Judicious resource managers or administrative intermediaries: A systematic review of family physician perspectives on the administrative process of referring patients to other clinicians in high income countries.

In the antiretroviral therapy era, as people living with HIV (PWH) age, the decline of HIV-associated dementia has been accompanied by a growing burden of earlier Alzheimer-type pathology and other milder, heterogeneous cognitive impairments, underscoring the need for proactive detection and multidisciplinary management within routine HIV care. Yet, cognitive care remains largely absent, particularly in low- and middle-income countries (LMIC). We evaluated readiness to integrate a multidomain cognitive-rehabilitation program into tertiary HIV clinic in Malaysia and identified implementation determinants. We used a sequential mixed-methods design. An online Knowledge-Attitude-Practice survey was distributed to all infectious-disease physicians nationwide (N = 94). Qualitative data were generated through focus-group discussions with health care providers (HCPs) and in-depth interviews with PWH aged >40 years. Transcripts were analyzed thematically using the Consolidated Framework for Implementation Research (CFIR 2.0). Forty-nine physicians responded (52.4% response), median age was 44 years (inter-quartile range (IQR) 38-51), and 71.4% were female. While 71-82% demonstrated satisfactory knowledge and attitudes toward cognitive health, 88% reported poor practice; only 20.5% routinely screened older PWH. Thirty-three HCPs from multidisciplinary backgrounds participated in five focus groups, alongside 19 in-depth interviews with PWH. Three interlinked domains emerged: (1) knowledge-practice gap related to uncertainty around screening tools, referral pathways, and evidence applicability; (2) systemic barriers including time constraints, high caseloads, lack of guidelines, and workforce limitations; and (3) stigma affecting acceptability. Facilitators included strong patient motivation for brain health, allied health upskilling, physician-initiated referrals, and dedicated care coordination. Integration of multidisciplinary cognitive rehabilitation is hindered by modifiable structural deficits in knowledge translation, workforce organization, and guideline support. HIV-adapted screening algorithms, formalized referral processes, and task-shared coordinator roles could enable earlier cognitive interventions for older adults living with HIV in Malaysia and similar LMIC settings.

The diagnosis of extrapulmonary tuberculosis (EPTB) often depends on advanced imaging, invasive tissue sampling, and multidisciplinary referral pathways. These complex, procedure-dependent diagnostic processes are particularly vulnerable to disruption during periods of health system strain. During the COVID-19 pandemic, the reallocation of healthcare resources, restrictions on elective procedures, and delays in diagnostic services may have disproportionately affected EPTB detection, leading to missed or delayed diagnoses. Migrant populations, who already face structural barriers to healthcare access related to language, socioeconomic factors, and referral processes, may be especially vulnerable to such diagnostic disruptions during public health emergencies. We conducted a retrospective observational study using complete provincial tuberculosis dispensary records from Mardin, a border province in southeastern Turkey. All tuberculosis cases diagnosed between 2017 and 2025 were included. Diagnostic periods were defined as pre-COVID (2017-2019), COVID (2020-2022), and post-COVID (2023-2025). Cases with concomitant pulmonary and extrapulmonary involvement were classified as pulmonary tuberculosis (PTB). Distributions of PTB and EPTB by diagnostic period and nationality (local vs. migrant) were compared using chi-square or exact tests, as appropriate. For microbiological analyses, hypothesis testing was restricted to cases with available results. Factors associated with EPTB were evaluated using Firth penalized logistic regression to reduce small-sample bias and separation. A total of 525 tuberculosis cases diagnosed between 2017 and 2025 were included (mean age 37.8 ± 19.3 years; 51.2% male), of whom 49 (9.3%) were migrants. Overall, 235 cases (44.8%) were classified as extrapulmonary tuberculosis (EPTB). In the local population, EPTB proportions varied across periods (47.4% pre-COVID, 35.2% during COVID, and 54.9% post-COVID; p = 0.0034). Among migrants, EPTB proportions also differed across periods (26.9%, 16.7%, and 63.6%, respectively; exact p = 0.0425), although estimates were imprecise due to small strata sizes. Among locals, AFB positivity among performed tests and culture positivity among determinate results varied across periods (p = 0.0041 and p = 0.0001, respectively). In Firth penalized logistic regression male sex and the COVID period were associated with lower odds of EPTB. Migrant status showed lower odds but did not reach statistical significance, and the post-COVID period was not statistically significant. These findings reflect changes in the PTB/EPTB case-mix among notified TB cases rather than population incidence. We observed a transient shift in the PTB/EPTB case-mix during the COVID period with a post-COVID rebound. While these patterns are compatible with pandemic-related changes in diagnostic pathways, mechanisms cannot be directly assessed in registry data without denominators and service-level diagnostic volumes. Maintaining access to referral- and procedure-dependent diagnostic pathways remains important, particularly for vulnerable populations. Not applicable.

Social risk screening is a significant expansion of clinical care that raises a complexity of challenges for healthcare providers and patients alike. To understand the experience of responding to social risk screens among patients with mental health needs, how they prioritize health-related social needs when seeking care, and the impact of social risk screening on the patient-health system relationship. Qualitative study; one-on-one key informant interviews. Primary care patients at an academic urban safety-net hospital in Boston, MA. Primary data were collected via qualitative interviews with patients who presented at primary care with a mental health concern (e.g., depression, anxiety) in the past 1-3months and completed a social risk screening from December 2020 to August 2021. Interviews were held via Zoom in English, audio-recorded and transcribed. Interviews focused on patients' experience of being screened for social risks and needs, their conceptualizations of social risk domains (e.g., housing, food, transportation, etc.), and the importance of these needs relative to medical care access. A deductive analysis using the Information-Motivation-Behavioral Skills model was applied to identify themes. A total of 148 individuals were approached with 30 participating in semi-structured interviews (20.3% recruitment rate): 19 (63%) participants self-identified as female and 14 (47%) as Black/African American. Data revealed that asking patients about their social needs further emphasizes their already vulnerable position when seeking medical care, particularly when addressing mental health concerns. Patients stated that they were reluctant to disclose future health-related social needs when prior reported needs were not supported or addressed. When patients reported prior instances of sharing health-related social needs where those needs went unaddressed, instances of "double loss" occurred, leading to potential distrust in the medical system. It is important that health systems implement effective referral processes and have adequate resources to address patient disclosed needs, especially for at-risk patient populations.

Social and Clinical Variables Associated with Outpatient Mental Health Care Utilization following Positive Suicide Risk Screening.

While diabetes prevention programmes (DPPs) effectively reduce the risk of type 2 diabetes, optimising referral to these programmes is challenging. Our prior research (a qualitative study on the pilot of the National Diabetes Prevention Programme (NDPP) and a systematic review) identified a range of barriers and facilitators to referral from healthcare workers' perspectives. This study aims to gain consensus on the main factors influencing referral to a newly established NDPP and using the Behaviour Change Wheel (BCW) to select behaviour change techniques (BCTs) for an implementation strategy to improve referral to the programme in the future. A two-round modified online Delphi survey prioritised 17 barriers and facilitators of the referral process, followed by a mapping exercise with the BCW, which guided the identification of techniques to change referral behaviour from general practice. The survey took place online with healthcare professionals working in the primary care setting in Ireland (April to June 2024). The NDPP was in the pilot phase and was not available in all areas. This study sought to learn from this pilot phase to inform the referral process, which was not yet fully established. Healthcare professionals eligible to refer or involved in referral to the NDPP in Ireland (general practitioners, practice nurses and dietitians delivering the NDPP) took part in the Delphi survey. Recruitment was through a number of gatekeepers, a health service manager and professional groups who shared invitations to participate with eligible healthcare professionals. In the Delphi survey round 1, respondents were asked to rate the importance of 17 factors (nine facilitators and eight barriers) influencing referral on a 5-point Likert scale (not important to very high importance) and an open text box captured other suggested important factors. Barriers included limited practical information about the availability of the programme, concerns about workload, competing priorities and concern about patient motivation, the time commitment for patients and referral delays. Facilitators included electronic referral and feedback, promotion of the programme by healthcare professionals and consultation with patients before referral. Consensus was defined as agreement of ≥70% for each factor in the combined categories of high importance/very high importance, low/moderate importance or not important. Factors not reaching consensus after the first round were included in round 2 with any new factors from round 1. Factors that did not reach consensus or reached consensus as not important or of low/moderate importance were excluded. Only factors reaching consensus as being of high importance/very high importance across the two rounds were included in the final prioritised list. The Delphi survey had 37 responses to round 1 and 23 (62%) responses to round 2. 12 factors reached consensus as being of high/very high importance to improve referral. The 12 factors are mapped to seven intervention functions in the BCW and to nine key BCTs (feedback on the outcome of the behaviour, social support, instruction on how to perform a behaviour, information about the health consequences, information about social and environmental consequences, demonstration of the behaviour, prompts/cues, credible source and restructuring the physical environment). The strategy to improve referrals should include education delivered by educators to referrers, educational materials on the DPP and practical support to facilitate referrals. The health service should continue to provide electronic referrals and electronic prompts to refer could be considered as part of the electronic health record. This study systematically prioritises factors perceived to influence referral and identifies BCTs to improve referral to an NDPP. The BCTs are a starting point for a strategy to improve referral to DPPs. Further consultation with stakeholders is recommended to discuss the acceptability, feasibility and operationalisation of the BCTs in the Irish setting.

This scoping review aims to identify factors influencing adherence to dental guidelines following radiation therapy (RT) and to describe dental outcomes associated with poor adherence. The authors conducted a comprehensive search of PubMed, Embase, Web of Science, and Google Scholar databases, reported using the PRISMA-ScR guidelines. Studies were included if they reported on rates of dental adherence among post-RT head and neck cancer (HNC) patients. Data were extracted on rates of guideline adherence, dental health outcomes, barriers to care, and interventions. Twelve studies with a pooled sample size of 2925 patients met inclusion criteria. Adherence to post-RT dental guidelines ranged from 19% to 93%. Commonly reported barriers to adherence included lack of patient education, financial hardship, limited dental provider availability, access to health insurance, and poor care coordination. Facilitators of adherence included integrated survivorship clinics, pre-RT dental counseling, and structured follow-up programs. Interventions with multidisciplinary collaboration and streamlined referral processes showed promise in improving adherence rates. Adherence to dental guidelines post-RT is influenced by a combination of individual, provider, and systemic factors. While several interventions show potential, further research is needed to develop effective implementation strategies. Strengthening multidisciplinary communication, improving patient education, and implementing structured follow-up may enhance long-term oral health outcomes for HNC survivors.

Autism spectrum disorder (ASD) is a neurodevelopmental condition frequently associated with comorbidities and high support needs, posing significant challenges for the provision of patient-centered and humanized healthcare. Specialized healthcare programs have been developed to address these needs, yet evidence on user experiences within such models remains limited. This qualitative study explored the experiences of patients with ASD, caregivers, and healthcare professionals involved in AMITEA, a specialized public healthcare program in Madrid, Spain. Three focus groups (n = 24) were conducted following the Picker model of patient-centered care. Data were analyzed using a hermeneutic phenomenological approach, in accordance with COREQ guidelines. Participants reported several strengths of the AMITEA program, including respectful and personalized care, effective communication, emotional support, coordination across hospital services, and environmental adaptations tailored to sensory needs. Identified limitations included insufficient coordination beyond the specialized unit, limited resources, challenges during the transition to adulthood, barriers in referral processes, and a lack of ASD-specific training among professionals outside the program. The findings highlight the value of specialized, patient-centered approaches for individuals with ASD, emphasizing the importance of personalized support, adapted environments, and professional training. Extending these practices beyond specialized units may contribute to improved equity, continuity, and humanization of care across healthcare systems.

Prolonged hospital stays represent a critical indicator of efficiency in emergency services and are associated with increased costs, adverse events, and system overload. This study aimed to describe the factors related to prolonged stays among pre-surgical patients in the Adult Emergency Department of Edgardo Rebagliati Martins Hospital during 2024. Methods: A descriptive, observational, and cross-sectional study was conducted. Clinical and administrative records of pre-surgical patients treated in the emergency department were reviewed. Structural, technological, and human resource factors, as well as triage, surgical scheduling, and discharge processes, were assessed. Data were analyzed using descriptive statistics with SPSS software. Results: Surgical delays, bed saturation, and limited availability of specialized personnel were the main factors related to prolonged hospital stays. In addition, insufficient use of diagnostic technology and poor interdepartmental coordination contributed to longer waiting times and increased hospital occupancy. These findings suggest that prolonged stays depend not only on clinical factors but also on operational management and institutional infrastructure. Conclusion: Reducing prolonged hospital stays requires integrated interventions focused on optimizing human and technological resources and improving referral, triage, and discharge processes. Strengthening hospital management through an operational efficiency and patient-centered care approach is recommended.

The American Academy of Pediatrics recommends immediate referral of children screening at elevated likelihood of autism for diagnostic evaluation, early intervention, and audiology. However, most children screening at elevated autism likelihood are not referred. We aimed to synthesize decision-making processes related to generalist referrals to specialists for children with increased autism likelihood in the United States. We examined (i) rates of referral from generalist to specialist providers across medical and geographic settings, (ii) child/family factors that influence provider referrals, and (iii) facilitators and barriers to timely referral. We searched PubMed, PsycINFO, and Embase for studies that discussed autism likelihood in young children, discussed generalist to specialist referral, used empirical methods, and were set in the United States. We extracted the setting, study design, referral rates, child and family factors associated with referrals, and facilitators and barriers to referral. A total of 38 articles were included. In studies with no intervention elements, providers refer children to evaluations and early intervention services at rates ranging from 20% to 58.4%. In intervention studies, referral rates ranged from 45% to 98% after intervention. Perceived symptom severity and greater caregiver concern were associated with increased referral rates. Barriers to referral included providers' lack of confidence in screening tools and lack of local diagnostic and intervention sites. Interventions to facilitate rates of referral varied widely in their characteristics and outcomes. This review was restricted to the United States and included few high-quality experimental interventions. Increased research efforts should focus on increasing referral rates to early intervention, which is appropriate even for children with false positive results screening at elevated autism likelihood. Rigorous studies that optimize referral processes across providers and settings are needed.

Abstract Introduction Emergency laparotomy is associated with high risk of mortality and morbidity. NELA best practice tariff identifies Geriatrician input as a key performance indicator for all patients over 80 years of age and those who are over 65 and living with frailty. Evidence suggests geriatrician-led comprehensive geriatric assessment (CGA) may improve post-operative outcomes, but only 8% received one between 2019–2020 in our Trust (national average 27%). The aim of this project was to create a standardised referral system between general surgeons and ageing and complex medicine (ACM) team. Method This 3-cycle quality improvement project consisted of two key multi-faceted interventions, which were assessed using data from secretaries’ emails and the Health Information System (HIS). The first intervention was a standardised referral proforma and pathway, aiming to reduce inappropriate and increase NELA referrals. The second intervention involved appointing a dedicated NELA nurse (summer 2024), who undertook a digital transformation project to improve the acute abdomen pathway, including building an electronic referral process to ACM team. Results The first intervention improved referrals for NELA patients from 0 (Sept 2023-Jan 2024) to 6 (March–June 2024). Since building the digital pathway and the referral order going live in March 2025, we have received and completed 18 NELA referrals (March–June 2025). Frailty scoring was made mandatory in the surgical assessment document and referral became active automatically. Geriatricians working on the frailty session absorbed the referrals and completed CGAs for all patients. In NELA audit figures, this has improved our performance from 40% of patients having had a geriatrician review in March 2024 to 100% for the period November 2024 to January 2025. Conclusions By working together across surgical and medical specialities, and particularly by creating the digital pathway for acute abdomen, we have significantly improved the percentage of general surgery patients receiving geriatrician review.

Generalized joint hypermobility (GJH) is often challenging to assess, but its presence could suggest a syndromic diagnosis of Ehlers-Danlos Syndromes (EDS). An automated and objective method for estimating joint hypermobility with Beighton score using short video clips is proposed. A total of 225 adults (91.8% female, median age 32.0, range 18-64) referred to a specialized EDS clinic were recruited for this study. A video-based method relying on pose-estimation libraries was developed to predict per-joint hypermobility of both elbows, knees, fifth fingers, thumbs, and spine; as well as the overall Beighton score. The system was developed on the first 100 individuals (training set), and validated on the remaining 125 individuals (test set). The system screened out 31.9% of the training set and 32.0% of the test set as not having GJH, while recalling 89.1% and 91.9% of the true positives on the train and test set, respectively. The consistency of the system between the training and test sets suggests that it generalizes well to unseen individuals. The system was tuned to be with a focus on sensitivity to avoid screening out individuals with GJH. As such, the specificity of the system is 52.1% on the training set and 42.4% on the test set. The proposed system can objectively screen individuals for possible GJH and also screen out those without GJH during the referral process, reducing the burden on specialized EDS clinics while providing early diagnostic triage. Future research will focus on deploying the tool as a mobile application.

Automatic processing of gastrointestinal endoscopy referrals and patient instructions using large language models.

Abstract Background Prolonged wait times for gastroenterology (GI) specialist care is a longstanding issue in Canada, contributing to increased patient frustration, symptom burden and potential adverse outcomes. The Canadian Association of Gastroenterology (CAG) Wait Time Consensus Group created recommended guidelines for consultation and procedure wait times across 24 areas of gastroenterology according to acuity, which is used as a benchmark for Canadian institutions. Gastrointestinal diseases contribute to 15% of national health care expenditures. Currently, it is estimated that 1.8 gastroenterologist are needed per 100,000 people in Canada, and with rising rates of both international and interprovincial migration to Calgary, further improvement initiatives are needed to access to GI specialist services. Previous work in Calgary resulted in the creation of a GI central access triage (CAT) system, a single point entry model with a goal improving access to GI specialist care. While overall successful, the high demand for GI services continues to result in long waitlists. Aims To reduce the median wait times for urgent GI consultations from 180 to 90 days, within 24 months, to better align with CAG Wait Time Consensus Group recommendations. Methods Using the QI Model for Improvement framework, we outlined the current process for GI referrals through the CAT system. Data collection began in July 2025 and is continuing monthly through the first PDSA cycle. The planned interventions include waitlist clean up tools, workforce planning, and “three-strike” policy for unresponsive referrals. Our outcome measure is ‘days on the waitlist,’ the total time from referral to urgent consult appointment (target is 90 days). Process measures include number of duplicates or previously seen patients removed, and balancing measures include burden on nursing and physician teams. Results In June and July 2025, GI CAT received 2423 and 2389 total consults respectively. The first PDSA cycle is currently underway. The baseline median wait time for urgent consults is 186 days. There were 1327 patients on the urgent waitlist, pre-initiative (June 2025), and data from July 2025 shows 1377 patients. By July 2025, less patients (77/1377) were waiting greater than 180 days compared to June 2025 (89/1327). Quantitative data on timeliness and completion rates will be analyzed following the first PDSA cycle. Conclusions While the initial data does not demonstrate significant changes in total number of patients, initiative implementation began closer to mid-July, so these results may not accurately reflect the impact. We anticipate that implementation of iterative PDSA cycles will improve median wait times for access to urgent GI specialist care, with the goal of sustainability and minimizing staff fatigue to create an enduring impact. Funding Agencies None

Proton beam therapy (PBT) offers dosimetric advantages in pediatric radiotherapy by reducing radiation exposure to healthy tissues. However, broad implementation raises important ethical, logistical, and equity considerations, especially in settings with limited access to advanced technologies. This position paper by the Paediatric Radiation Oncology Society (PROS) reviews the clinical rationale for selecting radiotherapy modalities in children, with a specific focus on ethical utilization of PBT. The document synthesizes evidence on the benefits and limitations of modern photon and proton therapies, explores disparities in access, outlines the role of local pediatric radiation oncologists, and addresses the impact of industry-driven messaging on family decision-making. While PBT offers clinical benefit in selecting pediatric cancers, high-quality photon-based treatments such as IMRT and VMAT remain effective and widely accessible alternatives. The referral and evaluation process for PBT is complex and may introduce treatment delays. Travel and financial burdens can exacerbate disparities. PROS underscores the critical role of local pediatric radiation oncologists in counseling families, and calls for balanced, evidence-based communication from providers and industry stakeholders. PROS advocates for an ethical, equitable, and evidence-informed approach to radiotherapy modality selection in children, reflecting holistic considerations beyond dosimetry. Proton therapy should be pursued when clinically indicated and accessible without compromising timely care. Investment in a comprehensive radiation therapy infrastructure, including professional education, collaborative research, and responsible public messaging, is essential to optimize pediatric cancer outcomes globally.

Maternal mortality remains disproportionately high in low-income and middle-income countries, where pyramidal health systems and inadequate referral processes often delay access to emergency obstetric care. The Three Delays Model has long been used to analyse delays in maternal care globally, but it fails to capture the full complexity of referral-related delays within pyramidal health systems. Drawing on the example of Madagascar, this paper reviews the limitations of the traditional model and proposes a revised 'Six Delays Model'. This model expands the traditional three delays to include the following six stages: 'delay in seeking initial care', 'delay in reaching initial care', 'delay in receiving initial care', 'delay in seeking referral care', 'delay in reaching referral care', 'delay in receiving referral care'.This revised model improves granularity, integrates patient-provider and inter-provider dynamics that influence referral decisions and reflects both individual and community-level factors that influence decision-making. By mapping delays accurately along the patient journey, the revised model provides a more actionable model for policymakers and implementers seeking to reduce maternal mortality. While more complex, the expanded model offers necessary nuance and adaptability for pyramidal health systems and supports targeted intervention design to address systemic barriers to timely and adequate obstetric care.

Disparities and temporal trends in referral for bladder cancer diagnosis: A worsening epidemic.

The pathways for patient referral for specialist musculoskeletal care is fragmented and poorly integrated with other healthcare services. These systems lead to delays in diagnosis, treatment, access to specialist care, and increased healthcare costs. A rural tertiary sport medicine clinic initiated a self-referral Acute Injury Clinic (AIC) to address these issues. The primary purpose was to determine the utilization and access of the AIC. The secondary purpose was to determine the type and incidence of injuries, and the time to tertiary or definitive care. The AIC model utilised a team approach by a physiotherapist and sport medicine physician to assess and diagnose acute injuries that occurred within 10 days. Orthopaedic surgery consultations were completed on the same day or via internal referral processes when indicated. Electronic medical records were reviewed for all AIC assessments completed between December 2022 and October 2024. Demographic data (age, sex) and confirmation of acute injury within the last 10 days were recorded to determine utilization and access. To determine type and incidence of injury and time to tertiary and definitive care, the injury site, diagnosis, activity at the time of injury, time from injury to AIC assessment, and time from AIC assessment to orthopaedic consult and surgery were recorded. Overall, 945 patients were assessed at AIC. Five hundred and one (53.0%) identified as male and 444 (47.0%) identified as female. Patients ranged in age from 7 to 97, with a mean age of 37.7 (SD=17.9). Preliminary analysis of the March – October 2023 (n=262) consultations indicated that 222 (84.7%) injuries were acute. The mean time from injury to AIC assessment was 9.6 days (SD=9.2). Two hundred and thirty-one patients (88.2%) received a definitive diagnosis, with 31 (11.8%) requiring further investigation. The most common activity at the time of injury was a snow sport (skiing/snowboarding) (n=76, 29.0%), followed by slips and falls (n=19, 7.3%), biking (n=17, 6.5%), hiking (n=15, 5.7%), soccer (n=13, 5.0%), and running (n=12, 4.6%). The most common site of injury was the knee (n=147, 56.1%), followed by the shoulder (n=50,19.1%), ankle (n=22, 8.4%), Achilles (n=7, 2.7%), wrist (n=5, 1.9%) and elbow (n=5, 1.9%). Further analysing the 147 knee injuries, the most common diagnosis was anterior cruciate ligament injury (n=55, 37.4%). Thirty-four (61.8%) of these injuries required surgery with a mean time of 98.9 days (range=0–398) and 218 days (range=20–575) from AIC assessment to consent for ACL surgery, and to surgery respectively. Further analysis of the initial 2-years of AIC consultations will be conducted, including comparing AIC and usual care for access and care costs for injuries and surgeries. Preliminary results indicate a successful implementation of a self-referral acute injury clinic, with 88% of consultations resulting in a diagnosis within 10 days of injury. Less than 12% of AIC patients required further investigations. Time to orthopaedic surgery consultation and surgery was reduced compared with provincial care reporting.

The National Health Service in England is piloting an extension of access to its Digital Weight Management Programme, a digital service to support behavioural and lifestyle changes for weight loss. Access is being piloted to include referrals for patients with a body mass index above a threshold level set by the National Health Service England and who either have a diagnosis of osteoarthritis of the knee or hip (musculoskeletal referrals - 11 pilot sites) or are on elective surgical care waiting lists (elective care referrals - 10 pilot sites). There is a marked variation across sites in the number of patients referred. To understand reasons for variation (local implementation, barriers and facilitators) and experiences of the implementation and functioning of referral pathways for musculoskeletal and elective surgical care patients into the National Health Service Digital Weight Management Programme. A comparative case study (n = 7 sites) methodology was used, employing a mixed-methods approach following a sequential explanatory design: descriptive analysis of quantitative referral data from National Health Service England; staff (n = 25) and patient (n = 18) interviews and online workshops. Thematic analysis was conducted. Osteoarthritis treatment and elective surgery providers in the National Health Service in England. Interviews: staff and patients at three musculoskeletal and four elective care pilot sites. Workshops: staff at all pilot sites. Referral of osteoarthritis and elective surgery patients to the National Health Service Digital Weight Management Programme. Patients' and staff's views. Sites that created referral processes that optimised clinical staff time (e.g. automation and use of administrative staff) and involved ways to capture body mass index if missing from patient records were more likely to have a higher number of referrals. Despite generally positive attitudes towards the Programme, many staff felt they had insufficient information to describe it accurately to patients, which may impact both offering and acceptance of referrals. Strong leadership and personal staff motivation arealso likely to impact referral offers. Similarly, patients were more likely to accept a referral if it aligned with their attitudes towards weight management and was offered at a time where they felt they could engage with the Programme. Data were available on numbers of patients referred but not on numbers of eligible patients not referred. All patients interviewed had accepted referral to the Programme: we were unsuccessful in our attempts to recruit patients who had declined referral. No patients from minority ethnic groups volunteered to be interviewed. There is a considerable variation between case study sites in the details of how they have implemented new pathways for referring patients to the National Health Service Digital Weight Management Programme. These differences likely reflect varying local contexts. No single best model for the referral pathways has been identified. It would be desirable to capture the experiences of patients from diverse ethnic backgrounds and from patients who declined referral. Larger, longitudinal and observational studies could help understand the specifics of referral conversations as well as the effectiveness and cost-effectiveness of these referral pathways against other pathways to the Programme to aid decision-making and development of support materials for staff. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR167932.

Distal radius fractures (DRF) represent up to 20% of fractures in the emergency department. Delays to surgery greater than 14 days are associated with poorer functional outcomes and increased healthcare utilization/costs. At our institution, the average time to surgery is greater than 19 days due to separation of surgical and nonsurgical care pathways and a lengthy referral process. To address this challenge, we aimed to create a convolutional neural network (CNN) capable of automating DRF x-ray analysis and triaging. We hypothesize this model will accurately predict whether an acute isolated DRF fracture in a patient under age 60 will be treated surgically or nonsurgically based on radiographic input. We included 163 patients (93 surgical, 70 nonsurgical) under age 60 who presented to the ED between 2018–2023 with an acute isolated DRF and were referred for clinical follow up. Radiographs taken within 4 weeks of their injury were collected in posterior-anterior and lateral views before being pre-processed for model training. The gold standard for diagnosis equivalence was the surgeon's clinical decision of treating the patient surgically or nonsurgically. 723 radiographic pairs were used for model training. The best-performing model was obtained using 7 CNN layers, 1 fully connected (FC) layer, an image input size of 256x256 pixels, and a 1.5x weighting for volarly displaced fractures. Model performance metrics at the per-scan and per-patient level were evaluated (Table 1). Values for True Positive, True Negative, False Positive and False Negative were calculated (Figure 3). A CNN-based algorithm can predict with 88% accuracy whether treatment of an acute isolated DRF in a patient under age 60 will be treated surgically or nonsurgically. By promptly identifying patients who would benefit from expedited surgical treatment pathways, this model can reduce wait times and subsequently enhance patients' outcomes. For any figures or tables, please contact the authors directly.