Referral Behavior Research Articles

Primary care nurses’ readiness to promote digital health technology use among patients

Abstract Background Digital health technologies (DHTs) aim to optimise resource allocation and improve public health outcomes as care supplements. However, many patients do not access them independently. Nurses, as central contacts for primary care patients, can integrate digital health assessments, patient portals, remote monitoring, and teleconsultations into practice. Insight into their readiness to promote patients’ use of DHTs is important for efficient dissemination strategies. We examined nurses’ referral of patients to use DHTs and whether digital dedication (enthusiasm, inspiration, and pride for DHTs) and service guidance skills were associated with referral behaviour. Methods In spring 2023, the national ‘2023 survey on information systems for registered nurses’ gathered data from 549 nurses in Finnish primary care, comprising registered nurses (62%) and public health nurses (38%). The outcome, frequency of nurses’ DHT referrals, was assessed on a scale ranging from never to daily. We used multivariable ordinal logistic regression to examine associations, adjusted for career length, unit, and location. Results Among the nurses, 31% never or seldom referred patients to DHTs, while 19% did so monthly, 32% weekly, and 18% daily. Multivariable model showed that with each one-point increase in digital dedication (scale 1-5), the odds of referring patients to DHTs more frequently increased by 43% (OR = 1.43, 95% CI 1.21-1.70). Nurses who rated their service guidance skills as good (OR = 1.76, 1.01-3.05) or excellent (OR = 2.89, 1.28-6.62) had greater odds of referring patients to DHTs more frequently compared to those with less advanced skills. Conclusions Referring patients to DHTs is not a common practice for primary care nurses and can undermine care equity. Nurses’ motivation and knowledge about DHTs should be fostered, which may enhance patient referrals. Developing guidelines to assess patients’ digital capability and needs for effective service coordination is paramount. Key messages • Digitally committed and service-aware primary care nurses may refer patients to use DHTs more often than their peers, but we could not consider if suitable DHTs were available for patients encountered. • Nurses should be motivated to use digital tools and provided with instructions for proficiently coordinating services in order to address patients’ underutilisation of DHTs and promote equitable care.

Abstract B123: Multilevel influences on Black and Hispanic/Latine patient participation in early phase cancer clinical trials

Abstract Black and Hispanic/Latine patients are disproportionately burdened by cancer yet underrepresented in cancer clinical trials. Diverse participation in cancer clinical trials is essential to identify potential group differences in risks and benefits and to ensure equitable access to cutting-edge therapeutics. Prior research has focused on barriers to representation in later phase trials with less focus on early phase cancer clinical trials (EPCCTs). EPCCTs may include unique barriers to representation based on safety focus and intensive monitoring. We investigate multi-level influences on EPCCT participation for Black and Hispanic/Latine patients through in-depth qualitative interviews with (n=30) Black or Hispanic/Latine metastatic cancer patients and (n=30) oncology providers/staff from two community practices. Using the Ecological Model as a guiding framework, we explored facilitators and barriers to diverse EPCCT participation at the patient level, provider level, health system/policy level, and community level. We utilized Rapid Qualitative Inquiry to gain pragmatic, accurate understanding. At the patient level, we identified informational (e.g., understanding of cancer), emotional (e.g., trust), and instrumental (e.g., transportation) influences on Black and Hispanic/Latine participation. The most pervasive barrier to EPCCT inclusion was lack of invitation for Black and Hispanic/Latine patients. At the provider/staff level, key barriers to representation included low EPCCT knowledge among providers, preconceptions about barriers for Black and Hispanic/Latine patients, and perceived loss of control/relationship with patients/caregivers. At the health system/policy level, critical barriers included insufficient time to discuss EPCCTs, concerns about impact of trials on systems (e.g., wait-time for scans), and provider discomfort with referral process (sending patients to Phase I team without specific trial knowledge). At the community level, salient influences on patient decision-making were identified (e.g., peers, youtube). We conducted a systemwide survey of (n=81) oncology providers and their attitudes, beliefs, and behaviors regarding EPCCTs; we determined how attitudes and beliefs related to EPCCT referral behaviors. We have planned interventions to mitigate each barrier and leverage each facilitator to increase representation. It is critical to identify and address relevant local barriers to ensure equitable access to novel therapeutics and generalizability of scientific discoveries. Citation Format: Jessica Lewis, Amy Smoyer, Erin Singleton, Marcella Nunez-Smith, Imran Saeed, Patricia LoRusso. Multilevel influences on Black and Hispanic/Latine patient participation in early phase cancer clinical trials [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B123.

Exploring the influence of submission devices on customer referral creation and receiver reactions in customer referral programs

AbstractCustomer referral programs (CRPs) are considered an effective means of customer acquisition through which firms stimulate existing customers to refer services and products to potential new customers. Digitalization and technological developments have led to the common practice of using digital devices like smartphones or laptops to create and submit customer referrals. This is the first study to investigate the influence of submission devices in CRPs from both the sender's and receiver's perspective. Based on four experiments, we demonstrate that smartphone‐generated referrals are shorter and less positive than those composed on laptops/PCs. These differences in text length and valence negatively influence receiver responses, leading to lower purchase intentions due to the perceived usefulness of the referral mediating this relationship. Our findings underscore the important role of submission devices for online referral behavior and contribute to the growing body of research on device‐mediated consumer behavior, offering crucial insights to optimize the promotion and design of CRPs.

What Medical Specialties do ME/CFS Sufferers Consult? A Public Health Study on the need for Better Medical Education and Training

The disease ME/CFS is unknown to many doctors in Germany. Within the healthcare system, significant deficits in dealing with ME/CFS patients have been repeatedly revealed. Hence, the aim of the present study was to identify the specialties of the doctors consulted by ME/CFS patients and to find out whether information on the medical procedure in the context of the diagnosis process can be derived from this. As part of the APAV-ME/CFS survey, the quantitative responses of 674 adult ME/CFS sufferers (>20 y.; 554 ♀, 120 ♂) who already had a medical ME/CFS diagnosis were statistically examined. The sampling was done by self-activation and via the snowball principle. The data were primarily evaluated descriptively. An analysis of variance was carried out to consider possible relationships. Almost a quarter of the patients said they had suffered from ME/CFS for 6 to 10 years. Diagnosis was made within 10 years of disease onset in 62%. For 6.4% it took 21-40 years. 75% of the participants consulted 6 to 15 different doctors from a wide range of disciplines in the course of the disease, in particular from general medicine, neurology, internal medicine and psychosomatics/psychiatry. Diagnosis was made in particular by GPs and immunologists. On average, the test persons named 11 mostly neuroregulatory symptoms. The results suggest that in the context of finding a diagnosis in Germany for ME/CFS, referral behaviour to specialists based on single ME/CFS symptoms or rather arbitrary contacting of doctors from a wide variety of disciplines has prevailed so far. Therefore, training and further education measures on the subject of ME/CFS are urgently needed in all specialist disciplines in the resident, inpatient and rehabilitation sectors.

Oncologists’ palliative care referral behaviour: testing utility of social exchange theory as an explanatory framework

BackgroundAdults and children with cancer are referred to palliative care infrequently or late. Oncologists often gatekeep these referrals. Social exchange theory is used to explain physician referral behaviour in various clinical settings. Its utility in a cancer palliative care setting is not known.MethodsWe used Karl Popper’s hypothetico-deductive approach to test the hypothesis. The hypothesis was that social exchange theory is a helpful framework for explaining oncologists’ palliative care referral behaviour in a cancer setting. The utility of the theoretical framework was tested against the empiric findings of a systematic review and original research.ResultsMost components of social exchange theory known to explain physician referral behaviour like beliefs about the provider or service, emotions triggered during the professional engagement, its symbolism and stigma, the complexity of the referral task, efforts needed to achieve it, its cost, benefit, and value were similar in a cancer setting. Empirical findings suggest that oncologists provided strategies and solutions to better palliative care integration instead of comparing their existing engagement with potential alternatives and choosing them.ConclusionSocial exchange theory was found to be helpful in explaining oncologists’ palliative care referral behaviour. To further develop the social exchange theory based on the data used to test it, it is recommended to include feedback and solutions as a component of the theoretical framework alongside a comparison level for alternatives.

To boast or not to boast

In the current phase of artificial intelligence development, more and more attention is being paid to technologies that make autonomous decisions. Little attention has been paid to the customers’ and job seekers’ perceptions of heavily technology-empowered organizations in the management and marketing literature. The purpose of this research is to fill this research gap. A between-subject experiment with fictitious brands was conducted with 239 subjects to answer four hypotheses about customers’ attitudes, intention to use the offer, intention to recommend the company to others, and job seekers’ intentions. The results show that an autonomous algorithm universally influences job seekers more than customer referral behaviors. People confronted with brochures from banks and hospitals that use autonomous technologies express a higher intention to work in such organizations than in analogous institutions that do not offer such a service. However, only in banks that use autonomous algorithms the customers have a more positive attitude and a higher intention to use or recommend the service. The hospital’s unknown brand does not benefit from such an advertising approach. This is the first study ever conducted with fictitious brands of banks and hospitals to investigate the referral towards companies using autonomous technologies. The topic is worth exploring as key market players (such as Oracle) recognize autonomous technologies as the most ground-breaking innovation that will shape business in the coming years.

HSD126 Diagnosing Rare Diseases: Referral Behaviors of Physicians in the United States

HSD126 Diagnosing Rare Diseases: Referral Behaviors of Physicians in the United States

Towards Interdisciplinary Collaboration: Surveying Dentists' and Orthodontists' Perspectives on Orofacial Myofunctional Disorders and Therapy.

Children with malocclusion, combined with orofacial myofunctional disorders (OMDs), show increased risk of developing orthodontic problems and needs later in life. Speech-language therapists typically provide orofacial myofunctional therapy (OMT) after referral by dentists, orthodontists or ENT specialists. Interdisciplinary treatment is often advisable to prevent relapse after orthodontic treatment. OMDs and OMT are often found to be controversial topics by dentistry professionals. This study aimed to investigate self-reported knowledge and attitudes of Flemish dentists and orthodontists towards OMDs and OMT. A survey containing 32 items on demographics, self-reported knowledge of OMDs and OMT, attitudes towards OMDs, OMT, and its use in clinical practice, and referral behaviour was filled out by 48 general dentists (48/79, 61%) and 31 orthodontists (31/79, 39%). The impact of specialization, degree of experience and educational programme was also evaluated. Fifty-six percent of all participants (44/79) reported insufficient to non-existent knowledge of OMT. Nevertheless, the general attitude towards the use of OMT was neutral (47%, 37/79) to (very) positive (48%, 38/79). Although they found correct, evidence-based knowledge on OMDs and OMT important, the majority indicated their formal training did not provide adequate information on OMDs (52%, 41/79) and OMT (62%, 49/79). Specialization showed significant effects, as orthodontists reported themselves knowledgeable on this topic significantly more often than general dentists (p < 0.001), and generally reported a more positive stance towards OMT (p = 0.022). Dentists and orthodontists indicated a general interest in the topic of OMDs and OMT, alongside an overall lack of information provided by formal education. Current findings suggest the necessity of re-evaluating current curricula on OMDs and OMT.

Healthcare providers' attitudes and associated factors on palliative care referral: A qualitative systematic review and meta-aggregation.

Early referral to palliative care has been viewed as providing opportunity for accomplishing end-of-life care goals of life closure, comfortable dying and effective grieving. However, previous studies have shown that palliative care referrals are being made too late. Healthcare providers play important role in helping terminally ill patients to early access and being referred to palliative care. It is necessary to understand healthcare providers' attitudes on palliative care referral and associated factors regarding referrals. This review aimed to identify and synthesise healthcare providers' attitudes and associated factors on palliative care referrals systematically. A systematic review of qualitative evidence and meta-aggregation was conducted and guided according to PRISMA guideline. PubMed, CINAHL, PsycINFO, EMBASE, Web of Science and Cochrane databases from inception to 24 October 2022. Database searches yielded 5856 references. Twenty-two studies met eligibility criteria and of moderate to high methodological quality were included. Studies occurred in USA, UK, Australia and France with 716 healthcare providers participants were included. A total of 378 codings were finally extracted and integrated into 41 categories, forming three synthesised findings: (1) Healthcare providers' attitudes towards palliative care referrals, (2) the influence of subjective norms on palliative care referral behaviour and (3) perceived behavioural control on palliative care referral behaviour. This review demonstrates a series of factors that affect the palliative care referrals, including the attitudes of healthcare providers, the participation of patients and families, the support of colleagues and supervisors, inter-professional collaboration, the availability of hospice resource, disease trajectory and socio-economic factors. Further research that addresses these factors and design relevant trainings on improving healthcare providers' attitudes, enhancing patient and family engagement, strengthening support networks and optimising resource allocation may aid to meet increasing demands of patients. This review not only guides healthcare providers in making better decisions about patient referrals by identifying and addressing barriers but also aids in the development of effective interventions that facilitate the early initiation of referrals. No patient or public contribution.

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI. Semi-structured interviews were conducted with 20 podiatrists, nurses and general practitioners in primary care. Directed content analysis was performed according to the framework method. Utterances were coded to TDF domains, and belief statements were defined by grouping similar utterances. Relevance of domains was confirmed according to belief frequency, presence of conflicting beliefs and the content of the beliefs indicating relevance. Nine TDF domains were identified as relevant to primary care clinicians: Knowledge, Environmental context and resources, Memory, Decision and attention processes, Beliefs about capabilities, Skills, Emotions, Reinforcement and Behavioural regulation. Relationships across domains were identified, including how primary care clinician confidence and working in a highly pressurized environment can affect behaviour. We have identified key barriers and enablers to timely recognition and referral behaviour. These beliefs identify targets for theory-driven behaviour change interventions to reduce delays in CLTI pathways.

Abstract PO2-16-08: Adjuvant Treatment Selection for County-Level Patients with HR+/HER2- Early Breast Cancer in a Real-Life Setting in China

Abstract Background: CHASE001 (NCT05544123), a prospective, non-interventional multicenter study exploring real-world treatment and referral behavior of Chinese county patients (pts) with HER2+ or HR+/HER2– breast cancer is ongoing since September 2022. A prespecified interim analysis (IA) on 750 HER2+ and HR+/HER2- early breast cancer (eBC) was reported at the ESMO Congress 2023. In the 2nd IA from CHASE001, adjuvant treatment selection for patients with HR+/HER2- eBC will be evaluated. Methods: The study was designed to enroll 2500 pts, including four cohorts (HER2+ eBC, HR+/HER2-eBC, HER2+ advanced BC, and HR+/HER2- aBC). In this IA, HR+/HER2- eBC pts after surgery were included. Descriptive statistics reported patient demographics, clinical and disease characteristics and treatment patterns. To investigate the factors associated with chemotherapy-free regimen, non-anthracycline chemotherapy regimen and ovarian function suppression (OFS), univariate and multivariate logistic regression analyses were conducted. Results: At data cutoff (May 17, 2023), 697 HR+/HER2- eBC pts (median age 52 years, 45.77% pT2, 50.93% pN0, 56.10% G2) were included from 26 institutions in China county areas, 338 (48.49%) were premenopausal. 584 (83.79%) received adjuvant chemotherapy, with a few (47/584, 8.05%) initially developing their treatment plan at a higher level hospital (national or provincial tertiary hospital). AC-T (309/584, 52.91%) was the most commonly used regimen. 181 (30.99%) pts received non-anthracycline chemotherapy regimen (mainly TC), and pts with N0, age≥65 years and ki67 < 20% had the strongest association to this regimen (multivariate OR=0.082, 95%CI [0.037,0.179], OR=0.463, 95%CI [0.250,0.859], and OR=0.642, 95%CI [0.418,0.985], respectively). Interestingly, on univariate analysis pts initially diagnosed in a higher level hospital were significantly associated with non-anthracycline regimen (P=0.0109), however on multivariate analysis it was no longer significant. 483 pts received endocrine therapy, including 234 (48.45%) premenopausal pts. The most commonly used endocrine regimen for premenopausal pts was OFS/OFS+ (122/234, 52.14%) ,of which half (61, 50%) were prescribed OFS+TAM/TOR; followed by TAM/TOR monotherapy (69/234, 29.49%). The proportions of patients classified as low, intermediate, and high clinical risk for recurrence (investigator assessed)were 33.62%, 42.67% and 23.71%. The OFS rate were 39.74% in low, 61.62% in intermediate and 70.91% in high risk pts, respectively. Multivariable analyses found that high clinical risk, age < 45 years and ki67 < 20% were strongly associated with the use of OFS (OR=0.210, 95%CI [0.066,0.674], OR=0.327, 95%CI [0.165,0.649], and OR=0.405, 95%CI [0.194,0.845], respectively). For postmenopausal pts, AI monotherapy (84.74%) was the most commonly used endocrine regimen. Conclusions: To our knowledge, this is the first real-world study evaluating the treatment patterns and referral behavior of BC pts in China counties. The 2nd IA results presented showed the current systemic adjuvant treatment preferences and influence factors from a large sample of HR+/HER2- eBC pts in China counties, which were generally consistent with China BC treatment guidelines. Table 1. Utilization of adjuvant systemic therapy regimens in 697 HR+/HER2− eBC pts, China counties AC-T: (dd)doxorubicin/epirubicin, cyclophosphamide, followed by (dd)paclitaxel/docetaxel; TC: paclitaxel/docetaxel, cyclophosphamide; AC: doxorubicin/epirubicin, cyclophosphamide; TAC: docetaxel, doxorubicin/epirubicin, cyclophosphamide; TAM: tamoxifen; OFS: ovarian function suppression; AI: aromatase inhibitors; TOR: toremifene; CDK4/6i: cyclin-dependent kinase 4/6 inhibitors; “Other” category includes various therapies used in <1% of patients each Citation Format: Yinghua Ji, Honglan Qu, Feidu Zhou, Juan Wang, Qianfu Wu, Guohua Dai, Mengyou Liu, Wenbo He, Wei Liang, Qiuli Meng, Yun Ren, Guoxiang Luo, Hongjian Wang, Hui Liu, Zien Qin, Yingguo Tian, Huali Tang, Hongmei Liu, Jun Luo, Zengfeng Yu, Guinv Hu, Jianzhi Gao, Xiang Tan, Yi Liu, Yuanjiang Zhang, Ming Wang, Min Zhang, Ping Lu. Adjuvant Treatment Selection for County-Level Patients with HR+/HER2- Early Breast Cancer in a Real-Life Setting in China [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 PO2-16-08.

Abstract 1008: Pilot evaluation of an online course for primary care providers on preparing patients for cancer discussions with their oncologists

Abstract Introduction: Cancer clinical trial (CCT) accrual is only 5-8%, and barriers to participate can be more acute for underserved groups. Enrollment of racial/ethnic minorities, older adults, adolescents, and young adults is not adequate to understand treatment outcomes unique to these populations. Education before seeing an oncologist can increase patients’ willingness to ask and consider receiving treatment through a CCT. Because primary care providers (PCPs) interact with patients during diagnosis, provide ongoing care, and are a trusted source of information, they can educate and normalize inquiries about therapeutic CCTs. The aim of this study was to pilot test an innovative, tailored online CCT course for PCPs. Methods: To participate, PCPs (MD, DO, NP, or PA) had to provide care in an outpatient setting, refer patients to a cancer treatment specialist in the past year, and be an English speaker residing in the U.S. or its territories. PCPs were recruited from Clinical Directors Network, University of Pennsylvania, and University of Florida. The 1-hour online course includes four modules hosted by a PCP and radiation oncologist with video segments of a CCT expert who summarized CCT recruitment research. Participants interact with patient scenarios and learn about the patient’s cancer diagnosis and medical/personal background. Videos of actors playing the roles of patient and doctor demonstrate communication skills taught in the course. PCPs completed short surveys prior to and immediately after completing the course. Results: 28 PCPs participated. PCPs were mainly MDs (88.9%), residents (17, 60.7%), White (46.4%), non-Hispanic/Latino (92.9%), and 50% women. Mean knowledge of CCTs scores (0-100%) increased significantly from pre (M=56.7, SD=17.5) to post (M=82.1, SD=12; p<.001) indicating that PCPs answered more true/false statements about CCTs correctly after training. Using a 1-5 scale with 5=strongly agree, PCPs’ attitudes and beliefs scores also increased significantly from pre (M=4.2, SD=.6) to post (4.7, SD=.4, p<.001) indicating that PCPs were more likely to agree they have a role in their patients’ cancer treatment, including CCTs, after training. Using the same scale, PCPs’ willingness to communicate about CCTs increased significantly from pre (M=4.4, SD= .5) to post (M=4.7, SD=.5, p=.007), indicating that PCPs were more willing to engage with patients diagnosed with cancer before referring them to a cancer specialist after training. Conclusions: Significant pilot findings in knowledge, attitudes and beliefs, and communication scores demonstrate that the online course was effective at educating PCPs about CCTs, and improving PCPs’ attitudes about the CCT referral process, and their willingness to engage in their patients’ cancer care. Future research will include a larger sample and explore the course’s impact on PCP’s referral behavior. Citation Format: Alyssa Crowe, Elisa S. Weiss, Margo Michaels, Domenic Durante, Maria Sae-Hau, Andrea Cassells, Carla L. Fisher, Jason Arnold, Taylor Vasquez, Ana Natale-Pereira, Raymond Mailhot, Zhongyue Zhang, Carma L. Bylund. Pilot evaluation of an online course for primary care providers on preparing patients for cancer discussions with their oncologists [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1008.

Dark side of algorithmic management on platform worker behaviors: A mixed‐method study

AbstractThis research investigates the impact of algorithmic management on worker behaviors, focusing on workers' commitment to service quality and referral tendencies. Drawing upon the job demands‐resources model, we argue that high levels of algorithmic management could create hindrance demands that impede service quality and demotivate referral behaviors. We propose that high workload, as a challenge demand, buffers the negative effects of algorithmic management on worker outcomes. We find support for our proposed research model in an experiment with a sample of 1362 platform‐based food‐delivery riders. We also conduct a qualitative study with 21 riders, which provides a more nuanced understanding of how algorithmic management affects workers' attitudes, behaviors, and referral tendencies.

An evaluation of first responders’ intention to refer to post-overdose services following SHIELD training

BackgroundFirst responders [law enforcement officers (LEO) and Fire/Emergency Medical Services (EMS)] can play a vital prevention role, connecting overdose survivors to treatment and recovery services. This study was conducted to examine the effect of occupational safety and harm reduction training on first responders’ intention to refer overdose survivors to treatment, syringe service, naloxone distribution, social support, and care-coordination services, and whether those intentions differed by first responder profession.MethodsFirst responders in Missouri were trained using the Safety and Health Integration in the Enforcement of Laws on Drugs (SHIELD) model. Trainees’ intent to refer (ITR) overdose survivors to prevention and supportive services was assessed pre- and post-training (1–5 scale). A mixed model analysis was conducted to assess change in mean ITR scores between pre- and post-training, and between profession type, while adjusting for random effects between individual trainees and baseline characteristics.ResultsBetween December 2020 and January 2023, 742 first responders completed pre- and post-training surveys. SHIELD training was associated with higher first responders’ intentions to refer, with ITR to naloxone distribution (1.83–3.88) and syringe exchange (1.73–3.69) demonstrating the greatest changes, and drug treatment (2.94–3.95) having the least change. There was a significant increase in ITR score from pre- to post-test (β = 2.15; 95% CI 1.99, 2.30), and LEO—relative to Fire/EMS—had a higher score at pre-test (0.509; 95% CI 0.367, 0.651) but a lower score at post-test (0.148; 95% CI − 0.004, 0.300).ConclusionTraining bundling occupational safety with harm reduction content is immediately effective at increasing first responders’ intention to connect overdose survivors to community substance use services. When provided with the rationale and instruction to execute referrals, first responders are amenable, and their positive response highlights the opportunity for growth in increasing referral partnerships and collaborations. Further research is necessary to assess the extent to which ITR translates to referral behavior in the field.

HSD93 Towards Diagnosing Rare Diseases: Referral Behavior of Physicians in Europe

HSD93 Towards Diagnosing Rare Diseases: Referral Behavior of Physicians in Europe

Impact of vertical integration in a referral-based healthcare system

Vertical integration has been growing steadily in healthcare and several studies have explored the impact of this phenomenon on prices, consumers, etc. In this work, motivated by changes in healthcare systems in China, we provide an operational perspective by investigating how vertical integration influences the referral behavior in primary care and the corresponding service provision at hospitals or specialists. We present an optimization model to explore the effect of different levels of vertical integration on generalists and specialists. We find that the healthcare system efficiency can indeed be improved with a moderate level of integration. However, when the level of integration increases beyond a certain threshold, healthcare costs may actually increase with more integration especially when generalists or primary care providers are inadequately trained and specialists are highly utilized. We find that full integration is not optimal. Moreover, aiming for a moderate level of integration is especially appropriate if the generalist’s ability to treat complex patients is limited and/or timely access to treatment is important. Our work also shows that physicians get higher payment without necessarily improving service quality when the integration level is higher. We discuss the implications of our results in the context of the Chinese healthcare system, although some insights may apply more broadly.

Help-and-Haggle: Social Commerce Through Randomized, All-or-Nothing Discounts

This paper studies a novel social commerce practice known as “help-and-haggle,” whereby an online consumer can ask friends to help her “haggle” over the price of a product. Each time a friend agrees to help, the price is cut by a random amount, and if the consumer cuts the product price down to zero within a time limit, she will get the product for free; otherwise, the product reverts to the original price. Help-and-haggle enables the firm to promote its product and boost its social reach as consumers effectively refer their friends to the firm. We model the consumer’s dynamic referral behavior in help-and-haggle and provide prescriptive guidance on how the firm should randomize price cuts. Our results are as follows. First, contrary to conventional wisdom, the firm should not always reduce the (realized) price-cut amount if referrals are less costly for the consumer. In fact, the minimum number of successful referrals the consumer must make to have a chance to win the product can be nonmonotone in referral cost. Second, relative to the deterministic price-cut benchmark, a random price-cut scheme improves firm payoff, extracts more consumer surplus, and widens social reach. Additionally, in most instances, it also reduces the promotion expense while increasing profit from product sales at the same time. Third, help-and-haggle can be more cost effective in social reach than a reward-per-referral program that offers a cash reward for each successful referral. However, using the prospect of a free product to attract referrals cannibalizes product sales, potentially causing help-and-haggle to fall short. Yet, if consumers are heterogeneous in product valuations and referral costs or face increasing marginal referral costs, help-and-haggle can outperform the reward-per-referral program. This paper was accepted by Elena Katok, operations management. Funding: L. Yang acknowledges the Berkeley Haas Center for Growth Markets [2022 Grant Award]. C. Jin acknowledges the Singapore Ministry of Education Academic Research Fund [Tier 1 Grant 251RES2101]. Z. Shao acknowledges support from the National Natural Science Foundation of China [Grant 72071188]. All authors acknowledge the Networks, Electronic Commerce and Telecommunications (NET) Institute [2022 Summer Research Grant]. Supplemental Material: The data files and online appendix are available at https://doi.org/10.1287/mnsc.2023.4948 .

(Em)powering the underdog: How power states enhance referral intention-behavior consistency for underdog entrepreneurs

This research aims to address consumers’ referral intention-behavior inconsistency when responding to entrepreneurs who explicitly position themselves as underdogs. In three experiments with referral behavioral outcomes associated with real new ventures, we identify consumers’ power states as a critical moderator and a viable solution to help enhance the correspondence between referral intention and behavior. Specifically, by altering consumers’ power perceptions (Studies 1 and 2) and by offering empowerment strategies via marketing campaigns (Study 3), consumers with a high sense of power are more likely to translate their referral intention for the underdog entrepreneurial endeavor into referral behavior, compared with those with a low sense of power. This research, therefore, provides theoretical, managerial, and organizational insights into how underdog entrepreneurs can effectively employ and benefit from their unique adversity in positioning themselves in the marketplace to pursue entrepreneurial success.

Predictors of referral behaviour and intention amongst physicians in a medical consortium based on the theory of planned behaviour: a cross-sectional study in China.

To promote patients' referral across healthcare institutions and integrated care delivery, we identified predictors of physicians' behaviour and intention to refer patients in a county medical consortium in China on the basis of the theory of planned behaviour (TPB). This census-based cross-sectional study was conducted in Yangxi Hospital Group (YHG). All physicians in county hospitals and township health centres were invited to participate. Structural equation modelling was employed to analyse the relationships between referral intention and behaviour and other TPB variables in the group of whole participants and in sub-groups. In total, 330 physicians participated in this study. One-third of participants were general practitioners, and half of them were from county hospitals. Referral behaviour of females (χ2 = 20.372, p < 0.001), who had lower education levels (χ2 = 17.859, p = 0.001), lower professional title (χ2 = 14.963, p = 0.005), and lower monthly salary (χ2 = 33.753, p < 0.001) were less frequent than the others. Among them, 116 (35.2%), 108 (32.7%), and 106 (32.1%) respondents reported that they had never referred patients, had referred patients 1-9 times, and had referred patients over 10 times during the past 3 months, respectively. The mean score of referral intention was 4.23/5 (SD = 0.71). In the model with all participants, a stronger referral intention (β = 0.218, 95% CI = 0.080-0.356) was associated with more frequent referral behaviour. The subjective norm (β = 0.703, 95% CI = 0.590-0.817) was the strongest predictor of physicians' referral intention, followed by perceived behavioural control (β = 0.234, 95% CI = 0.090-0.378). Mediated by referral intention, subjective norms (β = 0.153, p < 0.01) and perceived behavioural control (β = 0.190, p < 0.01) had significant indirect effects on physicians' referral behaviour. The model with participants in county hospitals showed similar results to the model with all participants. Meanwhile, in the model with participants in township health centres, there were no significant associations between referral behaviour and other TPB constructs. Physicians' referral behaviour was influenced by intention, subjective norms, and perceived behavioural control in Chinese county hospitals.

Nurturing resource availability of ridesharing platforms by priming goal-oriented operational effectiveness

Ridesharing platforms test incentive schemes with variable commissions where drivers are compensated proportionate to their inputs. The operational effectiveness implications of these incentives, however, remain largely unexplored. We test the differential effects of operational effectiveness parameters of drivers’ service quality, service failure, and monetary value on drivers’ referral and churn behaviors. At a process level, we demonstrate the beneficial effects of goal-oriented (versus informational) feedback on drivers’ monetary value and service performance outcomes. Further, we investigate the moderating role of drivers’ organizational justice perceptions on these relationships. Using exogenous data from a cluster-randomized field experiment with 1,698 ridesharing drivers across 8 cities, we show that goal-oriented feedback improves operational effectiveness parameters. Additionally, these parameters improve the platform’s resource availability with drivers’ higher referrals and lower churn. Comprehensively, platforms can derive benefits in operational effectiveness and resource availability by priming drivers using goal-oriented feedback in tandem with a variable commission.