SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article |
Primary care physicians act as gatekeepers for patient referrals to specialist care, diagnosis and management advice, or when specialist procedures are needed. However, unexplained variations in referral rates by primary care physicians have been noted. Inappropriate referrals have negative implications for patients, for the costs of care and for healthcare systems. This summary describes the evidence on interventions to improve referrals from primary care to secondary care.
Key messages
►Professional education that includes guidelines, checklists, video materials and educational outreach by specialists proba-bly improves the quantity and quality of referrals
►Joint primary care practitioner and consultant sessions probably result in improved patient outcomes
► Organisational interventions that may improve referral rates and referral appropriateness include:
- The provision of physiotherapy services in primary care
- Obtaining a second, in-house assessment of referrals
- Dedicated appointment slots at secondary levels for each primary care practice
►Professional education that only includes the passive dis-semination of referral guidelines probably leads to little or no difference in both the quantity and quality of referrals.
►The effects of financial incentives on referral rates are un-certain.
People making decisions about referrals between primary care and secondary care levels.
Akbari A, Mayhew A, Al-Alawi MA, et al. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database of Systematic Reviews 2008, Issue 4.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Primary care providers make decisions about which patients to refer to specialists for advice on diagnosis or management, and for specialised procedures and care. However, evidence suggests that such referral processes could be improved. Some patients may be referred inappropriately or they may not be referred when they ought to be; others are referred for unnecessary tests or procedures.
A previous systematic review by Grimshaw (1998) found relatively little research evaluating interventions to improve referral behaviour. Several subsequent studies have been completed, and the summary presented here is based on a review in which the effectiveness of interventions to improve referrals from primary care to specialist care was assessed.
| About the systematic review underlying this summary | ||
|
Review objectives: To assess the effects of interventions to change primary care outpatient referral rates or improve outpatient referral appropriateness
|
||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
|
Study designs & interventions |
Randomized trials, non-ran- domized trials, controlled be- fore-after studies, and inter rupted time series studies of interventions to change out- patient referral rates or im- prove outpatient referral ap- propriateness.
|
17 studies were found, of which 9 eval- uated professional educational inter- ventions, 4 evaluated organisational in- terventions, and 4 evaluated financial interventions. Of the 17 studies identi- fied, 10 were randomized trials, 1 was a non-randomized trial, 5 were controlled before-after studies, and 1 was an in- terrupted time series study. |
|
Participants |
Primary care physicians, including general practitioners, family doctors, family physicians, family practitioners, and other physicians working in primary healthcare settings, who fulfil primary healthcare tasks. |
Primary care physicians and specialist physicians. |
|
Settings |
Primary care and hospitals.
|
Primary care and hospitals.
|
|
Outcomes |
Objectively measured pro- vider performance in a healthcare setting (for exam- ple, referral rates or appropri- ateness of referral) or health outcomes. |
Number of primary care visits, referral rates, appropriateness of referrals, case mix of referrals, appropriateness of specialist investigations, costs of pre- scriptions. |
|
Date of most recent search: October 2007
|
||
|
Limitations: This is a well-conducted systematic review with only minor limitations
Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database of Systematic Reviews 2008, Issue 4. |
||
Akbari A, Mayhew A, Al-Alawi MA, et al. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database of Systematic Reviews 2008, Issue 4.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review identified 17 studies and, in total, 23 separate comparisons were made. Nine studies (14 comparisons) evaluated professional educational interventions, 4 studies evaluated organisational interventions and 4 studies (5 comparisons) evaluated financial interventions. The majority of the studies (16) were from high-income settings.
1) Professional education
Interventions included: the passive dissemination of local specialist referral guidelines; the dissemination of referral guidelines using structured referral sheets (using checklists designed to be completed at the point of referral as a way to prompt primary care physicians about the key elements of their own pre-referral investigations and patient management); and secondary care, provider-led, educational strategies.
►The passive dissemination of referral guidelines and check-lists probably results in little or no improvement in the quan-tity or quality of referrals. The certainty of this evidence is moderate.
► The combination of referral guidelines and structured checklists, together with video materials or educational out-reach, probably improves referral rates, referral appropriate-ness, and pre-referral patient management by primary care physicians. The certainty of this evidence is moderate.
►Referral guidelines with structured referral sheets probably result in little or no change in patient outcomes. The certainty of this evidence is moderate.
Joint primary care practitioner and consultant sessions probably result in improved patient outcomes. The certainty of this evidence is moderate.
Professional education |
||||
|
People: Primary care physicians Intervention: Referral guideline dissemination, with or without structural referral sheets or secondary care provider-led education Comparison:Routine referrals, i.e. no intervention |
||||
|
Outcomes
|
Impact
|
Certainty of the evidence
|
||
|
Referral rates
|
Passive guideline dissemination alone (2 studies) and referral guidelines with structured referral sheets (2 studies) resulted in little or no change in referral rates. Secondary provider-led education resulted in increased referrals for dyspepsia (relative change: +54%) (1 study); decreased referrals for orthopaedic surgery (relative change: ‑47.9%) (1 study); and no changes in referrals for tracer conditions (1 study). |
|
||
|
Patient load
|
A multi-faceted intervetion including guidelines, education, referral sheets, new staff and equipament changes, resulted in a 50% referral reduction (1 study). Referral guidelines, structured referral sheets, educational meeting, and open-access investigations for the assessment of urological conditions resulted in no differences in number of primary care consultations, but reduced waiting times for first specialist appointments (ratio of means of waiting times: 0.7, 95% CII 0.55 to 0.89) and increased the probability of a management decision being reached after one hospital appointment (OR 5.8; 95%CI 2.9 to 11.5)(1 study) |
|
||
| Appropriateness of referrals |
The use of a checklist and video by general practitioners probably improves referral appropriateness (1 study) Educational outreach led by secondary care providers probably improves referral appropriateness for specialised investigations of dyspepsia (1 study). Passive guideline dissemination, with or without outreach, probably leads to little or no difference in referral appropriateness for tracer conditions (1 study). |
|
||
|
Patient management |
Passive guideline dissemination, with or without outreach, probably leads to little or no difference in hospital patient management of tracer conditions (1 study). Referral guidelines together with structured referral sheets probably improve pre-referral and management of fertility problems by primary care practitioners (2 studies); this form of intervention also resulted in improved compliance with urological referral guidelines, and reduced waiting times for hospital outpatient appointments (1 study). Educational outreach by secondary care providers resulted in no changes in the number of investigations of orthopaedic patients, but did result in an increase in the use of injection therapy by primary care practitioners (30.6% study vs. 11.7% control, p<0.001) (1 study). |
|
||
| Patient outcomes |
Referral guidelines with structured referral sheets resulted in little or no change in patient outcomes for urological conditions at 12 months (1 study). Joint primary care practitioner and orthopaedic consultant sessions resulted in an increase in patients who were disorder‑free after a year (35.7% study vs. 23.7% control, p<0.05) (1 study). |
|
||
| GRADE: GRADE Working Group grades of evidence (see above and last page) | ||||
2) Organisational interventions
Organisational interventions include changes in who delivers healthcare, and how such care is organised or delivered. Four studies evaluated the effects of organisational changes on referrals to secondary care. These included an evaluation of physician disciplines (for example, whether the physicians were trained in family medicine or internal medicine), the provision of physiotherapy services in primary care, obtaining a second opinion in-house on referrals, and providing appointment slots within secondary care services in proportion to the size of the referring primary practice.
► The provision of physiotherapy services at the primary care level may decrease the number of referrals to orthopaedic and rheumatology specialist services. The cer-tainty of this evidence is low.
► Second opinions in-house may reduce referral rates and improve referral appropri-ateness. The certainty of this evidence is low.
►Dedicated appointment slots at secondary levels for each primary care practice may decrease referral rates to specialist care. The certainty of this evidence is low.
►Practices in which physicians are trained in family medicine compared to practices in which physicians are trained in internal medicine may result in a reduction in referrals and fewer visits to acute and emergency care. The certainty of this evidence is low.
Organisational interventions |
||||
|
People: Primary care physicians |
||||
|
Outcomes
|
Impact
|
Certainty of the evidence (GRADE) |
||
| Referral rates |
Providing physiotherapy in primary care may decrease orthopaedic and rheumatology referral rates (1 study); allocation of specialist appointment slots for primary care practices may improve referral rates (1 study); 30% of referrals were evaluated as “unnecessary” according to in-house, second opinions (1 study) |
|
||
| Patient load |
Family medicine practices referred less, had fewer emergency room attendances, fewer acute care clinic visits, and fewer other non-primary care clinic attendances compared with internal medicine physicians (1 study) |
|
) | |
| GRADE: GRADE Working Group grades of evidence (see above and last page) | ||||
3) Financial interventions
Four studies evaluated financial interventions: these included changes in provider remuneration, participation in fundholding schemes (UK National Health Service), and charging patients equivalent rates for being seen by a private specialist as by a hospital-based specialist. The certainty of the evidence provided by these studies was very low.
► The effects of financial interventions on referral rates are uncertain because the certainty of this evidence is very low.
A multi-faceted intervention including guidelines, education, referral sheets, new staff and equipment changes, resulted in a 50% referral reduction (1 study).
Referral guidelines, structured referral sheets, educational meetings, and open-access investigations for the assessment of urological conditions resulted in no differences in number of primary care consultations, but reduced waiting times for first specialist appointments (Ratio of means of waiting times: 0.7, 95% CI 0.55 to 0.89) and increased the probability of a management decision being reached after one hospital appointment (OR 5.8; 95%CI 2.9 to 11.5)(1 study).| Findings | Interpretation* |
|---|---|
|
APPLICABILITY
|
|
|
►Most of the included studies were conducted in high-income countries and within particular health systems. These systems included, for example, the publicly funded National Health System in the UK, and Medicaid in the USA. |
►The studies were based in well-resourced environments in which primary care services were provided by an adequate number of practitioners, and relatively easy access was available to specialist services. Such scenarios are not necessarily available or possible in many low- income countries. The study findings therefore need to be interpreted with caution when applied to low-income countries. |
|
EQUITY
|
|
|
►The studies were based largely in urban settings, in populations with relative equity in health and access to healthcare. |
►The interventions may increase inequity if they are not applied or adapted to populations in rural or remote areas or if there are substantial socio- economic variations or discrepancies amongst those receiving the intervention. |
|
ECONOMIC CONSIDERATIONS
|
|
|
►Costings were included in several studies but full economic evaluations were seldom reported. |
►Limited information is available on the cost- effectivenes of the interventions. Local costings should therefore be undertaken, particularly in settings differing from the original investigations. |
|
MONITORING & EVALUATION
|
|
|
►Studies were conducted over relatively short time periods (a maximum, for example, of two years), and in health systems in high-income countries. The studies focused on the measurement of process outcomes; very few studies assessed patients’ health outcomes. |
►Any interventions implemented based on the review findings should include a monitoring component to assess the performance of the intervention within the context. Evaluations should measure the appropriateness of the referrals, not only the number of referrals. Patient outcomes should also be considered. |
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
|
Related literature
Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman AD, O’Brien M. Changing provider behavior: An overview of systematic reviews of interventions. Medical Care 2001; 39:Supplement 2, II-2 - II-45.
Getting evidence into practice. Effective Health Care 1999; 5:(1). www.york.ac.uk/inst/crd/pdf/ehc51.pdf
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C, Vale L et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004; 8:(6). www.hta.nhs.uk/fullmono/mon806.pdf
NorthStar – How to design and evaluate quality improvement interventions in healthcare: NorthStar is a tool providing a range of information, checklists, examples and tools based on current research on how best to design and evaluate quality improvement interventions. www.rebeqi.org/?pageID=36&ItemID=18
Coulter A. Does the referral system work? Roland M, Coulter A, editor(s). Hospital Referrals. Oxford: Oxford University Press, 1992.
Wilkin D. Patterns of referral: explaining variation. Roland M, Coulter A, editor(s). Hospital Referrals.
Oxford: Oxford University Press, 1992.
This summary was prepared by
Dudley LD, Faculty of Health Sciences, University of Stellenbosch and Tomás
Pantoja, Escuela de Medicina,
Pontificia Universidad Católica de Chile, Chile
Conflict of interest
None declared. For details, see: www.supportsummaries.org/coi
Acknowledgements
This summary has been peer reviewed by: Harriet Nabudere, Ayub Akbari,
and Hanna Bergman
This review should be cited as
Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C.
Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database of
Systematic Reviews 2008, Issue 4. Art. No.: CD005471. DOI: 10.1002/14651858.CD005471.pub2.
The summary should be cited as
Dudley LD, Pantoia T. Do educational, organisational or financial interventions improve referrals from primary to secondary care? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org
Keywords
All Summaries:
evidence-informed health policy, evidence-based, systematic review, health sys-tems research, healthcare, low and middle-income countries, developing coun-tries, primary healthcare, primary care referral, patient referral, specialist referral, referral behaviour
