Quality indicators and variation in primary care: modelling GP referral patterns

Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study

OBJECTIVES

To estimate the impact of altering referral thresholds from out-of-hours services on older patients' further use of health services and risk of death.

DESIGN

Cohort study using patient data from primary and specialised health services and demographic data from Statistics Norway and the Norwegian Cause of Death Registry.

SETTING

Norway PARTICIPANTS: 491 653 patients aged 65 years and older contacting Norwegian out-of-hours services between 2008 and 2016.

ANALYSIS

Multivariable adjusted and instrumental variable associations between referrals to hospital from out-of-hours services and further health services use and death for up to 6 months.Physicians' proportions of acute referrals of older, unknown patients from out-of-hours work were used as an instrumental variable ('physician referral preference') for their threshold of referral for such patients whose clinical presentations were less clear cut.

RESULTS

For older patients, whose referrals could be attributed to their physicians' threshold for referral, mean length of stay in hospital increased 3.30 days (95% CI 3.13 to 3.27) within the first 10 days, compared with non-referred patients. Such referrals also increased 6 months use of outpatient specialist clinics and primary care physicians. Importantly, patients with referrals attributable to their physicians' threshold had a substantially reduced risk of death the first 10 days (HR 0.53, 95% CI 0.31 to 0.91), an effect sustaining through the 6-month follow-up period (HR 0.72, 95% CI 0.54 to 0.97).

CONCLUSIONS

Out-of-hours patients whose referrals are affected by physician referral threshold contribute substantially to the use of health services. However, the referral seems protective by reducing the risk of death in the first 6 months after the referral. Thus, raising the threshold for referral to lower pressure on overcrowded emergency departments and hospitals should not be encouraged without ensuring the accuracy of the referral decisions, ideally through high-quality randomised controlled trial evidence.

Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts

BACKGROUND

There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use.

OBJECTIVE

To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety.

METHODS

This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design.

RESULTS

Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death.

CONCLUSIONS

GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.

Referral practices of medical practitioners in central South Africa to physiotherapy services for patients living with musculoskeletal conditions

BACKGROUND

Musculoskeletal diseases (MSDs) are a major cause of disability worldwide. It is essential to address effective MSD management, including appropriate referrals to physiotherapists and other healthcare professionals. Limited information is available regarding the referral practices of medical practitioners for patients with MSD. The doctors' referral practices to physiotherapists can impact the patient population and the South African health system.

OBJECTIVES

To investigate or understand the referral practices of medical practitioners in Bloemfontein, South Africa, to physiotherapy services, for individuals living with MSD.

METHOD

A quantitative study approach, implementing a semi-structured questionnaire, was used. Forty-nine participants completed the questionnaire.

RESULTS

The referral of patients with MSDs by medical practitioners to physiotherapy services varied and multidimensional factors influenced their referral practices. Medical practitioners were unsure of the specific role played by physiotherapists in the management of individuals living with MSD. A need for improved relationships and communication between medical practitioners and physiotherapists was identified.

CONCLUSIONS

Medical practitioners regularly referred individuals living with MSD to physiotherapists, but referral practices should be optimised in terms of evidence-based practice and the use of specialised physiotherapy services. In an attempt to decrease the burden of MSD, adequate awareness should be created for improved referral practices between medical practitioners and physiotherapists.

CLINICAL IMPLICATIONS

Collaborative development of detailed guidelines for apt, evidence-based referrals should be developed, to ensure early detection and management of individuals living with MSD. Health care professionals should be educated and encouraged to refer individuals living with MSD to physiotherapists for appropriate management with clinical benefits including improvement of HRQOL and cost effectiveness of this management not only to the individual but also to the health system in South Africa. Physiotherapists should try to communicate their role in the treatment of individuals living with MSD to medical practitioners for the benefit of the patient.

Do Health Service Use and Return-to-Work Outcomes Differ with GPs' Injured-Worker Caseload?

Purpose To determine whether healthcare use and return-to-work (RTW) outcomes differ with GPs' injured-worker caseload. Methods Retrospective analyses of the Compensation Research Database, which captures approximately 85% of all injured worker claims in Victoria, Australia was conducted. Four injured-worker caseload groups were examined that represented the 25th, 50th, 75th, and 100th percentiles of claimants seen per GP over the 8-year study period (2003-2010): (i) 1-13 claimants; (ii) 14-26 claimants; (iii) 27-48 claimants; and (iv) 49+ claimants (total claims, n = 124,342; total GPs, n = 9748).The characteristics of claimants in each caseload group, as well as the influence of caseload on three outcomes relevant to RTW (weekly compensation paid, work incapacity days, medical-and-like costs), were examined. Results Distinct profiles for high versus low caseload groups emerged. High caseload GPs treated significantly more men in blue collar occupations and issued significantly more 'alternate duties' certificates. Conversely, low caseload GPs treated significantly more women in white collar occupations, predominantly for mental health injuries, and issued significantly more 'unfit-for-work' certificates. Few significant differences were found between the two intermediate GP caseload groups. High caseload was associated with significantly greater medical-and-like costs, however, no caseload group differences were detected for weekly compensation paid or duration of time-off-work. Conclusions Training GPs who have a low injured-worker caseload in workers' compensation processes, utilising high caseload GPs in initiatives involving peer-to-peer support, or system changes where employers are encouraged to provide preventive or rehabilitative support in the workplace may improve RTW outcomes for injured workers.

Evaluating quality indicators for physical therapy in primary care

OBJECTIVE

To evaluate measurement properties of a set of public quality indicators on physical therapy.

DESIGN

An observational study with web-based collected survey data (2009 and 2010).

SETTING

Dutch primary care physical therapy practices.

PARTICIPANTS

In 3743 physical therapy practices, 11 274 physical therapists reporting on 30 patients each.

MAIN OUTCOME MEASURES

Eight quality indicators were constructed: screening and diagnostics (n= 2), setting target aim and subsequent of intervention (n = 2), administrating results (n = 1), global outcome measures (n = 2) and patient's treatment agreement (n = 1). Measurement properties on content and construct validity, reproducibility, floor and ceiling effects and interpretability of the indicators were assessed using comparative statistics and multilevel modeling.

RESULTS

Content validity was acceptable. Construct validity (using known group techniques) of two outcome indicators was acceptable; hypotheses on age, gender and chronic vs. acute care were confirmed. For the whole set of indicators reproducibility was approximated by correlation of 2009 and 2010 data and rated moderately positive (Spearman's ρ between 0.3 and 0.42 at practice level) and interpretability as acceptable, as distinguishing between patient groups was possible. Ceiling effects were assessed negative as they were high to extremely high (30% for outcome indicator 6-95% for administrating results).

CONCLUSION

Weaknesses in data collection should be dealt with to reduce bias and to reduce ceiling effects by randomly extracting data from electronic medical records. More specificity of the indicators seems to be needed, and can be reached by focusing on most prevalent conditions, thus increasing usability of the indicators to improve quality of care.

Assessment of referrals to a multidisciplinary outpatient clinic for patients with back pain

Objective

Each year our multidisciplinary outpatient clinic for patients with back pain receives a large number of referrals from primary care physicians, manual physiotherapists, and chiropractors. We wanted to assess the quality of the referrals regarding the information provided about case history, clinical findings, and results from additional investigations.

Material and methods

Two hundred and eighty six consecutive referrals received in the time period from 1 October 2008 to 1 March 2009 were reviewed. We investigated if the referrals contained 12 given items. The items were defined by consensus of the broad range of specialists working at the multidisciplinary outpatient clinic. All registered items were regarded as useful when assigning patients with a priority and appropriate caregiver at the outpatient clinic. The 12 items that our group felt were reflective of good referrals were information about occupational status, duration of symptoms, pain distribution, sensory symptoms, use of analgesics, alleviating and/or aggravating factors, systems enquiry (i.e. urination, bowel movements, and sleep), provided treatment, deep tendon reflexes, motor function, sensory examination, and radiculopathy tests (i.e. straight leg raise and/or foraminal compression test).

Results

Two hundred and fifty six (89·5%) referrals were from primary care physicians, and the remaining came from physicians in internships, manual physiotherapists, and chiropractors. Six (2·1%) referrals contained all 12 items. On average each referral contained 5·95 items (95% CI: 5·66–6·25). Information about analgesics, sensory symptoms, systems enquiry, and alleviating and aggravating factors was most frequently missing. Information about provided treatment, motor function, deep tendon reflexes, clinical tests, and occupational status was included in about half of the referrals. In 27·3% of the referrals from primary care physicians information about clinical findings was missing. Referrals from manual physiotherapists contained statistically significant more information (9·67 items, 95% CI: 7·63–11·70) than from the other groups (P<0·001). The number of patients registered with each primary care physician did not affect the number of items in the referrals.

Conclusion

Many of the referrals were inadequate. Inadequate referrals can lead to prolonged waiting time for examination and treatment. Referrals with relevant information about patient history and clinical findings are essential in order to assign patients with an appropriate caregiver at the outpatient clinic and to determine if and which diagnostic imaging findings are of clinical relevance.