Explore the vast range of titles available.

Background The Chinese government has introduced a series of hierarchical medical policies to ensure continuity of care, but referrals remain difficult to implement effectively. This study aimed to evaluate the chronic disease referral network and explore the problems associated with the specific implementation of referrals. Methods This study was a repeated cross-sectional study of monthly data collected between August 2017 and December 2023 in Luohu district, Shenzhen, China. Social network analysis was used to construct a referral network for chronic disease patients. Density, degree centrality, and betweenness centrality were calculated to assess the relationships and status among different levels of care and their trends. Results Over seven years, 104,682 chronic disease patients were referred, with a predominance of downward referrals. The number of upward referrals (Z = 2.5776, P trend < 0.01) and downward referrals (Z = 4.7723, P trend < 0.001) increased significantly. Primary care facilities (PCFs) were strongly associated with the tertiary hospital (0.51–0.98). The out-degree of all levels of medical institutions showed a significant increasing trend ( P trend < 0.05). The coronavirus disease 2019 (COVID-19) pandemic did not cause significant level changes in network metrics but accelerated the upward trend in the out-degree of secondary hospitals ( P  < 0.05). The in-degree of secondary hospitals and PCFs showed a significant increasing trend ( P trend < 0.01). Public PCFs had significantly higher network metrics compared to private PCFs ( P  < 0.001). Conclusions The referral network has a vertical flow pattern conducive to the division of labour, cooperation, and resource integration of medical institutions in the region, and a hierarchical medical order is taking shape. However, poor communication between secondary hospitals and other institutions, high demand for data informatisation, and the gap between private and public PCFs may hinder further progress.

Telemedicine can help specialists in providing efficient care to patients from a distance and it has been growing steadily in healthcare. This study aims to provide an operational perspective by investigating the effect of telemedicine on patients' choices, healthcare providers' service decisions, service quality and total social welfare. We propose an optimization model that incorporates patients' choices and physicians' actions under two scenarios: full coverage and partial coverage. We analyze the model and conduct numerical experiments to explore the impact of telemedicine in a referral-based healthcare system with heterogeneous patients. The findings show that telemedicine can induce greater collaboration between generalists and the specialist, which would result in the specialist spending less time on each patient. Interestingly, we find that after the introduction of telemedicine, the average quality cost decreases under full coverage but increases under partial coverage. Moreover, the introduction of telemedicine could lead to higher social welfare as it improves the accessibility of services to patients, especially in rural areas. Finally, this study also demonstrates that the referral-based healthcare system may benefit more from telemedicine when there is a heavier travel burden for patients or a higher financial incentive for generalists. The introduction of telemedicine mainly contributes to the patients' service accessibility, particularly for patients in remote areas, and can foster closer collaboration between generalists and specialists. However, in hospitals where medical resources are already strained, it may worsen specialist overuse and lead to lower service quality. These findings highlight that telemedicine is not universally beneficial. The policymaker should consider regional coverage conditions and use targeted financial incentives to improve its effectiveness within referral-based healthcare systems.

Primary care physicians' (PCP) referral rates to digital health programs are highly variable. This study explores whether knowledge of the digital remote blood pressure monitoring (RBPM) program and information on referral patterns influence PCPs' intention to refer patients. This study aims to examine the relationship between PCPs' knowledge of the digital RBPM program and information on their own prior referral rates versus their own with their peers' referral rates and their likelihood to refer patients to the digital RBPM program. This is a mixed methods study integrating quantitative analysis of electronic health record data regarding the frequency of PCPs' referrals of patients with hypertension to a digital health program and quantitative and qualitative analyses of survey data about PCPs' knowledge of the program and their intention to refer patients. PCPs responded to a clinical vignette featuring an eligible patient. They were randomized to either receive their own referral rate or their own plus their peers' referral rate. They were assessed on their intent to refer eligible future patients. Descriptive and multivariable linear regression analyses examined participant characteristics and the factors associated with their intent to refer patients. Narrative reasons for their intention to refer were thematically analyzed. Of the 242 eligible PCPs invited to participate, 31% (n=70) responded to the survey. From electronic health record data, the mean referral rate of patients per PCP was 11.80% (SD 13.30%). The mean self-reported knowledge of the digital health program was 6.47 (SD 1.81). The mean likelihood of referring an eligible patient (on a scale of 0 to 10, with 0 being not at all, and 10 being definitely) based on a vignette was 8.54 (SD 2.12). The own referral data group's mean likelihood to refer was 8.91 (SD 1.28), whereas the own plus peer prior referral data group was 8.35 (SD 2.19). Regression analyses suggested the intention to refer the vignette patient was significantly associated with their knowledge (coefficient 0.46, 95% CI 0.20-0.73; P<.001), whereas the intention to refer future patients was significantly associated with their intent to refer the patient in the vignette (coefficient 0.62, 95% CI 0.46-0.78; P<.001). No evidence of association was found on receiving own plus peer referral data compared with own referral data and intent to refer future patients (coefficient 0.23, 95% CI -0.43 to 0.89; P=.48). Physicians' intention to refer patients to a novel digital health program can be extrapolated by examining their intention to refer an eligible patient portrayed in a vignette, which was found to be significantly influenced by their knowledge of the program. Future efforts should engage PCPs to better inform them so that more patients can benefit from the digital health program.

We use a detailed operational and clinical data set from a maternity hospital to investigate how workload affects decisions in gatekeeper-provider systems, where the servers act as gatekeepers to specialists but may also attempt to serve customers themselves, albeit with a probability of success that is decreasing in the complexity of the customers’ needs. We study the effect of workload during a service episode on gatekeepers’ service configuration decisions and the rate at which gatekeepers refer customers to a specialist. We find that gatekeeper-providers (midwives in our context) make substantial use of two levers to manage their workload (measured as patients per midwife): they ration resource-intensive discretionary services (epidural analgesia) for customers with noncomplex service needs (mothers with spontaneous onset of labor) and, at the same time, increase the rate of specialist referral (physician-led delivery) for customers with complex needs (mothers with pharmacologically induced labor). The workload effect in the study unit is surprisingly large and comparable in size to those for leading clinical risk factors: when workload increases from two standard deviations below to two standard deviations above the mean, noncomplex cases are 28.8% less likely to receive an epidural, leading to a cost reduction of 8.7%, while complex cases are 14.2% more likely to be referred for a physician-led delivery, leading to a cost increase of 2.6%. These observations are consistent with overtreatment at both high and low workload levels, albeit for different types of patients, and suggest that smoothing gatekeeper workload would reduce variability in customer service experience. This paper was accepted by Serguei Netessine, operations management .

Background Considering the challenges of the referral system in the family physician program and the impact of COVID-19 pandemic on the performance of the relevant ministry’s programs, it is necessary to assess the performance of the referral system. This study was conducted with the aim of investigating the performance of the family physician referral system before and during COVID-19 in Golestan province. Methods The present repeated cross-sectional study was conducted on secondary data Recorded of 786,603 cases referred and cared by family physicians (including information on physicians’ and midwives’ visits, percentage of prescriptions and other information) in Golestan province from 2017 to 2022 in a census and retrospective manner. Data were collected using the reference ratio checklist and analyzed with SPSS 23 software at a significance level of less than 0.05. Results Referral to 10 types of medical specialties and 10 indicators of family physicians referral before and during COVID-19 were investigated. The highest and lowest percentages of referrals by family physicians were belonged to the surgical (17.6%) and infectious (2%) specialists before COVID-19, and internal medicine (15.07%) and urology (3%) specialists during COVID-19, respectively. Referral due to physician’s diagnosis increased by 19.3% compared to before Covid-19, target group increased by 0.86%, care decreased by 2.69% and reverse referral decreased by 36.1%. The amount of population covered by rural insurance, the amount of visits to midwives, the percentage of electronic appointments in the post-Covid-19 years have changed significantly compared to before.it (P-Value < 0.05). Conclusion The present study showed that the COVID-19 pandemic had a significant impact on family physician referral indicators, such as the process of referral to specialists, drug prescriptions, insurance coverage, one-time service population, and patient care, which can be used to eliminate the weaknesses and Strengthening the strengths of the programs being implemented in the face of possible pandemics is very useful and effective and can be used in the country. Finally, the results obtained from this research provide evidence to discuss the importance of the family physicians care and referral system in the face of special conditions for quality control in health policies.

Background Worldwide, many patients with cancer, are infrequently referred to palliative care or are referred late. Oncologists and haematologists may act as gatekeepers, and their views may facilitate or hinder referrals to palliative care. This review aimed to identify, explore and synthesise their views on referrals systematically. Methods Databases of MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science and Cochrane were searched for articles from 01/01/1990 to 31/12/2019. All studies were scored for their methodological rigour using Hawker’s tool. Findings were synthesised using Popay’s narrative synthesis method and interpreted using a critical realist lens and social exchange theory. Results Out of 9336 initial database citations, 23 studies were included for synthesis. Five themes were developed during synthesis. 1. Presuppositions of oncologists and haematologists about palliative care referral: Role conflict, abandonment, rupture of therapeutic alliance and loss of hope were some of the presuppositions that hindered palliative care referral. Negative emotions and perception of self-efficacy to manage palliative care need also hindered referral. 2. Power relationships and trust issues: Oncologists and haematologists preferred to gatekeep the referral process and wished to control and coordinate the care process. They had diminished trust in the competency of palliative care providers. 3. Making a palliative care referral: A daunting task: The stigma associated with palliative care, navigating illness and treatment associated factors, addressing patient and family attitudes, and overcoming organisational challenges made referral a daunting task. Lack of referral criteria and limited palliative care resources made the referral process challenging. 4. Cost-benefit of palliative care referral: Pain and symptom management and psychosocial support were the perceived benefits, whereas inconsistencies in communication and curtailment of care were some of the costs associated with palliative care referral. 5. Strategies to facilitate palliative care referral: Developing an integrated model of care, renaming and augmenting palliative care resources were some of the strategies that could facilitate a referral. Conclusion Presuppositions, power relationships, trust issues and the challenges associated with the task of referrals hindered palliative care referral. Oncologists and haematologists appraised the cost-benefit of making a palliative care referral. They felt that an integrated model of care, changing the name of palliative care and augmenting palliative care resources might facilitate a referral.

Background Outpatient child and adolescent mental health services (CAMHS) are faced with the challenge of balancing increasing demands with limited resources. An additional challenge is high rejection rates of referrals which causes frustration for referring agents and families. In order to effectively plan and allocate available resources within CAMHS there is a need for up-to-date knowledge on referral patterns and factors associated with rejection of referrals. Methods In this cross-sectional observational study we did a retrospective review of all referrals ( n  = 1825) for children (0–18) referred for assessment at the outpatient CAMHS of the North Denmark Region in 2018. Results The most common referral reasons to CAMHS were attention deficit disorder (ADHD/ADD) (27.9%), autism spectrum disorder (22.4%), affective disorders (14.0%) and anxiety disorders (11.6%). The majority of referrals came from general practitioners, but for neurodevelopmental disorders educational psychologists were the primary referral source. Re-referrals constituted more than a third of all referrals (35.9%). Children in care were overrepresented in this clinical sample and had an increased risk (Adj. OR 2.54) of having their referrals rejected by CAMHS. Referrals from general practitioners were also associated with an increased risk of rejection (Adj. OR 3.29). Conclusions A high proportion of children with mental disorders have a repeated need for assessment by CAMHS. There is a need for future research on predictors of re-referral to outpatient services to identify potential targets for reducing re-referral rates as well as research on how to optimize service provision for children with a repeated need for assessment. General practitioners are the main gatekeepers to CAMHS and research on interventions to improve the referral process should be aimed towards general practitioners.

A lifestyle front office (LFO) in the hospital is a not yet existing, novel concept that can refer patients under treatment in the hospital to community-based lifestyle interventions (CBLI). The aim of this study was to identify implementation barriers and facilitators regarding the implementation of an LFO in the hospital from the perspective of CBLI-professionals and to develop evidence-based implementation strategies to reduce these identified barriers. We conducted semi-structured interviews until data saturation, with 23 lifestyle professionals working in the community. A semi-structured topic guide was used, inquiring about (1) community-based lifestyle interventions; (2) their views about referral from the LFO; and (3) their preferences, needs and recommendations for collaboration with the LFO in the hospital. The online interviews lasted on average 46 minutes, were audio-recorded and transcribed verbatim. A thematic content analysis was conducted. Found barriers and facilitators regarding the LFO where mapped using the consolidated framework for implementation research (CFIR) whereafter evidence based strategies were developed using the CFIR-Expert Recommendations for Implementing Change Strategy Matching Tool V.1.0 (CFIR-ERIC). Barriers and facilitators were divided into two main themes: 1) barriers and facilitators related to the referral from LFO to CBLI (i.e. financial, cultural, geographical, quality) and 2) barriers and facilitators related to the collaboration between LFO and CBLI (i.e. referral, communication platform and partnership). Thirty-seven implementation strategies concerning 15 barriers were developed and clustered into six overarching strategies: identify referral options, determine qualifications lifestyle professionals, develop support tools, build networks, facilitate learning collaboratives, and optimize workflow. In this study, barriers and facilitators for the development of the LFO were found and matching implementation strategies were developed. Practical improvements, like identifying specific referral options or develop support tools, can be implemented immediately. The implementation of other strategies, like connecting care pathways in basic services, primary, secondary and tertiary care, will take more time and effort to come to full potential. Future research should evaluate all implemented strategies.

Background Public healthcare delivery in India faces several operational challenges, including congestion and long wait times at higher-level facilities and low utilization of lower-level facilities. Effective referral mechanisms can help address these issues. However, before designing and implementing potential new referral mechanisms, it is essential to understand patient and provider views. The objective of this study is to quantitatively assess patient and provider perceptions of both existing and potential new referral mechanisms and their association with patient socioeconomic and demographic attributes. Methods A cross-sectional survey was conducted to record and examine patient referral mechanisms – from patient and provider perspectives - currently operational at public healthcare facilities in an urban Indian district. Patient and doctor perceptions regarding potential new referral mechanisms were also assessed, such as medical referral with noncompliance penalties for out-of-turn visits to higher-level facilities, and operational referral, which involves referring patients to same-tier facilities with lower patient loads. Multinomial logistic regression was used to identify statistically significant associations between patient perceptions and socioeconomic and demographic attributes. Results Survey results provided quantitative evidence of nonadherence to existing referral mechanisms by a significant proportion of patients, and logistic regression analyses showed statistical associations between patient socioeconomic and demographic variables and their willingness towards implementation of potential new referral mechanisms. Conclusions Based on study findings, existing referral mechanisms can be strengthened, and potential new referral mechanisms, with appropriate refinements, can be introduced to mitigate overcrowding, care provision delays, and other operational challenges in Indian healthcare delivery.

The Indian healthcare system continues to remain unstructured leading to sub-optimal health outcomes, not just in rural but even in urban areas. While physicians play a crucial role in shaping treatment trajectories and managing the referral process, their perspective on the referral system has received very limited academic attention in India. This study attempts to understand the archetypical physician's referral mechanism and the factors influencing their referral practices. This study also highlights the challenges and possible solutions in operationalising an efficient referral process as suggested by the professionals. In-depth qualitative interviews were conducted with sixty-two physicians consisting of both general physicians and specialists from 19 different disciplines, associated with public and private hospitals in Bengaluru, India. The data, thus collected, was subjected to thematic analysis to generate relevant themes. Five themes emerged from the thematic analysis from a phenomenological perspective based on the physicians' lived experience. First of all, specialist physicians' availability, accessibility, experience, and reputation strongly influenced referral recommendations. It was also observed that due to lack of a comprehensive healthcare provider database, personal connections and professional networks are utilised. Moreover, although physicians prioritize patients' affordability and accessibility factors, referral counselling and caregiver-patient communication remained inadequate and required formalization. While the fourth theme clusters around several barriers related to communication, system inefficiencies, lack of awareness, accessibility and affordability among patients; the final theme suggests that the physicians emphasized on urgent need for clear guidelines, regulations and policies to streamline and monitor the referral system. This research highlights that physicians recognize the systemic gaps leading to unsolicited health outcomes; yet they are helpless in most cases. The participants emphasized that robust information systems connecting all relevant stakeholders are essential. The exploration reveals that the system will not adopt a structured referral method without the government taking interest in it.