Referral Specialists Research Articles

Scanners, schedules, and statutes: A tale of trauma, policy, and profit

EMTALA (Emergency Medicine Treatment and Labor Act) is an important federal mandate intended to improve access to emergency medical services for patients regardless of financial means. The act imposes strict guidelines on emergency departments, associated referral specialists, and ancillary services. Radiology departments must comply with all ETMALA requirements to avoid potentially incapacitating penalties to their institutions.

Kaposi's Sarcoma: Evaluation of Clinical Features, Treatment Outcomes, and Prognosis in a Single-Center Retrospective Case Series.

Kaposi's sarcoma (KS) is a rare angioproliferative tumor classified in four different clinical-epidemiological forms. The diagnosis is based on histopathological and immunohistochemical analyses. The treatment is heterogeneous and includes several local and systemic therapeutic strategies. Methods: This is a retrospective cohort study including 86 KS patients treated between 1993 and 2022 at the University Hospital of Padua (AOPD) and at the Veneto Institute of Oncology (IOV). The data were extracted from an electronic database. Survival curves were generated using the Kaplan-Meier method, and Cox regression models were employed to explore associations with overall and disease-free survival. The male sex (89.53%), classical variant (43.02%), and cutaneous involvement (77.9%) were predominant. More than 61.6% of patients received a single treatment. Surgery, antiretroviral therapy, and chemotherapy were the mostly adopted approaches. A persistent response was observed in approximately 65% of patients, with a 22% relapse rate (at least 2 years). The overall survival ranges from 90 to 70% at 2 to 10 years after the diagnosis. Iatrogenic KS demonstrated a higher mortality (52.9%). This study reflects our experience in the management of KS. Comorbidities are very frequent, and treatments are heterogeneous. A multidisciplinary approach involving multiple referral specialists is essential for the appropriate management of this disease during diagnosis, treatment, and follow-up.

Percepción del profesional sanitario sobre el paciente con síndrome de sensibilidad central-fibromialgia

Background and objectivesFibromyalgia is characterized by musculoskeletal pain and asthenia of chronic course. Fibromyalgia patients are often a challenge for the health care community as a whole. Existing studies are often limited to the opinion of rheumatologists or family physicians. With this study we seek to know what are the actions, perceptions and knowledge of health professionals as a whole when caring for patients with this disease. Materials and methodsDescriptive cross-sectional study, by means of a self-administered and anonymous survey. Distributed mainly in hospital wards and primary care centers. Statistical analysis of the variables collected was performed (P˂.05). ResultsTwo hundred surveys were collected, most of them physicians (63.5%; n=127) or nurses (25.5%; n=51). 71% of physicians reported using the WHO analgesic scale. 53% (n=59) use NSAIDs or paracetamol. Antidepressants are the third drug of choice. Most believe that the referral specialists should be rheumatologists or primary care physicians, a similar percentage, that management should be multidisciplinary. Fifty two percent feel discouraged or annoyed when dealing with these patients. Physicians have more negative connotations and believe that the care that the patient receives is mostly influenced by the diagnosis of fibromyalgia, compared to nurses and other professionals. ConclusionsOur study shows that the lack of knowledge and therapeutic tools generates, to a large extent, frustration and discomfort in health personnel. It is important to develop new approaches to this entity.

Using participatory action research to empower district hospital staff to deliver quality-assured essential surgery to rural populations in Malawi, Zambia, and Tanzania.

In 2017 the SURG-Africa project set out to institute a surgical, obstetric, trauma and anesthesia (SOTA) care capacity-building intervention focused on non-specialist providers at district hospitals in Zambia, Malawi and Tanzania. The aim was to scale up quality-assured SOTA care for rural populations. This paper reports the process of developing the intervention and our experience of initial implementation, using a participatory approach. Participatory Action Research workshops were held in the 3 countries in July-October 2017 and in October 2018-July 2019, involving representatives of key local stakeholder groups: district hospital (DH) surgical teams and administrators, referral hospital SOTA specialists, professional associations and local authorities. Through semi-structured discussions, qualitative data were collected on participants' perceptions and experiences of barriers to the provision of SOTA care at district level, and on the training and supervision needs of district surgical teams. Data were compared for themes across countries and across surgical team cadres. All groups reported a lack of in-service training to develop essential skills to manage common SOTA cases; use and care of equipment; essential anesthesia care including resuscitation skills; and infection prevention and control. Very few district surgical teams had access to supervision. SOTA providers at DHs reported a demand for more feedback on referrals. Participants prioritized training needs that could be addressed through regular in-service training and supervision visits from referral hospital specialists to DHs. These data were used by participants in an action-planning cycle to develop site-specific training plans for each research site. The inclusive, participatory approach to stakeholder involvement in SOTA system strengthening employed by this study supported the design of a locally relevant and contextualized intervention. This study provides lessons on how to rebalance power dynamics in Global Surgery, through giving a voice to district surgical teams.

Hospital palliative medicine. Revision of a care model implemented at a university hospital

Palliative Medicine (PM) is a specialty whose objective is to prevent and alleviate suffering associated with advanced diseases. Hospital palliative medicine has benefits in symptom control, quality of life and cost containment. Hospital PM support teams that serve as referral specialists are in charge of a PM care model. To describe the clinical experience of a PM support team in a tertiary hospital in Chile. Review of clinical records of patients referred to a hospital PM support team between March 2015 and July 2018. Administrative data of referrals, sociodemographic and clinical characteristics of patients, their investigated problems and the interventions proposed by the PM team were described. During the study period, 790 referrals were registered, most of them from the internal medicine department (31%) or critical care (24%). During the study period, the number of annual referrals increased from 177 to 237 and the time lapse after hospital admission decreased from five to three days. The mean age of patients was 65.8 years and their main diagnosis was an oncological disease in 81%. The most frequently identified symptoms were fatigue in 71% of patients, depression in 68% and pain in 60%. The main interventions proposed by the PM team were communication support in 64% of patients, analgesia in 62% and education for family caregivers in 49%. The hospital PM team proposes a care model that allows the evaluation and a therapeutic approach for patients suffering from advanced diseases, using a multidimensional perspective including their families.

The relationship between orthodontic treatment and temporomandibular disorders: A dental specialists' perspective.

ABSTRACTIntroduction: The relationship between temporomandibular disorders (TMDs) and orthodontic treatment/malocclusion has changed from a cause-and-effect association to an idea without sufficient evidence. Objective: This survey was designed to assess the beliefs of different disciplines - orthodontists, oral surgeons, and oral medicine specialists - on the relationship between TMDs and orthodontic treatment, with regard to treatment, prevention and etiology of TMDs. Method: A survey in the form of questionnaire was designed and distributed to 180 orthodontists, 193 oral surgeons and 125 oral medicine specialists actively involved in treating TMDs. The questionnaire aimed to collect basic information about each participant and their beliefs, and clinical management of patients with TMDs. Results: Halve of the responding orthodontists and most of the oral surgeons (69.9%) were male participants, whereas the majority of oral medicine specialists (83.3%) were female respondents. The participants’ age ranged from 29 to 58 years. The majority of orthodontists believes that there is no relationship between orthodontic treatment and TMDs, and that orthodontic treatment does not provoke TMDs or prevent the onset of the disorder. However, oral surgeons and oral medicine specialists have different and conflicting opinions. Most surgeons tended to treat those patients, while most of the other two disciplines tended to seek an interdisciplinary approach. Chi-square test was done to find an association between the referral status and specialists’ experience, and to compare between the different disciplines’ belief. Conclusions: Orthodontist’s beliefs were in accordance with the scientific evidence, whereas most oral surgeons and oral medicine specialist believed that orthodontic treatment may provoke TMDs. Therefore, continuing program series development is important to embrace the concept of the multidisciplinary team approach and improve the health care and quality of life for those patients.

Clients' perception of referral and veterinary specialists in a U.K. small animal referral hospital.

A 2011 RCVS report published following review of veterinary referral and specialisation suggested that the general public may have a lack of understanding of what constitutes specialisation. Our questionnaire study evaluated client understanding of the term 'Specialist' and the information obtained prior to referral. Questionnaires were completed prior to consultation. Client age, medical knowledge, how referral was initiated, options discussed by the primary care practice for treatment, expectations of the referral appointment, understanding of the term Specialist and what constitutes specialist training were assessed. A total of 241 questionnaires were completed: 6.2% (15/241) of clients were working in the veterinary/medical industry; 52% (104/200) of clients assumed they were seeing a Specialist for consultation but only 49% (51/104) saw a Specialist; 0.4% (1/232) of owners correctly identified a Specialist as a clinician with a diploma, and incorrect definitions included having experience with a procedure or a postgraduate certificate; 13.6% (31/228) of clients identified that an internship and residency constituted Specialist training; and 66.8% (155/232) of clients had not researched the referral process. From the population sampled, a minority of clients understand the term Specialist and the postgraduate training this entails. Clients may erroneously assume they are receiving Specialist consultation.

HIPPOCRATES® project: A proof of concept of a collaborative program for hepatitis C virus micro-elimination in a prison setting.

BACKGROUNDIn the last few years we have witnessed a revolution in the treatment of hepatitis C virus (HCV) infection. With the introduction of direct-acting antiviral agents (DAAs), sustained virological response (SVR) is achieved in more than 95% of the patients. The focus is now being turned to the global targets set by the World Health Organization, with the aim of achieving HCV elimination by 2030. Prison inmates constitute one of the high-risk groups, and receive treatment less frequently due to several barriers in access to health care.AIMTo describe the management and follow-up of a cohort of HCV monoinfected patients treated with DAA in the prison setting, where tertial referral liver center specialists locally provide, on-site assessment and treatment for the prisoners.METHODSA prospective observational study was conducted from April 2017 to March 2020, which included all HCV monoinfected prison inmates in the largest Northern Portugal prison. Demographic, clinical, and laboratory data, as well as transient elastography measurements, were collected onsite by the medical team and prospectively recorded. Patients were treated with DAA according to international guidelines. The primary endpoint was SVR at post-treatment week 12. RESULTSThere were 98 monoinfected HCV male inmates (mean age, 42.7 ± 8.6 years) included in the analysis. Injecting drugs or tattooing were reported in 74.5%, with 38.8% of the latter being done in prison. Alcohol consumption of more than 30 g/d was referred in 69.4%. The most prevalent genotype was 1a (54.1%), followed by 3 (27.6%), 4 (9.2%) and 1b (6.1%). Pretreatment fibrosis degree was mild-to-moderate (F0-F2) in 77.6% and severe in 22.4% (F3-F4). Treatment regimens chosen were: 45.9% elbasvir/grazoprevir, 29.6% sofosbuvir/velpatasvir, and 12.2% sofosbuvir/ledispavir and glecaprevir/pibrentasvir. No major adverse events were observed. SVR at post-treatment week 12 was 99%.CONCLUSIONIn a population considered to be both hard-to-access and a cornerstone for HCV elimination, the onsite evaluation and treatment of HCV-infected prisoners, achieved an exceptional highly effective success rate. This type of collaborative program should be considered to be expanded, to support hepatitis C elimination efforts.

Abstract P1-03-10: The implementation of a patient referral service in a Brazilian cancer center

Abstract BACKGROUND: Healthcare systems face problems of cost increases and poor delivery organization. Integrated delivery may reduce costs and improve quality and health outcomes. OBJECTIVE: To describe how the A.C. Camargo Cancer Center, aiming at greater integration, implemented a referral service for breast cancer patients. METHODS AND RESULTS: The process was divided in three phases: 1) AS IS ANALYSIS, 2) BENCHMARKING, 3) PILOT & IMPLEMENTATION. 1) AS IS ANALYSIS A.C. Camargo was responsible for treating 16% of all breast cancer cases that arose from 2000 to 2012 in São Paulo State. Prior to implementation of the program, there was no special patient classification at the initial appointments. 2) BENCHMARKING As proposed by MD Anderson Cancer Center, we used the patient's classification at the time of an appointment request (regular screenings, undiagnosed or breast cancer patient). As proposed by Memorial Sloan Kettering Cancer Center, we used a "Physician Referral Service" staffed by "Referral Specialists" and "Trained Oncology Nurses" to collect patient information prior to the first appointment. As suggested by Princess Margaret Cancer Center, we collected patient care data (e.g., abnormal imaging, palpable lump). 3) PILOT & IMPLEMENTATION Phase I: Feb. 13, 2017 to Dec. 28, 2017. We reached 7% of new patients in the Breast Surgery Department (BSD): 48% were in the Cancer Group, 45% in the Abnormal Imaging Group (Undiagnosed) and 7% in the Palpable Lump Group. New patients were classified by the Call Center. Electable cases were referred to the Nurse Navigator, who proceeded with appointments according to protocol. Root cause analysis of non-captured patients led to the following improvements: extension of participant Call Center cells, script review, and implementation of a training program. The Phase I results led to the following improvements: 1) reclassification of a subgroup with highly suspicious images as the "Cancer Group"; 2) Transfer of the new referral and scheduling functions to the Call Center; and 3) Implementation of new "first appointment items", personalized for each patient group. This information was displayed to the physician and operations staff in advance of the consultation. Phase II: Dec. 29,2017 to June 28, 2018. We reached 100% of new patients in the BSD: 17% were in the Cancer Group, 23% in the Abnormal Imaging Group, 8% in the Palpable Lump Group, and 53% in the Regular Screening Group. Phase II results led to the following improvement: 1.) Distribution of the cancer groups'first appointment items equally among surgeons. Phase III: From June 29, 2018 to the operation. Implemented new appointment items for new clinical patients and for pre-treatment returns. CONCLUSION: With implementation of the Referral Service, the BSD at A.C. Camargo is now able to identify the reason for each appointment before the first consultation. This practice promotes operational predictability and more effectively organizes the personalized journey of each patient, including care on the part of Nurse Navigators for the most critical cases. REFERENCE: Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001 Citation Format: Makdissi FB, Costa Filho ER, Conti EC, Santos LC. The implementation of a patient referral service in a Brazilian cancer center [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-03-10.

Evidence-Based Physiatry: The Center for Disease Control Guideline on Pediatric Mild Traumatic Brain Injury and the Expanded Role of Physiatry.

A mild traumatic brain injury (mTBI) or concussion is the most commonly occurring type of traumatic brain injury in adults and children. Between 2005 and 2009, the United States Center for Disease Control estimated 2–3 million pediatric mTBI-related emergency department and primary care visits occurred. Although there are subtle variation in definitions of mTBI, a consensus has formed around defining this injury as an acute neurological disturbance manifesting with confusion and/or disorientation after a mechanical force to the head and meeting the following parameters: (1) length of loss of consciousness of less than 30 mins; (2) posttraumatic amnesia less than 24 hrs; and (3) a Glasgow Coma Scale of 13–15, 30 mins after injury or at time of presentation to medical care. Guidelines have emerged to direct treatment of specific groups that commonly sustain mTBI, such as the Consensus Statement on Concussion in Sport directed at student athletes, the Ontario Neurotrauma Foundation guidelines for those with mTBI and persistent symptoms, and Veteran’s Affairs/Department of Defense guidelines for mTBI in military service members and veterans. However, evidence based guidelines for pediatric mTBI in the United States were lacking until the most recently published Center for Disease Control Guideline on the Diagnosis and Management of mTBI among Children (https://www.cdc.gov/media/releases/2018/p0904-tbi-guidelines.html).1 GUIDELINE DEVELOPMENT AND METHODOLOGY The new Center for Disease Control guideline is a set of 19 recommendations based on a systematic review of the literature and expert consensus. Clinical questions were developed by the Pediatric Mild Traumatic Brain Injury Work Group, a panel of experts that included rehabilitation specialists and physiatrists. Guidelines were developed in three clinical areas diagnosis, prognosis, and management/treatment. A systematic review of pediatric mTBI and related topics from 1990 to 2015 was conducted using the American Academy of Neurology Guidelines. Each recommendation was based on evidence obtained in the systematic review as well as other relevant scientific information and expert opinion deemed significant by the work group. This work considered strength of evidence as well as additional factors, such as the risks and benefits of the recommendation, importance of the recommendation, feasibility, patient preference, and financial cost. WHAT ARE THE HIGHLIGHTS IN THE NEW GUIDELINES? These guidelines outline a series of practical and feasible recommendations for emergency department, primary care, and specialty providers focusing on readily available mTBI assessment tools, early identification of poor prognostic factors, and education and active rehabilitation as mainstays of treatment. A complete list of recommendations is located in the guideline supplement and patient and family resources are available online (https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html).1 In summary, the guideline recommends against the routine use of neuroimaging or serum based biomarkers for diagnosis of mTBI, except when intracranial injury is suspected. Age-appropriate symptom inventories and computer-based cognitive testing should not be used alone but in conjunction with clinical assessment. In the area of prognosis, the guidelines strongly support education of patients and families about the general course of recovery in pediatric mTBI (1–3 mos) and risk factors that are associated with prolonged recovery (premorbid conditions, injury, and noninjury-related factors). Close monitoring of individuals with multiple risk factors for prolonged symptoms and referral to specialty care within 4–6 weeks of injury if symptoms persist. The guidelines strongly support education of patients and families regarding warning signs in the acute period, the emergence of postconcussive symptoms, prevention of a second, overlapping head injury, and guidance for return to school and activity. Although rest was once the mainstay of concussion treatment, the guideline emphasizes a brief period (2–3 days) of reduced activity in the acute period followed by a gradual return to school and noncontact physical activity that does not exacerbate symptoms. The guideline supports the use of individualized return to school plans based on symptom severity and highlights the importance of a collaborative effort in return to school recommendations. Referral specialists and formal neuropsychological testing is recommended in students struggling with return to school or with persistent cognitive symptoms, respectively. Treatment recommendations focus on multidisciplinary care and dedicated symptom-based treatments for acute and chronic headache, sleep dysfunction, and vestibular and oculomotor symptoms are provided. WHY IS THIS RELEVANT TO PHYSIATRISTS? Physiatrists are uniquely positioned to care for children with mTBI because of their role in leading multidisciplinary rehabilitation teams and their specific clinical expertise in pediatric rehabilitation, sports medicine, and traumatic brain injury. The guideline recommends referral to specialty and rehabilitation care in the early subacute period meaning that the number of children with mTBI referred to specialists, such as physiatry, will likely increase. The guideline supports a paradigm shift in the treatment of mTBI from a rest and recover model to an active rehabilitation, symptom-based approach including physical activity, cognitive activity, and specialized rehabilitation (i.e., vestibular). Such an approach is an ideal forum to leverage physiatric skills.

Referring equine veterinarians' expectations of equine veterinary specialists and referral centers.

OBJECTIVE To explore referring equine veterinarians' expectations of equine veterinary referral centers and specialists. DESIGN Qualitative, focus group interview-based study. SAMPLE 6 focus groups comprised of equine practitioners with experience in referral of clients and patients to equine specialists or referral centers (48 referring veterinarians [rDVMs]). PROCEDURES Focus group sessions were conducted independently and followed a standardized discussion guide consisting of open-ended questions and follow-up probes. Discussions were recorded, and thematic analysis was performed on the content. RESULTS The overarching theme of participants' discussions was that specialists and referral centers are an extension of the care that rDVMs provide to their clients and patients. The 5 areas that participants described as important to this expectation were rDVM-client relationships, rDVM involvement during referral care, collegial rDVM-specialist relationships, communication between rDVMs and specialists, and the boundaries of referral care. Participating practitioners wanted to be involved during the referral process, which was seen as being facilitated by having a collegial relationship with the specialist and through effective communication during the course of referral care. CONCLUSIONS AND CLINICAL RELEVANCE Relationships and communications between rDVMs and specialists are important aspects of equine veterinary medicine. Both rDVMs and specialists are likely to benefit from pursuing opportunities to further their relationship by using up-front communication to establish clear role expectations and clear processes for sharing information.

What would help low-income families? Results from a North American survey of 2-1-1 helpline professionals.

Almost half of young American children live in low-income families, many with unmet needs that negatively impact health and life outcomes. Understanding which needs, proactively addressed, would most improve their lives would allow maternal and child health practitioners and social service providers to generate collaborative solutions with the potential to affect health in childhood and throughout the life course. 2-1-1 referral helplines respond to over 16 million inquiries annually, including millions of low-income parents seeking resources. Because 2-1-1 staff members understand the availability of community resources, we conducted an online survey to determine which solutions staff believed held most potential to improve the lives of children in low-income families. Information and referral specialists, resource managers, and call center directors (N = 471) from 44 states, Puerto Rico, and Canada ranked the needs of 2-1-1 callers with children based on which needs, if addressed, would help families most. Childcare (32%), parenting (29%), and child health/health care (23%) were rated most important. Across all childcare dimensions (e.g. quality affordable care, special needs care), over half of the respondents rated community resources inadequate. Findings will help practitioners develop screeners for needs assessment, prioritize resource referrals, and advocate for community resource development.

Gold Award: Building the Capacity of Frontline Providers to Treat Mental and Substance Use Disorders Among Pregnant and Postpartum Women.

Gold Award: Building the Capacity of Frontline Providers to Treat Mental and Substance Use Disorders Among Pregnant and Postpartum Women.

Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial

BackgroundReplication of intervention research is reported infrequently, limiting what we know about external validity and generalisability. The Smoke Free Homes Program, a minimal intervention, increased home smoking bans by United...

Supporting family child care and quality improvement: findings from an exploratory survey of Illinois child care resource and referral agency staff

Improved quality in home-based child care (family child care and family, friend, and neighbor care) is increasingly recognized as a vital component of early care and education service systems in the U.S. and abroad and is a target of recent federal and state policy initiatives in the U.S. This article presents data from a statewide survey of 73 child care resource and referral specialists across Illinois who work with family child care providers on a regular basis through home visiting, training, and technical assistance. Descriptive findings suggest that specialists who work with family child care providers perform a unique role in the early care and education field. The study examines job roles, common challenges and rewards, and needs for training. Specialists’ training needs include understanding the unique context of family child care, home visiting, coaching, and working with families. Understanding the training and professional development needs of support staff as well as the challenges faced in carrying out this work has the potential to inform state professional development systems as well as other initiatives aimed at improving quality in this sector of the early care and education workforce.

Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial

Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial

E-Referral System by Means of Decision Support System

This research aims to study, analyze, design and develop a web-based referral system for the recommendation of appropriate referred hospitals. Decision support system is applied to reduce time to find provider information that qualify with referral policy, medical specialists, bed, healthcare coverage, how emergency, distance and transportation time. This e-referral system scopes referral area from Siriraj hospital to other health care providers in Bangkok and metropolitan region (Nakhon Pathom, Nonthaburi, Pathum Thani, Samut Prakan and Samut Sakhon), with a total of 240 hospitals. This approach uses a rule-based system to match providers with Siriraj referral policy. Then, these matched providers’ data are analyzed to calculate its weight value.

Analysis of Patients' Needs After Liver Transplantation in Tuscany: A Prevalence Study

BackgroundThe reorganization of the healthcare system in Tuscany aims at characterizing the hospitals as a place for the treatment of acute patients. This event, together with the improvement of long-term survival after orthotopic liver transplantation (OLT), calls for a management network able to ensure effective continuity of care for patient needs in the posttransplantation period. Materials and MethodsAn observational study of prevalence has been carried out with the primary objective to evaluate patients' needs and criticalities both in routine daily life and in urgency in the posttransplantation period and the capacity of the regional health system to support them. A survey, using a semi-structured questionnaire consisting of 27 questions, was administered to all patients resident in Tuscany who underwent transplantation from 2000 to 2010. The survey tool assessed the following: socio-demographic data, personal, family and social difficulties, problems emerged in the clinical routine and urgency, resolution modality, relationships with the general practitioner and the referral specialist, and services the patients would appreciate receiving in their province of residence. ResultsIn the study, 346 patients matched the inclusion criteria of the study, 324 gave telephone consent to participate in the survey, and 225 responded (69.4%). The most frequent difficulties were as follows: depression (39.5%), difficulty in returning to work (29.3%), low income (22.6%), lack of self-sufficiency (22.6%), addictions (19.1%) (cigarette smoking 16.4%), 12.4% eating disorders, and 18.9% other difficulties (social isolation, absence of a family network, and so on). The main reasons for dissatisfaction were as follows: difficulty to obtain the required laboratory tests and lack of a reference structure at the local health facility. Few patients have a referral specialists in their area and most of them primarily refer to the Transplant Center even late after the procedure. DiscussionEarly diagnosis of specific conditions (depression, addiction, and eating disorders) should be implemented in the follow-up period and services such as counselling, dietary support, rehabilitation, and social services should be provided locally. An integrated management system between the transplantation center and the local facilities (hospitals, general practitioners, primary care, and laboratories) should be implemented and referral specialized centers should be identified locally.

Emergence of a university of health sciences: Health professions education in Tanzania

From independence in 1961 Tanzania approached development with an ambitious, socialist agenda, including plans for educating its health workforce to reach rural villagers whose needs German and British rulers had relegated behind those of Europeans, Indians, and Arabs. The new nation's health system was to provide services by employing non-elitist university graduates and auxiliary health workers - educated using resources of poor Tanzanians. This article documents how the Muhimbili University of Allied Health Sciences (MUHAS) evolved from independence, gaining its charter in 2007. Faculty face overwhelming challenges to prepare graduates to lead a health system where the workforce numbers, in every category of auxiliary and professional, have not kept pace with a population that has quadrupled since 1961. The article reviews development of what are now the MUHAS Schools of Dentistry, Medicine, Nursing, Pharmacy, and Public Health and Social Sciences - in their social and economic context. It closes with reflections about important changes for MUHAS since independence. MUHAS and other health professional schools need to collaborate, sharing meager national resources, to dramatically scale up enrollment. Graduates lead the health system and the many schools that educate health workers from village health post managers through referral hospital specialists and researchers. The text is accompanied by a detailed timeline.

Effect of cost efficiency reporting on utilization by physician specialists: A difference-indifference study

To assess whether health plan implementation of specialist profile reports not associated with any health plan administered reward or consequence that measured physician cost efficiency relative to peers, and shared with specialists and primary care referral sources only, were associated with changes in specialist behaviour. Blue Care Network of Michigan is a non-profit statewide Health Maintenance Organization and wholly owned subsidiary of Blue Cross Blue Shield of Michigan. This study used administrative data from 2002 to 2006 and included only providers and adult (ages 18-65) commercial membership located in Southeastern Michigan. A difference-in-difference study design of before and after specialist cost efficiency reporting on six specialties to both specialists and primary care referral sources, but not health plan members, to determine whether specialists who performed worse than peers changed the level of utilization of their own physician services without any direct health plan reward or consequence. Substantive changes were noted for interventional cardiology (-32.3%, P ≤ 0.01), orthopaedics (-13.3%, P ≤ 0.01) and otolaryngology (-15.9%, P ≤ 0.02). Less established, yet negative changes were noted for ophthalmology (-11.9%, P ≤ 0.01), gastroenterology (-3.2%, P = 0.23) and urology (-3.1%, P = 0.52). Simple and transparent reports on specialist cost efficiency distributed to referral sources and specialists using a more laissez-faire style reporting only health plan programme can engage providers and be associated with reductions in utilization. Possible mechanisms include explicit pressure from referral sources or self-motivated change by specialists.