in GC sessions and GC scope of practice; (2) establishing and maintaining IPCP between GCs and MHPs; (3) benefits, barriers, and limitations of IPCP; and (4) next steps to develop future IPCP. The findings suggest that there are varying approaches to IPCP that are influenced by perceptions of provider scope of practice. IPCP may mitigate some previously described referral barriers related to logistics, and the availability of trusted MHPs with knowledge of a GCs specialty, thereby improving patient and provider satisfaction.

Temporal trends and barriers for inpatient palliative care referral in metastatic gynecologic cancer patients receiving specific critical care therapies.

Existing evidence suggests that palliative care (PC) is highly underutilized in metastatic gynecologic cancer (mGCa). This study aims to explore temporal trends and predictors for inpatient PC referral in mGCa patients who received specific critical care therapies (CCT). The National Inpatient Sample from 2003 to 2015 was used to identify mGCa patients receiving CCT. Basic characteristics were compared between patients with and without PC. Annual percentage change (APC) was estimated to reflect the temporal trend in the entire cohort and subgroups. Multivariable logistic regression was employed to explore potential predictors of inpatient PC referral. In total, 122,981 mGCa patients were identified, of whom 10,380 received CCT. Among these, 1,208 (11.64%) received inpatient PC. Overall, the rate of PC referral increased from 1.81% in 2003 to 26.30% in 2015 (APC: 29.08%). A higher increase in PC usage was found in white patients (APC: 30.81%), medium-sized hospitals (APC: 31.43%), the Midwest region (APC: 33.84%), and among patients with ovarian cancer (APC: 31.35%). Multivariable analysis suggested that medium bedsize, large bedsize, Midwest region, West region, uterine cancer and cervical cancer were related to increased PC use, while metastatic sites from lymph nodes and genital organs were related to lower PC referral. Further studies are warranted to better illustrate the barriers for PC and finally improve the delivery of optimal end-of-life care for mGCa patients who receive inpatient CCT, especially for those diagnosed with ovarian cancer or admitted to small scale and Northeast hospitals.

Referral Barriers of Post-Mastectomy Patients for Breast Reconstruction among General Surgeons in Yemen

Referral Barriers of Post-Mastectomy Patients for Breast Reconstruction among General Surgeons in Yemen

Telerehabilitation in patients with recent hospitalisation due to acute decompensated heart failure: protocol for the Tele-ADHF randomised controlled trial

BackgroundCardiac rehabilitation in patients with chronic heart failure (CHF) has favourable effects on exercise capacity, the risk at hospital (re-)admission and quality of life. Although cardiac rehabilitation is generally recommended it is still under-utilised in daily clinical practice, particularly in frail elderly patients after hospital admission, mainly due to low referral and patient-related barriers. Cardiac telerehabilitation (CTR) has the potential to partially solve these barriers. The purpose of this study is to evaluate the effects of CTR as compared to standard remote care after hospital admission on physical functional capacity in CHF patients.MethodsIn this randomised controlled trial, 64 CHF patients will be recruited during hospitalisation for acute decompensated heart failure, and randomised to CTR combined with remote patient management (RPM) or RPM alone (1:1). All participants will start with RPM after hospital discharge for early detection of deterioration, and will be up titrated to optimal medical therapy before being randomised. CTR will start after randomisation and consists of an 18-week multidisciplinary programme with exercise training by physical and occupational therapists, supported by a (remote) technology-assisted dietary intervention and mental health guiding by a physiologist. The training programme consists of three centre-based and two home-based video exercise training sessions followed by weekly video coaching. The mental health and dietary programme are executed using individual and group video sessions. A wrist-worn device enables remote coaching by the physical therapist. The web application is used for promoting self-management by the following modules: 1) goal setting, 2) progress tracking, 3) education, and 4) video and chat communication. The primary outcome measure is physical functional capacity evaluated by the Short Physical Performance Battery (SPPB) score. Secondary outcome measures include frailty scoring, recovery after submaximal exercise, subjective health status, compliance and acceptance to the rehabilitation programme, and readmission rate.DiscussionThe Tele-ADHF trial is the first prospective randomised controlled trial designed for evaluating the effects of a comprehensive combined RPM and CTR programme in recently hospitalised CHF patients. We hypothesize that this intervention has superior effects on physical functional capacity than RPM alone.Trial registrationNetherlands Trial Registry (NTR) NL9619, registered 21 July 2021.

Clinician Perspectives on Palliative Care for People with Hepatocellular Carcinoma: Facilitators of and Barriers to Referral.

(1) Background: Little is known about facilitators of and barriers to palliative care referral for people with hepatocellular carcinoma (HCC). The objective of this study is to identify facilitators and barriers of palliative care referral described by HCC-treating clinicians. (2) Methods: Semi-structured interviews (n = 16) were conducted with HCC-treating clinicians at two centers, focusing on referral patterns, palliative care needs, and disease course. A code book was created, axial coding was used to code all interviews, and selective coding was used to identify facilitators and barriers of palliative care referral. (3) Results: Facilitators included helpfulness at times of transition; help with management of certain symptoms; provision of psychosocial support; and positive experiences with referral. Barriers included feasibility concerns; lack of information about palliative care and who is appropriate; lack of symptoms requiring outside referral; and concerns that palliative care conveys loss of hope. (4) Conclusions: Participants noted the helpfulness of palliative care at specific points in the disease trajectory and cited barriers related to feasibility, lack of need, lack of awareness, and loss of hope. The results show actionable issues that can be addressed in future research to leverage the benefits of and overcome the barriers to palliative care for people with HCC.

Referral to Vision Rehabilitation Services for Uveitis Patients: Referral Criteria and Barriers

ABSTRACT Purpose Despite the benefits of vision rehabilitation services (VRS) for uveitis patients, limited literature has examined issues in VRS access within uveitis. We surveyed American Uveitis Society members regarding VRS referral practices, criteria, and barriers. Methods Survey responses were collected from November 2022 to January 2023. Analysis summarized responses and compared response patterns of frequently-referring and infrequently-referring providers through Fisher’s exact tests and logistic regression. Results Most of the 33 respondents completed 1 to 5 monthly referrals using criteria of visual acuity loss, visual field loss, and difficulty performing vision-related activities. Key referral barriers included cost of services and insufficient patient-provider communication regarding vision loss. The practice of speaking to patients about vision loss during clinic visits was correlated with higher VRS referral rates (P = 0.047). Conclusions Greater patient-provider communication about vision loss may represent an opportunity to increase access to VRS.

Impact of best practice advisory on genetic counseling referral patterns for patients with endometrial cancer.

5606 Background: The National Comprehensive Cancer Network (NCCN) recommends that patients with endometrial cancer under age 50 undergo germline genetic testing. Despite this recommendation, completion rates are suboptimal for patients with gynecologic malignancies. The reasons for failure to complete testing are unknown, but oncology providers may not refer patients to genetic counselors, who frequently order this testing. Best practice advisories (BPAs) in electronic medical records can alert providers of patients who meet guideline-based treatments and testing criteria. It is unknown how oncology providers interact with a BPA indicating patients with endometrial cancer meet NCCN germline testing criteria. The objective of this study is to evaluate genetic counseling referral patterns after implementing a BPA. Methods: Our team developed a BPA to prompt oncology providers to order genetic counseling referrals for patients diagnosed with endometrial or uterine cancer under age 50. We reviewed all provider-BPA interactions between go-live (January 2022) and January 2023. Patient demographic, histopathologic, and cancer treatment data were collected. Provider actions, including BPA cancellation and order placement, were collected. The Chi-Square goodness of fit test was used to identify differences in referral rates by patient or disease characteristics. Results: The BPA displayed 1121 times for 103 patients. Attending physicians received 535 alerts, fellow physicians – 269, and advanced practice providers (APPs) – 317. The median number of alerts per patient was 7 (range 1-87). Of the 103 patients, 23 were excluded from analysis due to no diagnosis of endometrial cancer, patient declined referral, previously completed, or a lack of provider visits within the study period. Of the 80 eligible patients, 36 (45%) received referrals; 18 were placed by attending physicians, 17 by fellows, and one by an APP. Patients under age 40 versus age 40-49 were more likely to be referred (65% vs. 35%; p = 0.011). Patients with active disease were more likely to be referred than those in surveillance (65% vs. 18%; p &lt; 0.001). There were no differences in referral rates by primary language, race, body mass index ≥40, fertility-sparing versus definitive treatment, stage I versus stage II-IV disease, or grade 1-2 versus three tumors. Conclusions: Despite implementing a BPA, only 45% of eligible patients received indicated referrals. Attending and fellow physicians frequently manage patients with active disease and often order referrals; however, APPs frequently manage patients in surveillance and infrequently place referrals, highlighting an opportunity for education. In addition, patients aged 40-49 are less likely to be referred, suggesting a need for new strategies to improve referral rates. Further research is indicated to identify referral barriers for patients undergoing active treatment.

Long travel times from health center to hospital reduce caesarean section access: a study from Kirehe District, Rwanda.

timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.