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Goldthorpe J, Walsh T, Tickle M, Birch S, Hill H, Sanders C, Coulthard P, Pretty IA. An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundOral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.Research questionsCan an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?DesignA mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.SettingThe ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.ParticipantsPatients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.InterventionsA consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.Main outcome measuresDiagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.ResultsIn the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.ConclusionsImplementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.Study limitationsThe geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.Future workThe findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanna Goldthorpe
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Martin Tickle
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stephen Birch
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Harry Hill
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Caroline Sanders
- Division of Population Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Paul Coulthard
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Iain A Pretty
- Division of Dentistry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Diagnostic accuracy of maxillofacial trauma two-dimensional and three-dimensional computed tomographic scans: comparison of oral surgeons, head and neck surgeons, plastic surgeons, and neuroradiologists. Plast Reconstr Surg 2011; 127:2432-2440. [PMID: 21617475 DOI: 10.1097/prs.0b013e318213a1fe] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The authors' objectives were to study differences in diagnostic accuracy between two- and three-dimensional computed tomographic scans and among the specialties of plastic surgery, head and neck surgery, oral surgery, and neuroradiology, since this had not previously been done. METHODS Four groups of subspecialists completed time-proctored tests of 20 maxillofacial trauma scans with zygomatic arch, zygomatic complex, orbital, Le Fort I, II, III, mandibular and panfacial fractures from five institutions (n = 40). Accuracy of diagnosis and indication for surgery, efficiency, and preference were assessed. Comparison between two- and three-dimensional scans, between expert (experienced attending) versus novice (resident/fellow), and among the four subspecialties was performed. RESULTS For two- and three-dimensional scans, two-dimensional was more accurate for orbital floor/medial wall (40 percent and 34 percent) and frontal sinus (26 percent for diagnostic) fractures. Two-dimensional examinations took 2.3 times longer but were preferred (85 percent). Experts and novices had similar accuracy with three-dimensional scanning, but experts were more accurate with the two-dimensional scanning. Experts were 3.3 times faster with two-dimensional scanning but not with three-dimensional scanning. Accuracy of diagnosis among subspecialists was similar, except that oral surgery was less accurate with orbitozygomatic fractures (79 percent versus 90 to 92 percent); neuroradiology was less accurate with indications for surgery (65 percent versus 87 to 93 percent). CONCLUSIONS Differences in diagnostic accuracy exist between two- and three-dimensional maxillofacial scans and between expert and novice readers but not between subspecialties. Combined modalities are preferred.
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You JJ, Yun L, Tu JV. Impact of picture archiving communication systems on rates of duplicate imaging: a before-after study. BMC Health Serv Res 2008; 8:234. [PMID: 19014501 PMCID: PMC2590608 DOI: 10.1186/1472-6963-8-234] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Accepted: 11/12/2008] [Indexed: 11/21/2022] Open
Abstract
Background Electronic health information systems, such as picture archiving communication systems (PACS), are commonly believed to reduce the need for duplicate testing. However, empirical data to support this belief are not available. Methods Before-after study using administrative claims data from the Ontario Health Insurance Plan to determine whether the introduction of PACS at 10 hospitals in the Thames Valley region of southwestern Ontario, Canada between June 2004 and December 2005 reduced the frequency of duplicate imaging examinations. The imaging modalities studied were: chest and abdominal X-ray; computed tomography of the abdomen/pelvis, head, and chest. The frequency of duplicate testing was examined at 3 different time frames: 7 days, 30 days, and 60 days after a given index test. Results Overall frequencies of duplicate imaging were: 2.7% within 7 days of an index imaging test, 6.7% within 30 days, and 9.8% within 60 days. Comparing the 12 months before and 12 months after PACS, absolute reductions in the frequency of duplicate X-rays using 7-day, 30-day, and 60-day time frames were: 0.2% (P = 0.01), 0.6% (P < 0.001), and 0.9% (P < 0.001), respectively. In contrast, there were absolute increases in the frequency of duplicate CT scans after PACS of 0.0% (P = 0.92), 0.5% (P = 0.01), and 0.5% (P = 0.01), respectively. Conclusion The frequency of duplicate imaging is relatively low and we did not find large reductions in duplicate imaging after the introduction of PACS. Independent evaluation of electronic medical systems should be conducted to confirm widely held beliefs of their potential benefits.
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Affiliation(s)
- John J You
- Department of Medicine, McMaster University, 1200 Main Street West, HSC-3V51, Hamilton, Ontario, L8N 3Z5, Canada .
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