Referral Behavior Research Articles

The use of public performance reporting by general practitioners: a study of perceptions and referral behaviours

BackgroundPublic performance reporting (PPR) of hospital data aims to improve quality of care in hospitals and to inform consumer choice. In Australia, general practitioners (GPs) are gatekeepers to secondary care with patients requiring their referral for non-emergency access. Despite their intermediary role, GPs have been generally overlooked as potential users of PPR of hospital data, with the majority of the PPR research focussing on consumers, surgeons and hospitals.MethodsWe examined the use of PPR of hospital data by GPs when referring patients to hospitals. Semi-structured interviews were conducted with 40 GPs, recruited via the Victorian Primary Care Practice-Based Research Network and GP teaching practices in Victoria, Australia. The interviews were recorded, transcribed and analysed thematically.ResultsWe found that the majority of GPs did not use PPR when referring patients to hospitals. Instead, they relied mostly on informal sources of information such as their own or patients’ previous experiences. Barriers that prevented GPs’ use of PPR in their decision making included: lack of awareness and accessibility; perceived lack of data credibility; restrictive geographical catchments for certain hospitals; limited choices of public hospitals in regional and rural areas; and no mandatory PPR for private hospitals.ConclusionsOur findings suggest that lack of PPR awareness prevented GPs from using it in their referral practice. As gatekeepers to secondary care, GPs are in a position to guide patients in their treatment decisions and referrals using available PPR data. We suggest that there needs to be greater involvement by GPs in the development of hospital performance and quality indicators in Australia if GPs are to make greater use of them. The indicators require further development before GPs perceive them as valid, credible, and of use for informing their referral practices.

Paging the eCardiologist: insights into referral behaviour of primary care physicians from qualitative analysis of a cardiology eConsult service

ObjectiveThe purpose of this study is to investigate determinants of primary care physician cardiology referrals by performing qualitative analysis of questions asked by primary care physicians in cardiology electronic consultation services (eConsults).SettingA health region in eastern Ontario, Canada, where primary care providers have had access to an eConsult service since 2010.ParticipantsWe included all consecutive cardiology eConsults initiated by registered primary care provider users of our eConsult service and who initiated one or more eConsult between July 2014 and January 2015. We excluded eConsults in which the primary care provider attached a document without asking a question. A convenience sample of 100 consecutive eConsults initiated by 61 primary care providers was analysed after excluding 14 eConsults.Primary and secondary outcome measures: Primary care provider eConsult questions are categorised into thematic categories based on the constant comparison method of qualitative analysis with external validation by content experts. Secondary outcomes include sample primary care provider eConsult questions to illustrate each theme and any emergent subthemes.ResultsThematic saturation occurred after analysis of 30 eConsults. An additional 70 eConsults were coded with no new emergent themes. Themes include exceptions to clinical guidelines (n=13), non-cardiac treatment in a cardiac patient (n=13), specific investigation/management (n=18), interpretation of diagnostic testing (n=46), clinical concerns despite normal testing (n=4) and screening for positive family history (n=6). Subthemes include multiple comorbidities and mild abnormalities on cardiac tests.ConclusionsWe report categories of clinical questions that drive primary care provider cardiology eConsults. Multimorbidity leads to cardiology eConsults as primary care providers try to apply treatment guidelines in medically complex patients. Mild test abnormalities unrelated to clinical problems commonly lead to cardiology eConsult requests. Further research is needed to determine how guidelines can better account for multimorbidity, and how cardiologists can better communicate with primary care providers to put cardiac test results in clinical context.

Collegiate Athletic Trainers' Knowledge of the Female Athlete Triad and Relative Energy Deficiency in Sport.

The female athlete triad (Triad) and relative energy deficiency in sport (RED-S) specify the consequences of energy imbalance. Athletic trainers (ATs) are positioned to identify athletes who are fueling themselves inadequately and experiencing related health and performance consequences. To assess the knowledge of collegiate ATs about the Triad and RED-S and to examine variability in related screening and referral behaviors among National Collegiate Athletic Association divisions. Cross-sectional study. Collegiate athletic training departments. Head ATs at National Collegiate Athletic Association member institutions (n = 285, response rate = 33%). An electronic survey was administered. The number of Triad components that were correctly identified and screening and referral behaviors related to Triad components were measured. Nearly all respondents (98.61% [n = 281]) had heard of the Triad; a smaller proportion (32.98% [n = 94]) had heard of RED-S. On average, respondents correctly identified 2 components of the Triad. We observed differences by sex, with women correctly identifying more components than men ( U = 12.426, P = .003). More than half (59.93% [n = 163]) indicated that athletes at their institutions were screened for eating disorders. Nearly three-quarters (70.55% [n = 115]) of respondents indicated that all female athletes at their institutions were screened annually for menstrual dysfunction. More comprehensive referral behaviors for athletes identified as experiencing menstrual dysfunction or a bone injury (eg, athlete referred to a nutritionist, dietitian, or counselor) occurred at Division I institutions than at Division II and III institutions. Continuing education for ATs about the Triad and RED-S may encourage a more comprehensive approach to referral and screening after a diagnosis of menstrual dysfunction or bone-stress injury. Using institutional opportunities, such as preparticipation screening, for identifying components of the Triad or RED-S and specifying protocols for referring athletes who screen positive for 1 of these components should also be explored.

\u201cOnce the delivery is done, they have finished\u201d: a qualitative study of perspectives on postnatal care referrals by traditional birth attendants in Ebonyi state, Nigeria

BackgroundWhile 79% of Nigerian mothers who deliver in facilities receive postnatal care within 48 h of delivery, this is only true for 16% of mothers who deliver outside facilities. Most maternal deaths can be prevented with access to timely and competent health care. Thus, the World Health Organization, International Confederation of Midwives, and International Federation of Gynecology and Obstetrics recommend that unskilled birth attendants be involved in advocacy for skilled care use among mothers. This study explores postnatal care referral behavior by TBAs in Nigeria, including the perceived factors that may deter or promote referrals to skilled health workers.MethodsThis study collected qualitative data using focus group discussions involving 28 female health workers, TBAs, and TBA delivery clients. The study conceptual framework drew on constructs in Fishbein and Ajzen’s theory of reasoned action onto which we mapped hypothesized determinants of postnatal care referrals described in the empirical literature. We analyzed the transcribed data thematically, and linked themes to the study conceptual framework in the discussion to explain variation in TBA referral behavior across the maternal continuum, from the antenatal to postnatal period.ResultsDifferences in TBA referral before, during, and after delivery appear to reflect the TBAs understanding of the added value of skilled care for the client and the TBA, as well as the TBA’s perception of the implications of referral for her credibility as a maternal care provider among her clients. We also found that there are opportunities to engage TBAs in routine postnatal care referrals to facilities in Nigeria by using incentives and promoting a cordial relationship between TBAs and skilled health workers.ConclusionsThus, despite the potential negative consequences TBAs may face with postnatal care referrals, there are opportunities to promote these referrals using incentives and promoting a cordial relationship between TBAs and skilled health workers. Further research is needed on the interactions between postnatal maternal complications, TBA referral behavior, and maternal perception of TBA competence.

Professionals' knowledge, attitude and referral behaviour of preimplantation genetic diagnosis for hereditary breast and ovarian cancer

Hereditary breast and ovarian cancer caused by a BRCA1/2 mutation is the most frequent indication for preimplantation genetic diagnosis (PGD) in the Netherlands. The extent to which involved professionals are informed about this option, however, is unclear. The few available international studies mostly represent a limited range of professionals, and suggest that their knowledge about PGD for hereditary cancer syndromes is sparse and referral for PGD is based on limited understanding. A cross-sectional survey assessing awareness, knowledge, acceptability and PGD-referral for BRCA was completed by 188 professionals involved in the field of breast and ovarian cancer or reproduction. One-half of professionals were aware of PGD for BRCA, and most had a low to moderate level of knowledge. A total of 86% considered PGD for BRCA acceptable and 48% had referred patients with BRCA for PGD. Awareness and knowledge was higher among professionals who worked at a university hospital (compared with a general hospital). Knowledge of PGD was positively associated with discussing and referring for PGD, and PGD acceptability was associated with previous awareness. Although PGD counselling is the primary responsibility of the geneticist, other involved professionals may be gatekeepers as patients rely on them for raising awareness and referral.

‘Just a GP’: a mixed method study of undermining of general practice as a career choice in the UK

ObjectivesFailure to recruit sufficient applicants to general practice (GP) training has been a problem both nationally and internationally for many years and undermining of GP is one possible contributing factor....

Targeting general practitioners: Prospective outcomes of a national education program in radiation oncology.

We report on learning outcomes of a standardized national education program aimed at improving general practitioner (GP) knowledge about radiation therapy (RT) and referral pathways to radiation oncologists (ROs). In 2014, a GP education program was developed through the Targeting Cancer public awareness campaign of the Royal Australian and New Zealand College of Radiologists (RANZCR) Faculty of Radiation Oncology. The sessions were held in RT departments and comprised of RO-led case-based group learning and a department tour. Pre- and immediate post-session surveys assessed four domains: Objective knowledge about RT, understanding of referral pathways to ROs, self-reported referral behaviours, feedback on the session. A 6-month follow up survey assessed ongoing knowledge retention. Eighteen sessions were held nationwide between October 2014 and March 2016. One hundred and seventy-four were surveyed. Pre-session, 96% of GPs reported their knowledge of RT required improvement. Post-session, 95% rated their knowledge as 'excellent', 'above average' or 'competent'. 32.5% of GPs were not aware of the location of their local RT department. 81% reported patients would benefit from having clearer referral pathways to ROs. 96% agreed the GP's role is to refer cancer patients to relevant specialists to discuss treatment options. However, only 49% were comfortable referring directly to an RO. Post-session rose to 92%. All respondents felt the session improved their understanding of RT. In the follow up survey, 17 respondents (94%) reported the session had improved their ability to care for cancer patients. A national GP education program improves GP knowledge about RT and may influence patient referrals for RT.

Who Asks Most? Institutional Incentives and Referral Activity in the European Union Legal Order

By enabling the Court of Justice to engage domestic judges, the preliminary ruling mechanism is widely recognized to have played a major role in European integration. Yet both the incentives and motivation to cooperate with the Court of Justice are believed to vary significantly across domestic courts. We explore how domestic courts differ in their referral behaviour depending on the position they occupy in the juridical hierarchy using a novel dataset, which extends, complements and corrects data initially collected by Stone Sweet and Brunell (1998). We find that first instance courts pioneered the use of the preliminary ruling procedure, but that appellate and peak courts subsequently overtook them. We explain these shifts by the combined effect of institutional consolidation, organizational design and legal rules. We argue that resort to Article 267 TFEU was initially “accidental” but became institutionalised as more courts submitted references. This, in turn, allowed the division of labour underpinning the organization of national judiciaries to reshape referral dynamics.

Periodontal screening and referral behaviour of general dental practitioners in Flanders.

The objective of this study was to investigate the screening and referral behaviour of Flemish dentists concerning periodontitis and more specific, the use of the Dutch Periodontal Screening Index (DPSI). An online questionnaire was electronically distributed through the different professional dental societies. It consisted of two parts: the first aimed at describing the profile of the dentist. The second part inquired the screening method, when this was applied, periodontal risk factors and referral behaviour. One thousand fifty dentists attended to the questionnaire. One hundred fifty-nine questionnaires were excluded since they did not match the target audience. Sixty-four percent of Flemish dentists used DPSI as a periodontal screening method, 28% screened based on probing pocket depth, 4% used solely radiographs and 4% had no screening method at all. The usage of DPSI is influenced by the year of graduation: the longer the dentists were graduated, the less they used DPSI. No influence of sex, education centre and location was found. Referral behaviour is influenced by different patient- and dentist-related factors. Regarding the screening behaviour, there seems a consensus among Flemish dentists that a periodontal probe should be used. For referral, there is no consensus about if and when to refer to a specialist. It is encouraging that 92% of the Flemish general dental practitioners use a probe when screening for periodontitis. However, DPSI is mainly used by younger dentists. An effort should be made to encourage all dentists to use this, so that in every patient, periodontitis can be detected timely, securing the best treatment outcome.

Distinguishing variation in referral accuracy from referral threshold: analysis of a national dataset of referrals for suspected cancer

ObjectivesTo distinguish between variation in referral threshold and variation in accurate selection of patients for referral in fast-track referrals for possible cancer. To examine factors associated with threshold and accuracy...

Consumer Activities and Reactions to Social Network Marketing

The purpose of this paper is to understand consumer behavioral models with respect to their reactions to social network marketing. Theoretical background was focused on online and social network usage, motivations and behavior. The research goal is to explore consumer reactions to the exposure of social network marketing based on the following criteria: level of brand engagement, WOM referral behavior, and purchase intentions. Consumers are investigated on the basis of their attitudes toward social network marketing and basic socio-demographic covariates using data from a sample size of 700 Bulgarian respondents (age group 21-54 years, Internet users, urban inhabitants). Factor and cluster analyses are applied. It was found that consumers are willing to receive information about brands and companies through social networks. They like to talk in social networks about these brands and companies and to share information as well (factor 2, brand engagement). Internet users are willing to share information received through social network advertising (factor 1, WOM refferal behavior) but they would not buy a certain brand as a result of brand communication activities in social networks (factor 3, purchase intention). Several practical implications regarding marketing activities through social networks are drawn.

How Incentive Structure Affects the Effectiveness of Referral Strategy: Evidence from a Randomized Field Experiment on a Lending Platform

Large and high quality user base is an important determinant of firm performance. Firms spend a great amount of resources in building referral programs to grow user base. Yet, substantial variations exist in the effectiveness of these referral programs with various incentive structures. We argue that the extent to which referral programs can grow user base depends on how existing users evaluate the cost and benefit of their referral behavior. Using a large-scale randomized field experiment with around one hundred thousand participants on one of the largest P2P lending platforms in China, we find that referral programs structured as self-benefit (egoistic) appeal or other-benefit (altruistic) appeal significantly reduce the number of new users brought by the existing users but new users from other-benefit appeal made more investment. Our study demonstrates that under certain circumstances, these referral programs structured as egoistic or altruistic incentive structure may backfire.

Theory of planned behaviour: general practitioners’ prescribing and referral behaviour

Rationale and aims: The vast majority of patients seen in general practice present with a mental health component to their illness. Despite current clinical guidelines, suggesting referral to psychological-based treatments being a more appropriate course of action, anti-depressant prescription remains high for those suffering common mental health problems (CMHPs). This study aimed to investigate General Practitioners’ (GPs) behaviour regarding the prescription of antidepressants and referral to psychological-based treatment for individuals with CMHPs, using the Theory of Planned Behaviour (TPB). Method: Online and postal questionnaires were developed in line with the TPB model following consultation, pilot study and cognitive debriefing. Questionnaires were distributed to all working GPs in Wales, UK. Data underwent statistical analysis.Results: Analysis of responses (n=127) showed a GP’s decision to prescribe antidepressants to patients with CMHPs is significantly influenced by both ‘attitude’ and ‘subjective norm’, while perceived behavioural control was non-significant. Over half of the study GPs did not feel in control of prescribing antidepressants to those with CMHPs. GPs’ intention to refer for psychological-based treatment was significantly influenced by attitude, while further analysis showed GPs did not feel in control of referring for psychological-based treatment.Conclusion: Using TPB helped to explain GPs’ antidepressant prescribing and referral to psychological-based treatment behaviours. GPs’ intention to prescribe and refer were shown to be moderated by behavioural and normative beliefs, while control beliefs were non-significant. The presence of personal experience as a predictable feature to prescribing and referral behaviour is something that could figure more prominently within early phases of medical training.

Intention to Enact and Enactment of Gatekeeper Behaviors for Suicide Prevention: an Application of the Theory of Planned Behavior

Gatekeeper training for suicide prevention was evaluated on a college campus to examine the impact of training on gatekeeper enactment of behaviors in support of suicide prevention and identify predictors of enactment of gatekeeper behaviors. Trained gatekeepers (N=216) displayed greater perceived knowledge and self-efficacy for suicide prevention and reported higher rates of self-reported actual gatekeeper behaviors, including inquiring about suicidal ideation and referring for mental health treatment when they encountered someone in distress, compared to their untrained counterparts (N=169). Consistent with the Theory of Planned Behavior, SEM results indicated that attitudes, self-efficacy, and perceived knowledge explained intentions to engage in gatekeeper behaviors, accounting for 59% of the variance in intentions to inquire about suicidal ideation and supporting the role of attitudes and perceived behavioral control in intentions to act. These intentions explained self-reported actual gatekeeper behaviors among participants who encountered someone in distress, with each one-point increase in intention associated with nearly twice the likelihood of both inquiring about suicidal ideation and referring someone for mental health care. On the other hand, self-reported situational barriers were associated with a decreased likelihood of referral behavior, indicating the role of actual behavioral control over volitional actions. Findings support the value of gatekeeper training for promoting factors that influence the likelihood of action on behalf of suicide prevention.

A Cross-sectional Analysis of Motivation and Decision Making in Referrals to Lifestyle Interventions by Primary Care General Practitioners: A Call for Guidance.

To explore (1) general practitioners' (GPs') motivations to refer to lifestyle interventions and to investigate the association between GPs' own lifestyle behaviors and their referral behavior and (2) patient indicators in the decision-making process of the GPs' referral to lifestyle interventions. A cross-sectional study was conducted among 99 Dutch primary care GPs. Their motivation to refer was assessed by beliefs regarding lifestyle interventions. GPs' referral behaviors were assessed-considering referral and self-reported actual referral-as well as their own lifestyle behaviors (physical activity, dieting, being overweight). Decision making regarding referring patients to lifestyle interventions was assessed by imposed patient indicators, spontaneously suggested decisive patient indicators, and case-based referring (vignettes). A substantial group of GPs was not motivated for referral to lifestyle interventions. GPs' referral behavior was significantly associated with their perceived subjective norm, behavioral control, and their own physical activity and diet. Most important, patient indicators in referral to lifestyle interventions were somatic indicators and patients' motivation for lifestyle interventions. GPs' motivation and referral behavior might be improved by providing them with tailored resources about evidence-based lifestyle interventions, with support from allied health professionals and with official guidelines for a more objective and systematic screening of patients.

Abstract C79: Use of social network analysis to examine racial disparities in screening colonoscopy referral

Abstract Background: In Illinois for the year 2016, colorectal cancer (CRC) is projected to cause 2,030 deaths, making it the leading cause of non-tobacco related cancer mortality. African American (AA) Illinois residents have an approximately 7% greater incidence and a 30% higher mortality rate when compared to white residents. Guideline consistent routine screening is known to reduce death related to CRC. Screening colonoscopy is the most commonly performed CRC screening test. However, African Americans are known to have lower rates of both screening and diagnostic colonoscopy completion compared to whites. Chicago's South Side includes 34 of the city's 77 recognized community areas and is home to a combined population of more than 800,000 residents, of whom greater than 75% are African American. The contiguous communities that make up the South Side cover approximately 60% of Chicago's land area. There are 41 facilities throughout Chicago that perform outpatient screening colonoscopy, of with 13 (32%) are located on Chicago's South Side. The University of Chicago Medical Center (UCMC) is the largest healthcare provider on the South Side and represents 30% of the local capacity for screening colonoscopy services. Objective: The objectives of this study were to use social network analysis (SNA) to explore the structure of the screening colonoscopy referral network utilized by community-based primary care physicians for colonoscopies that were completed at the UCMC during calendar years 2013 and 2014. Methods: A retrospective chart review was performed for all individuals who completed a screening colonoscopy during years 2013 and 2014 at the UCMC. Screening colonoscopies were identified using CPT codes: G0105 and G0121. For each screening colonoscopy procedure, the referring PCP and colonoscopy provider (colonoscopist) were identified from screening colonoscopy procedure reports. A referral-tie was assigned between a PCP and colonoscopist, if the PCP's name was listed as the referring physician on the procedure report and the colonoscopist's name was listed as the performing physician. SNA was performed using UCINet for windows and network mapping was performed using Netdraw. Descriptive statistics were performed using STATA 13.1. Results: 405 outpatient screening colonoscopies were completed during the study interval (mean age, 58.4 ± 10 years; 62% female; 40% AA, 44% white). 60% of patients were privately insured, 31% Medicare, and 10% were public insurance or uninsured. A total of 261 individual community PCPs were identified as referring physicians, with a mean frequency of referrals/PCP of 1.18 ± 0.85 and a range of 1 referral up to 25 referrals. Following a SNA of PCP to colonoscopist referral ties, the resulting referral network exhibited a core/periphery structure. 13 PCPs (5%) belonged to the network core and 248 (95%) belonged to the network periphery. PCPs who belonged to the network core had a greater mean referral rate compared to the periphery (3.77 vs. 1.05 referrals; p<0.001). PCPs who belonged to the network core accounted for 24% of referrals for AA patients versus 4% for whites (p<0.001). Conclusions: The screening colonoscopy referral network at the UCMC exhibits a core/periphery structure. Amongst AA patients, screening colonoscopy referrals were disproportionately clustered within the network core amongst a highly inter-connected group of community-based PCPs. This variation in referral patterns indicates that patient characteristics, such as race, may affect the structure of the screening colonoscopy referral network. These variations in the structure of the referral network may impact PCP referral behavior and subsequently patient recommendation for and utilization of CRC screening. Screening colonoscopy referral networks may represent an under-recognized determinant of racial disparities in CRC screening. Citation Format: Keith B. Naylor, Olufemi Kassim, Karen E. Kim, John Schneider. Use of social network analysis to examine racial disparities in screening colonoscopy referral. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C79.

Characterization of U.S. State Laws Requiring Health Care Provider Reporting of Perinatal Substance Use

BackgroundState policies pertaining to health care provider reporting of perinatal substance use have implications for provider screening and referral behavior, patients’ care seeking and access to prenatal substance use disorder treatment, and pregnancy and birth outcomes. ObjectivesThis study sought to characterize specific provisions enacted in state statutes pertaining to mandates that health care providers report perinatal substance use, and to determine the proportion of births occurring in states with such laws. MethodsWe conducted a systematic content analysis of statutes in all U.S. states that mentioned reporting by health care providers of substance use by pregnant women or infants exposed to substances in utero; inter-rater reliability was high. We calculated the number of states, and proportion of U.S. births occurring in states, with processes for mandatory reporting of perinatal substance use to authorities, and substance use disorder treatment provision for individuals who are reported. ResultsTwenty states (corresponding with 31% of births) had laws requiring health care providers to report perinatal substance use to child protective authorities, and four states (18% of births) had laws requiring reporting only when a health care provider believed the substance use was associated with child maltreatment. About one-half of states (13) with any reporting law had a provision promoting substance use disorder treatment in the perinatal period. ConclusionsFindings inform the ongoing debate about how health policies may be used to reduce the population burden of perinatal substance use.

Referrals for new client acquisition in professional services

PurposeThe purpose of this paper is to address the following research question: What are the perceptions of professionals and consumers regarding the antecedents of client referrals in the financial advice sector?Design/methodology/approachA total of 61 qualitative interviews were conducted, with the following three key groups: independent financial advisers (IFAs; 20 interviews), clients of IFAs (26 interviews) and consumers who manage their own financial affairs and do not use the services of an IFA (15 interviews).FindingsThe financial advisers interviewed believe that client referrals are important to their business success, that they can influence clients to become ambassadors who will consciously seek out new clients and that excellent service will motivate clients to provide referrals. However, the interviews with the clients painted a different picture. While advisers believe that they can influence client referral behavior, the clients did not believe that they were influenced by the adviser to make referrals.Research limitations/implicationsThe sampling method was non-random and relied on the professional contacts of the principal researcher as a starting point, from which a network of contacts was established to identify interviewees. The study casts doubt on the ability of professional service providers to influence client referral behavior. This novel finding deserves further research investigation.Practical implicationsThere is clearly scope for greater measurement in connection with referrals in professional service businesses. The propensity for clients to refer should be included as a metric in the performance measurement of professional service providers, in addition to standard financial measures. This would encourage the service provider to consider referrals during client interactions.Originality/valueThe study reports on a substantial qualitative study involving both professional service providers and their clients. While the providers believe that client referrals are critical to their business success, the evidence collected provides little or no support for this belief. Clients report they are not motivated to refer. Advisers do not explicitly measure referrals. The reality of referrals seems not to match the mythology.

Epidemiology of child mortality in a tertiary hospital, New Delhi

Background: India accounts for 21% death among under-five children but the profile of the children admitted in tertiary hospitals is poorly documented. We conducted secondary analysis of all hospital admissions in pediatrics wards for 1½ years to understand outcomes in different age groups. Methods: Data from October 2014 to March 2016 were retrieved and analyzed, with a focus on the age distribution at admission and death, duration of stay and outcome. Results: Almost 10% admitted children died and another 15% left the hospital before completing treatment. The analysis of 2135 deaths suggests that half of the children died within 24 h of admission. Death rate was highest among children on their 1st day of life (39%), and it reduced gradually with increase in age. Infants share 71% of all the deaths. Conclusion: Maximum death within 1st day of admission demands a further review of our referral system and health seeking behavior.

Effects of suspicion on the perception of online referrals: the role of congruity and message sidedness

This research investigates how a consumer's suspicion that an online referral may result from marketers' involvement affects referral persuasiveness. Two referral characteristics are examined in this regard: referral congruity and message sidedness. It is demonstrated that referral congruity can motivate consumers to question the authenticity of online referrals and that message sidedness determines subsequently the type of motive attributed to observed referral behaviour. It is further shown that the perceived referral motive affects attitudes toward the recommended item as well as purchase intentions. Based on the findings implications are drawn for planning effective referral campaigns.