Referral Outcomes Research Articles

Time taken for cardiology care and one-year results for primary care physicians' referrals for cardiology consultation in heart failure patients: clinical implications for heart failure management

Abstract Background and Purpose The clinical trajectory of patients with heart failure (HF) is characterised by frequent episodes of decompensation requiring urgent medical assistance, hospitalisations, and an increased risk of mortality. HF clinical guidelines recommend early visits by health professionals after hospital discharge, yet little evidence exists regarding the associations between delayed medical attention and outcomes in HF patients. To assess the clinical impact of the time taken to receive cardiology care for referrals from primary care physicians (PCPs) to a cardiology department in HF patients, we selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021. Methods Using an interrupted time series regression model, we analysed the impact of integrating e-consultations into the healthcare model (implemented in 2013) and evaluated the time taken to receive cardiology care, as well as all-cause, cardiovascular (CV), and HF-related hospital admissions and mortality. The primary objective of this analysis was to examine the associations between delays in cardiology care following a PCP referral and 1-year outcomes (HF-related, cardiovascular, and total hospitalisations; and HF-related, cardiovascular, and total mortality). Results Almost 50% were women, and the mean age was 77.8 years. Arterial hypertension (79.6%), diabetes (34%), atrial fibrillation (51.4%), ischemic heart disease (20.4%), and cerebrovascular disease were the most prevalent comorbidities. The mean time from PCP referral to cardiology consultation in the overall population was 22.3 days: <8 days in 53.9%, 8-14 days in 17.1%, 15-30 days in 15.9%, and >30 days in 13.0% of patients, respectively. One year after cardiology consultation, 68.6% of patients required assistance in an Emergency Department; 22.5% were hospitalised for any cause, 14.9% for cardiovascular reasons, and 9.2% for HF-related issues. Moreover, total mortality at 1-year was 8.6%, comprising 4.3% cardiovascular mortality and 1.3% HF-related deaths. Multivariate analysis of the relationship between the time taken to receive cardiology care and 1-year outcomes revealed a significant increased risk associated with a longer delay in cardiology assistance, particularly evident in the subgroup of patients with previous hospital admissions due to worsening HF (see Table). Conclusions Throughout the follow-up period, a reduced time taken to receive care was independently associated with better 1-year outcomes. We believe that our experience can contribute to the development of a more efficient ambulatory care pathway for HF patients, especially those at high risk, such as those with a history of hospitalisation due to worsening events. Our findings further support the clinical guideline recommendation for early contact by health professionals following hospital discharge, extending it to include PCP referrals for cardiology consultations.

The Impact of the COVID-19 Lockdown on Cancer Referrals in Primary Care in the UK: Two Years On

Background: Cancer is common, with most cancer patients presenting initially to a general practitioner. The COVID-19 pandemic led to changes in the delivery of primary care, which could have affected cancer referrals. This observational study looked at two-week cancer referrals (2WRs) made before, during and after the first UK COVID-19 lockdown in 2020, at a GP practice in the Wirral, England. Methods: A search was conducted to find the cancer referrals made between 23rd March 2020 - 1st July 2020, during the first lockdown. Using the same methodology, cancer referral data was collected for the corresponding time periods in 2019 and 2021. The number of 2WRs and positive diagnostic yields were then compared. Results: The number of cancer referrals decreased by 40.4% in 2020, compared to 2019. In 2021, the number of referrals then increased by 225%, compared to 2020. Overall, the number of cancer referrals increased between 2019-2021. The positive diagnostic yield for the 2020 2WRs increased by 251.4%, compared to that of 2019. The calculated yield for the 2021 data then decreased by 10.8% compared to 2020. Overall, the positive diagnostic yield increased between 2019-2021. Conclusion: The numbers and outcomes of cancer referrals at this Wirral GP practice have changed considerably following the first UK COVID-19 lockdown in 2020, and the influence of the pandemic was still affecting cancer referrals in 2021. A greater focus on early cancer detection in primary care could help overcome the ways in which the pandemic has affected primary care delivery.

COVID-19 Pandemic Impact on Uro-Oncological Disease Outcomes at a German Referral Center

Introduction: To assess differences in referral and pathologic outcomes for uro-oncology cases prior to, during, and after the COVID-19 pandemic, comparing clinical and pathological data from cancer surgeries performed at a university medical center between 2018 and 2023. Methods: We collected data of 212 patients with radical prostatectomy (RP) for prostate cancer, 157 patients with radical cystectomies (RCs) for bladder cancer, 36 patients with radical nephroureterectomies (RNUs) for upper tract urothelial carcinoma, 133 patients with partial nephrectomies (PNs), and 160 patients with radical nephrectomies (RNs) for renal cancer, 93 patients with orchifunicolectomy for testicular cancer, 39 patients with newly diagnosed penile cancer. Data from patients treated between 2018 and February 2020 (before the COVID-19 pandemic) were compared with data from patients treated between March 2020 and March 2022 (during the COVID-19 pandemic) and between April 2022 and February 2023 (after the COVID-19 pandemic). Results: No differences in terms of main pathologic features were observed in patients undergoing RP, RNU, orchifunicolectomy, or circumcision and/or penectomy. Further, a lower pathological tumor stage was diagnosed for RN after the COVID-19 pandemic (p < 0.05). A higher age at diagnosis for penile cancer was observed during the pandemic cohort in comparison to the pre-COVID-19 pandemic cohort (p < 0.05), but this did not translate into a worse pathological stage or lymph node involvement. Another notable change was the shortening of the length of stay (LOS) for orchifunicolectomy over the pandemic (p < 0.05). Conclusion: Neither decline in uro-oncologic activity nor pathological features were observed at our institution before, during, and after the COVID-19 pandemic. A significantly lower pathological tumor stage for RN after the COVID-19 pandemic was seen. Penile cancer was diagnosed at a significantly higher age during the COVID-19 pandemic, and a decrease in LOS for orchifunicolectomy was observed.

Physician-to-Physician eConsultations to Ophthalmologists at an Academic Medical Center.

Physician-to-physician electronic consultation (eConsults) are used across specialties; however, their effectiveness in ophthalmology has not been reported. This study evaluated the feasibility and diagnostic accuracy of a physician-to-physician ophthalmology eConsult program, assessed the timeliness of in-person evaluation, and characterized the clinical questions of non-ophthalmology providers. Retrospective review of patients for whom an ophthalmology eConsult was placed to Massachusetts Eye and Ear from February 2019-August 2021. The eConsults were reviewed to identify submission-to-response time, primary diagnoses by eConsultant, and referral outcomes. The eConsults were categorized based on clinical question, urgency, and ophthalmic condition addressed. Demographic data on patients and referring providers were collected. One hundred ophthalmology eConsults were placed, and 100% were responded to by an ophthalmologist. An average of 1.6 ± 1.9 days elapsed from the time of eConsult to completion. Of the 30 patients who presented for in-person evaluation at an ophthalmology clinic, diagnostic concordance between eConsultant and in-person ophthalmologist was observed in 93% of cases (n = 28 of 30). An average of 28.9 ± 27.4 days from eConsult response to in-person follow-up was observed. The most common clinical inquiries were about appropriate triage/referral (24.4%), management (22%), and diagnosis (19.7%). All eConsults were non-urgent. The most common ophthalmic condition addressed was chalazia/hordeola (14%). Only 5% of patients presented to an emergency department for the same ophthalmic concern addressed by eConsult. Ophthalmology eConsults provide timely access to nonurgent ocular diagnosis, triage, and management and in our study seem to provide high rates of diagnostic accuracy for nonurgent ophthalmic conditions. Using ophthalmic eConsults can facilitate timely access to specialty care and reduce patient and provider burden.

The Transition of Patients with an ACE: Referral Pathway and Outcomes

AimsTransition of paediatric patients is challenging. This study aimed to assess the transition pathway for patients who underwent an ACE procedure as a child and to understand ongoing support requirements. MethodsA retrospective review was conducted of all patients on the Pelvic Floor Clinical Specialist Nurse’s (PFCNS) database from a tertiary adult hospital. Patients receiving their ACE as an adult or patients who did not attend any outpatient appointments (OPAs) were excluded. Data was gathered on complications, additional procedures and outcomes. ResultsSixty-three patients met the inclusion criteria. The median age at referral to an appropriate team was 18 years but the median age of referral to the PFCNS was 23 years. Only 7(11 %) were referred to the PFCNS by Paediatric Services. Patients experienced a variety of problems including change in equipment (n = 38, 60 %), change in washout regime (n = 28, 44 %), ACE leakage (n = 15, 24 %), stenosis (n = 15, 24 %) and ineffective washouts (n = 11, 17 %). Of those where data was available, there was a median of 7 PFCNS and 2.5 Colorectal Consultant (CC) OPAs per patient. Surgical intervention was common including procedures to the ACE (n = 8, 13 %), excision of ACE (n = 5, 7.9 %) manual evacuation (n = 5, 7.9 %) and formation of a stoma (n = 1%). 35 (56 %) were still using their ACE with a median time since transition of 11 years. ConclusionPatients with an ACE need considerable ongoing support yet few are appropriately transitioned. There needs to be a clear transition pathway for these patients to the PFCNS and if appropriate a CC.

Development of a novel cancer diagnostic center to facilitate care coordination for patients with new or suspected diagnoses of cancer.

81 Background: Navigating a cancer diagnosis is a multifaceted challenge, characterized by intricate care coordination that creates potential for workup and treatment delays, lapses in care, and potentially negatively affecting clinical outcomes. We have developed a novel physician and advanced practitioner-led cancer diagnostic program (CDP) to help navigate patients with a suspected cancer through the diagnostic and staging workup, discussion of results, and linkage to oncologic care. Patients are referred to the CDP, an administrative intake coordinator creates a medical chart, verifies insurance, gathers records, and schedules appointments. An intake nurse reaches out within 24 hours to obtain clinical information and review of systems. Patients are offered an in-person or video visit with the advanced practitioner for history and physical, labs, and further coordination of testing. Here, we aim to describe the demographic and clinical patterns of referral and clinical outcomes of patients who were referred to a CDP over one calendar year. Methods: We retrospectively analyzed 154 patients with a new cancer diagnosis to have at least 1 encounter at the Johns Hopkins CDP between January 1, 2022, and December 31, 2022. Data were retrospectively collected from medical records and stored within Johns Hopkins REDCap. Descriptive analyses were used to describe the data. Results: Among the 154 total patients included in this analysis, 65.6% were White, 24.7% were Black, 3.2% were Asian, and 1.9% were of Hispanic, Latino, or Spanish origin. Insurance coverage was most frequently (46.8%), Medicare (40.3%), and Medicaid (8.4%). Referral distribution shows 50 inpatient and 104 outpatient referrals. Primary cancer diagnoses were most often gastrointestinal (39.6%), upper airway and lung (26.6%), and genitourinary (9.1%). Conclusions: The Johns Hopkins CDP exemplifies the potential for dedicated diagnostic and treatment initiation programs to improve oncologic care, particularly for vulnerable populations. The center facilitates expedited diagnostic resolution, to increased ease of workup for patients and providers, and potentially improve clinical outcomes such as linkage to care and time to treatment. Accepting referrals from inpatient and outpatient settings captures a broad patient pool, including those who may otherwise experience lapses in care owing to complex care navigation needs. In conclusion, we describe a novel care delivery model to potentially optimize healthcare delivery in oncologic care. Inpatient Referral Outpatient Referral Percent minority populations 34% 23.1% Stage 4 at diagnosis 74% 52.9% Patients initiating treatment with curative intent 42.3% 30% Median length of hospitalization 7 days N/A Median time from pathology results to discharge -2.5 days N/A Median time from pathology results to treatment initiation 20 days 16.5 days

Outcomes of Dementia Pathway Referrals Post Comprehensive Geriatric Assessment by a Community Specialist Team for Older Persons

Abstract Background The Model of Care for Dementia in Ireland (2023) outlines targets and recommendations for a Dementia service. A Dementia pathway was developed from a Community Specialist Team (CST) for Older Persons service to a local Memory Clinic service and this was evaluated with reference to the model of care. Methods All adults aged ≥70 years, who received a Comprehensive Geriatric Assessment (CGA) by a CST in 2022, and were referred to a Memory Clinic service, were included. Data including dates of referral and Memory Clinic attendance, age, gender, Clinical Frailty Scale score (CFS) and diagnosis were entered into Excel. These were analysed using descriptive statistics. Results Seventy-nine patients were referred to the Memory Clinic. Twenty-eight (35.5%) attended, with 51 (64.5%) non-attendances. Twenty-seven (34%) cancelled, 13 (16.5%) did not attend, 7 (9%) died before receiving an appointment, and 4 (5%) appointments were deferred at patient request. The mean age of patients referred was 82.39 years (SD=6.876). The male to female ratio of attendees was 1:1.3 and non-attendees was 1:1.9. The median CFS score of both attendees and non-attended was 5 (range 3-7). Eight (21%) of those who did not attend had moved to long term care, representing 10% of total referrals. The median waiting time for attendees was 10.5 months (Range 2-21). Thirteen (46%) patients received a diagnosis of Dementia, 3 (11%) Mild Cognitive Impairment (MCI), 2 (7%) Acquired Brain Injury and 10 (36%) received no memory diagnosis. Conclusion This Dementia pathway does not meet target 14 of the Model of Care. The waiting times exceed 6 weeks, resulting in missed opportunities to provide supports. Timely access to the pathway and supports to attend may increase attendance. A dedicated Memory Assessment and Support Service will address this deficit.

FP1.3 - SPEC MDT in Aneurin Bevan University Health Board

Abstract Aims The SPEC (significant polyp and early cancer) multi-disciplinary team (MDT) meeting was started in ABUHB in 2022 to discuss complex colonic and rectal polyp cases, such as polyps &amp;gt;20mm, likely to be sessile, or difficult to remove endoscopically. The aim was to evaluate the effectiveness and clinical role of the SPEC MDT. Methods Data for patients discussed in SPEC MDT since its conception in January 2022 until September 2023 was retrospectively collected from the SPEC MDT database, a prospectively collected database. This included patient demographics, reason for referral, polyp characteristics and MDT outcomes. Results In 21 months, there have been 38 SPEC MDTs, with 355 cases discussed (average of 9 cases per MDT). There was at least one laparoscopic colorectal surgeon, gastroenterologist and a histopathologist in every MDT in accordance with BSG guidelines. Main referral reasons included endoscopy findings (72%) and re-discussion post-procedure (22%). Twenty-three patients had adenocarcinomas and three had NETs. MDT outcomes were EMR (23%), endoscopic surveillance (21%), clinic to discuss (no) surgery (19%), TAMIS (16%), urgent endoscopy (13%) or other (8%). Conclusion As the busiest Health Board in Wales for Colorectal Cancers, the formation of SPEC MDT has been an important step in improving the detection and treatment of advanced polyps and early cancers. Although too early to measure the impact on early cancer detection rates and improved decision making for these patients, formalising the MDT process in line with BSG guidelines has been an important step in improving the service offered to patients.

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

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

Snakes and Ladders: The experience of being referred to and seen by Child and Adolescent Mental Health Services

BackgroundReferral processes in Child and Adolescent Mental Health Services (CAMHS) have been reported as stressful and inadequate by young people and parents/carers, who struggle during waiting periods for the referral outcome decision. The Covid19 pandemic was an unprecedented time of distress for young people, parents/carers, and healthcare staff, with increased mental health challenges and stretched staff having to adapt modes of care, thus exacerbating difficulties for CAMHS. AimThis qualitative study aimed to capture the unique lived experiences of young people, parents/carers, and CAMHS staff during the referral process in the peak of the Covid19 pandemic. MethodsAs part of the STADIA trial, between 2020 and 2022, 109 semi-structured interviews across 8 NHS sites were conducted with young people (aged 16–17), parents/carers, and NHS staff including clinicians, commissioners, managers, and researchers embedded in clinical services. Interviews were analysed using thematic analysis. ResultsThree themes were elicited to express young people, staff, and parents/carer experiences of the referral process, CAMHS, and the impact of Covid19: 1) referral as a starting point; 2) changes to methods of appointment delivery and their effect on CAMHS experience; and 3) experiences and evaluation of services. ConclusionAlthough CAMHS was seen as the pinnacle of mental health support, there was dissatisfaction with waiting times, limited communication, unclear referral processes, and limited clinical capacity and resources for young people, parent/carers, and staff. Covid19 forced CAMHS into adapting to a hybrid model of care, increasing accessibility for young people, parents/carers and staff and highlighting areas for improvement. Secure and consistent support and increases in staff resources are essential to address challenges with CAMHS delivery and improve the experiences of young people, parent/carers, and staff.

507 Assessing the Standard of Referral Letter Documentation and Outcomes of Claudicants in the Vascular Outpatient Clinic

507 Assessing the Standard of Referral Letter Documentation and Outcomes of Claudicants in the Vascular Outpatient Clinic

An analysis of referral patterns of traumatic brain injury at Groote Schuur Hospital Trauma Centre.

Traumatic brain injury (TBI) can result in significant morbidity and mortality if not diagnosed in a timely manner. Brain computed tomography (CT) is the diagnostic gold standard but is of limited availability in most South African public hospitals, resulting in transfer of TBI patients to tertiary hospitals. To describe the referral patterns and outcomes of patients with TBI referred to Groote Schuur Hospital Trauma Centre. This was a retrospective audit of all patients admitted to the Trauma Centre who had a brain CT scan for suspected TBI between 1 February 2022 and 31 March 2022. Demographic data (age, sex), mechanism of injury and Glasgow Coma Score were recorded. Referral pathways were determined, and final disposition of patients was recorded. A total of 522 patients had a brain CT for TBI. Of these, 314 (60.1%) were referred from other hospitals. CT scan was abnormal in 178 (34.1%) patients. Three hundred and two (58.6%) were discharged home within 24 hours. The mean time between referral and CT scan was 13 hours. More than half of patients referred for a CT scan were discharged from the Trauma Centre within 24 hours of admission, which indicates additional costs and inefficiencies in the health system. These data are useful to guide resource planning and allocation for district hospitals, since less expensive point-of-care modalities now exist to diagnose TBI, and which are useful in indicating the prognosis of patients.

Digital innovation for cancer risk assessment allows large-scale service redevelopment of regional cancer genetics service delivery.

Family-history assessment can identify individuals above population-risk for cancer to enable targeted Screening, Prevention and Early Detection (SPED). The online patient-facing cancer Family History Questionnaire Service (cFHQS) is a digitalised, resource efficient tool for family history data capture to facilitate this. The capturing of digital data from cFHQS allows for data interrogation of patients referred to Clinical Genetics for the purposes of service improvement. Digital data from 4,044 cFHQS respondents over a three-year period was collected and interrogated with respect to the number and type of familial tumour diagnoses to enable service improvement and streamlining of referral pathways. 81% of colorectal and 71% of breast screening assessments were population- or moderate-risk. Most patients who completed cFHQS reported more than one diagnosis of cancer/tumour/polyps in their family. 2.5% of family history assessment patients had a second indication that required assessment that would have been missed if single tumour type assessment was undertaken. Implementation of an innovative, digital family history data collection pathway has allowed large scale interrogation of referral patterns and assessment outcomes to enable service development. The high volume of inappropriate referrals to Clinical Genetics for population and moderate risk patients highlighted the need for dedicated secondary care pathway provision for these patients. The use of cFHQS streamlined family history assessment allows for redistribution of resources to improve equity and access to genetic cancer risk assessment.

Rural-Urban mild cognitive impairment comparison in West Michigan through EHR.

Mild cognitive impairment (MCI) is a significant public health concern and a potential precursor to Alzheimer's disease (AD). This study leverages electronic health record (EHR) data to explore rural-urban differences in MCI incidence, risk factors, and healthcare navigation in West Michigan. Analysis was conducted on 1,528,464 patients from Corewell Health West, using face-to-face encounters between 1/1/2015 and 7/31/2022. MCI cases were identified using International Classification of Diseases (ICD) codes, focusing on patients aged 45+ without prior MCI, dementia, or AD diagnoses. Incidence rates, cumulative incidences, primary care physicians (PCPs), and neuropsychology referral outcomes were examined across rural and urban areas. Risk factors were evaluated through univariate and multivariate Cox regression analyses. The geographic distribution of patient counts, hospital locations, and neurology department referrals were examined. Among 423,592 patients, a higher MCI incidence rate was observed in urban settings compared to rural settings (3.83 vs. 3.22 per 1,000 person-years). However, sensitivity analysis revealed higher incidence rates in rural areas when including patients who progressed directly to dementia. Urban patients demonstrated higher rates of referrals to and completion of neurological services. While the risk factors for MCI were largely similar across urban and rural populations, urban-specific factors for incident MCI are hearing loss, inflammatory bowel disease, obstructive sleep apnea, insomnia, being African American, and being underweight. Common risk factors include diabetes, intracranial injury, cerebrovascular disease, coronary artery disease, stroke, Parkinson's disease, epilepsy, chronic obstructive pulmonary disease, depression, and increased age. Lower risk was associated with being female, having a higher body mass index, and having a higher diastolic blood pressure. This study highlights rural-urban differences in MCI incidence and access to care, suggesting potential underdiagnosis in rural areas likely due to reduced access to specialists. Future research should explore socioeconomic, environmental, and lifestyle determinants of MCI to refine prevention and management strategies across geographic settings. Leveraged EHRs to explore rural-urban differences in MCI in West Michigan.Revealed a significant underdiagnosis of MCI, especially in rural areas.Observed lower rates of neurological referrals and completions for rural patients.Identified risk factors specific to rural and urban populations.

CSP2023: 298 - Evaluation of the appropriateness and outcomes of MRI referrals in a Physiotherapist led acute soft tissue knee clinic

CSP2023: 298 - Evaluation of the appropriateness and outcomes of MRI referrals in a Physiotherapist led acute soft tissue knee clinic

The Appropriateness and End Outcomes of Urgent Referrals to Outpatient General Adult Psychiatry

The Appropriateness and End Outcomes of Urgent Referrals to Outpatient General Adult Psychiatry

Emergency Department Referral of Patients With Chest Pain for Noninvasive Cardiac Testing and 2-Year Clinical Outcomes.

Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing. A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events. Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48-68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02-1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99-1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%). Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population.

Outcomes of paediatric and adolescent referrals into a specialist breast unit

Outcomes of paediatric and adolescent referrals into a specialist breast unit

Outcomes of advice and guidance referrals to a large breast surgery service

Outcomes of advice and guidance referrals to a large breast surgery service

Two decades of recipient and donor referrals for heart transplantation to Groote Schuur Hospital, Cape Town, South Africa: A retrospective study.

Heart transplantation in South Africa faces numerous challenges related to organ scarcity and unequal access to advanced heart therapy. There is an urgent need to analyse the current transplant referral pathway to optimise equitable access to transplantation. To provide an audit of heart transplant referrals to Groote Schuur Hospital, Cape Town, over a 23-year period, focusing on patient demographics, indications for referral, waiting-list dynamics, and transplant referral outcomes. The study utilised a retrospective patient folder review for the period 1 January 1997 - 31 December 2019 and audited the trends in heart transplant referrals and associated outcomes of the referral at a tertiary academic hospital. A total of 625 recipients were referred for heart transplantation, with the majority being male (n=412; 65.9%), while gender was undocumented for 69 cases (11.0%). The mean age was 38.1 (14.6) years, and 153 (24.5%) were listed for transplant, while 215 (34.4%) were deemed ineligible for listing. Contraindications for listing included social (n=106; 49.3%), medical (n=83; 38.6%) and psychological (n=26; 12.0%) factors, while 134 patients (21.4%) were considered too well. Poor social circumstances (n=38; 39.6%), poor insight (n=28; 29.2%) and poor compliance (n=21; 21.9%) were the most common non-medical reasons for not listing recipients, while obesity (n=30; 31.3%) and smoking (n=23; 24.0%) were notable medical contraindications. Forty-nine patients (7.8%) died during work-up, while 130 (85.0%) of the listed patients received a heart transplant. Of the 429 donor referrals, 139 (32.4%) were accepted for organ procurement. Reasons for declining donors included unsuitability for transplantation (30.3%), lack of capacity (1.8%), and recipient-donor mismatch (66.9%). Three-quarters of the referred patients were deemed unsuitable for heart transplantation for medical and/or social reasons. The ratio of referral to listing has decreased over time. However, once listed, the likelihood of receiving a transplant was high.