Patient self-referral patterns in a developing country: characteristics, prevalence, and predictors.

BACKGROUND: Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors. METHODS: This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients' mode of referral (self-referral or institutional referral) was considered the outcome variable. RESULTS: Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p < 0.001). Among patients attending the study sites through institutional referral, approximately 10% were referred from community clinics, 6% from union sub-centers, 25% from upazila health complexes, 22% from district hospitals, 22% from other tertiary care hospitals, and 42% from private clinics. Patients visiting the outpatient department (adjusted odds ratio [aOR] 3.3, 95% confidence interval [CI] 2.28-4.82, p < 0.001), residing in urban areas (aOR 1.29, 95% CI 1.04-1.64, p = 0.007), belonging to middle- and high-income families (aOR 1.34, 95% CI 1.03-1.62, p = 0.014, and aOR 1.98, 95% CI 1.54-2.46, p = 0.005, respectively), and living within 20 km of healthcare facilities (aOR 3.15, 95% CI 2.24-4.44, p-value < 0.001) exhibited a higher tendency for self-referral to tertiary care facilities. CONCLUSIONS: A considerable number of patients in Bangladesh, particularly those from affluent urban areas and proximity to healthcare facilities, tend to self-refer to tertiary care centers. Inadequacy of facilities in primary care centers significantly influences patients to opt for self-referral.

Getting Your Foot in the Door: Access to Surgical Care for Thyroid Disease.

INTRODUCTION: Access to specialty care can be challenging for patients, often involving multiple evaluations, laboratory tests, and referrals. To better understand the different pathways to specialty care, we examined the outcomes of patients evaluated for surgical thyroid disease at a single tertiary referral clinic. METHODS: We reviewed 691 patients seen in the endocrine surgery clinic for thyroid disease (2018-2021). Patient demographics, referral source, referral reason, and reason for not receiving an operation were collected. The number of days from referral to initial clinic visit and from initial clinic visit to an operation were also collected. The Chi-square test, the independent t-test, the Kruskal-Wallis test, the Dunn-Bonferroni post hoc test, and multiple logistic regression tests were performed using SPSS. RESULTS: The top reasons for referral were thyroid nodules (54.4%), hyperthyroidism (26.5%), and multinodular goiter (10.3%). Specialty clinic referrals came from endocrinologists (56.0%), self-referrals (15.5%), and primary care physicians (PCP; 14.4%). Self-referred patients had a shorter waiting time for an appointment than those referred by endocrinologists and PCPs. [median (IQR) (days) 12 (6-17) versus 16 (9-24) versus 16 (9-25), P < 0.001]. Overall, 450 (72.7%) patients underwent thyroid surgery. For those who underwent thyroidectomy, self-referred patients had a shorter time between initial clinic visit and the operation compared to those referred by endocrinologists and PCPs [median (IQR) (days) 2 (1-19) versus 19 (8-33) versus 16 (1-48), P < 0.001]. Patients referred for hyperthyroidism (odds ratio [OR] = 2.2, 95% confidence interval [CI] 1.3-10.5, P = 0.012 were more likely to undergo an operation than those referred for other reasons. CONCLUSIONS: Access to specialty care for thyroid disease is facilitated and optimized when self-referrals are permitted. Reducing or eliminating the requirement for a provider referral may improve patients' access.

Self-referrals and associated factors among laboring mothers at Dilla University Referral Hospital, Dilla, Gedeo Zone, Ethiopia: a cross-sectional study.

BACKGROUND: When medical cases are difficult to manage at the level of primary health care units (PHCU), formal referral assists patients transferring to a higher level of care. In contrast, self-referral and bypassing are synonymously used in literature to describe the phenomenon of patients skipping their units to get basic medical services, even though they are close to their residence. Though proper and timely referral prevents the majority of deaths from obstetric complications in developing countries, more than 50% of referrals are self-referral trends. Such patient practice is increasingly becoming a concern for many health-care systems. OBJECTIVE: To assess the magnitude of self-referrals and associated factors among laboring mothers at Gedeo Zone, Ethiopia. METHODS: Facility-based cross-sectional study was conducted from August 1-September 30/2021 among laboring mothers at Dilla University Referral Hospital. A systematic random sampling technique was used to select 375 laboring mothers. Data were collected using a face-to-face interview with a structured questionnaire. Data were entered into a computer using Epi-Data 4.6 statistical program and then exported to STATA version 16 for analysis. In bivariate analysis variables with a p-value ≤ 0.25 were selected as a candidate variable for the multivariable analysis. P-value < 0.05 at 95% confidence interval considered as a statistically significant associations in the multivariable analysis. RESULT: 375 eligible mothers participated in the study, with a response rate of 98.16%. The magnitude of self-referrals among laboring mothers was 246 (65.6%) with 95% CI (0.60-0.70). Time ≥ 30 min to reach nearby facilities (AOR = 1.74, 95% CI, 1.08, 2.81), having no medicine supplies at nearby facilities (AOR = 1.75, 95% CI, 1.08, 2.82), having no equipment and supplies at nearby facilities (AOR = 1.70, 95% CI, 1.03, 2.78), having ANC visits ˃ 3 times (AOR = 0.29, 95% CI, 0.15, 0.55) and having poor perception of health provider technical competence at nearby facilities (AOR = 2.97, 95% CI, 1.83, 4.79) were found as significant factors for self-referral. CONCLUSION: The magnitude of self-referral was high. Frequent Antenatal visits were protective, however time to reach the nearest facilities, perception towards health care providers, medicine, equipment and supplies at the nearest facilities were positive influencing factors. Government stakeholders should keep working on improving the quality of health service, especially at primary health care units(PHCU).

Unexpected high level of severe events even in low-risk profile chest pain unit patients.

AIMS: Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile. METHODS AND RESULTS: In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events. CONCLUSIONS: When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.

Preferences and barriers to the utilization of primary health care by sick physicians: a nationwide survey.

BACKGROUND: Physicians are often dissatisfied with their own medical care. Self-prescribing is common despite established guidelines that discourage this practice. From a pilot study, we know primary care physicians' (PCP) preferences, but we lack information regarding other specialties and work places. OBJECTIVES: The goal of this study was to examine whether physicians are satisfied with their personal primary care and how this could be improved. METHODS: We distributed an electronic survey to all physicians registered with the Israeli Medical Association. The questionnaire examined satisfaction with medical care, preferences for using formal care versus informal care, self-prescribing and barriers to using formal care. RESULTS: Two thousand three hundred and five out of 24 360 invited physicians responded. Fifty-six per cent of the respondents were satisfied with their personal primary care. Fifty-two per cent reported initiating self-treatment with a medication during the last year. Five and four per cent initiated treatment with a benzodiazepine and an antidepressant, respectively, during the last year. This was despite the fact that most physicians did not feel competent to treat themselves. Having a personal PCP was correlated with both a desire to use formal care and self-referral to formal care in practice. Regression analysis showed that the highest odds ratio (OR) for experiencing a large gap between desired and actual care were for physicians who had no personal PCP (OR = 1.92). CONCLUSIONS: Physicians frequently engage in self-treatment and in informal medical care. Whether the root cause is the health care system structure that does not meet their needs or the convenience of self-treatment is not known.

Self-referral and associated factors among patients attending adult outpatient departments in Debre tabor general hospital, North West Ethiopia.

BACKGROUND: Self-referral leads to diminished quality of health care service; increase resource depletion and poorer patient outcomes. However, a significant number of patients referred themselves to the higher health care facilities without having referral sheets globally including Ethiopia. Even though the problem is much exacerbated in Ethiopia, there is limited evidence regarding self-referral patients in Ethiopia in particular in the study area. OBJECTIVE: To assess the magnitude and associated factors of self-referral among patients at the adult outpatient department in Debre Tabor general hospital, North West Ethiopia. METHOD: Institution-based cross-sectional study was conducted from March 11-April 9, 2020 among 693 patients who attended adult outpatient departments. A systematic sampling technique was employed. Structured and pretested interviewer-administered questionnaire was used for data collection. Data were coded, cleaned and entered into Epi Info version 7.1 and exported to SPSS version 23 for further analysis. Binary logistic regression analysis was employed. In bivariable analysis p-value, less than 0.25 was used to select candidate variables for multivariable analysis. P-values less than 0.05 and 95% confidence intervals were used to select significant variables on the outcome of interest. RESULT: The proportion of self-referral was 443(63.9%) with 95% CI (60.5; 67.5). Formally educated, (AOR = 1.83; (95% CI: 1.12, 3.01)), enrolled to Community Based Health Insurance (AOR = 1.57; (95% CI: 1.03, 2.39)), poor knowledge about referral system (AOR = 2.07; 95% CI: (1.28, 3.39)), not and partially available medication in the nearby Primary Health Care facilities (AOR = 2.12; (95% CI: 1.82, 6.15)) & (AOR = 3.24; (95% CI: 1.75, 5.97)) respectively and history of visiting general hospital (AOR = 1.52; (95%CI: 1.03, 2.25)) were factors statistically associated with self-referral. CONCLUSION AND RECOMMENDATION: The proportion of self-referral was low compared to the Ethiopian health sector transformation plan 2015/16-20. Socio-demographic and institutional factors were associated with self-referral. Therefore, regional health bureau better to work to fulfill the availability of medications in the primary health care facilities. In addition, Community Based Health Insurance (CBHI) agency should work to implement the law of out-of-pocket expenditure which states to pay 50% for self-referred patients who claim utilization of healthcare.

An effective referral linkage is an integral component of a successful health care system for quality health service. Many developing countries have policies regarding referral system while transforming referral policies into practice between primary health care (PHC) facilities and higher-level facilities is challenging. This study was trying to answer the magnitude and factor associated with self-referral through structured interview questionnaires.The participants were asked about their socio-demographic characteristics, institutional related characteristics.There were 690 participants in this study. This study showed that the magnitude of self-referral was 63.9%. Educational status, knowledge about referral system, availability of medication in the nearby PHC facilities, enrollment to CBHI and history of visiting general hospital were factors significantly associated with self-referral.In conclusion, the proportion of self-referral was low compared to the Ethiopian health sector transformation plan 2015/16­20. Educational status, knowledge about referral system, availability of medication in the nearby PHC facilities, enrollment to CBHI and history of visiting general hospital were associated with self-referral. Policy action will be required to further improve ANC service utilization.

Self-referral to inpatient treatment program in a community mental health Centre in Central Norway: investigating the implementation, professionals' experiences and costs.

BACKGROUND: Self-referral to inpatient treatment (SRIT) is built on user participation and patient autonomy. SRIT was conducted for patients with severe mental disorders in a Norwegian Community Mental Health Centre. The aims of the present study were to describe the implementation of SRIT, explore the professionals' experiences of SRIT and assess the costs entailed. METHODS: Qualitative document analysis, interviews with professionals and quantitative analysis of register data from a randomized controlled trial were used. RESULTS: SRIT seemed to be implemented as intended. According to the professionals, SRIT allowed the patients to cope, be empowered, more active and responsible. Some professionals experienced increased responsibility for patients' medication and for assessing health and suicide risks. SRIT did not reduce hospital costs. The professionals were satisfied with nurse-led SRIT treatment. CONCLUSIONS: SRIT appears to be a high-quality mental health service that empowers and activates patients. Nurse-led treatment may entail more efficient use of professional resources. In future implementations of SRIT, the efficient use of service resources and the administration of beds should be investigated. More flexible availability should be considered in line with the intentions behind SRIT, as well as ensuring adequate professional training in assessing health and suicide risk.

Effects of Physician Experience, Specialty Training, and Self-referral on Inappropriate Diagnostic Imaging.

BACKGROUND: Although previous research has demonstrated high rates of inappropriate diagnostic imaging, the potential influence of several physician-level characteristics is not well established. OBJECTIVE: To examine the influence of three types of physician characteristics on inappropriate imaging: experience, specialty training, and self-referral. DESIGN: A retrospective analysis of over 70,000 MRI claims submitted for commercially insured individuals. Physician characteristics were identified through a combination of administrative records and primary data collection. Multi-level modeling was used to assess relationships between physician characteristics and inappropriate MRIs. SETTING: Massachusetts PARTICIPANTS: Commercially insured individuals who received an MRI between 2010 and 2013 for one of three conditions: low back pain, knee pain, and shoulder pain. MEASUREMENTS: Guidelines from the American College of Radiology were used to classify MRI referrals as appropriate/inappropriate. Experience was measured from the date of medical school graduation. Specialty training comprised three principal groups: general internal medicine, family medicine, and orthopedics. Two forms of self-referral were examined: (a) the same physician who ordered the procedure also performed it, and (b) the physicians who ordered and performed the procedure were members of the same group practice and the procedure was performed outside the hospital setting. RESULTS: Approximately 23% of claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists. Self-referral was not associated with higher rates of inappropriate MRIs. LIMITATIONS: Classification of MRIs was conducted with claims data. Not all self-referred MRIs could be detected. CONCLUSIONS: Inappropriate imaging continues to be a driver of wasteful health care spending. Both physician experience and specialty training were highly associated with inappropriate imaging.

How accessible and acceptable are current GP referral mechanisms for IAPT for low-income patients? Lay and primary care perspectives.

Background: Improving Access to Psychological Therapies (IAPT) constitutes a key element of England's national mental health strategy. Accessing IAPT usually requires patients to self-refer on the advice of their GP. Little is known about how GPs perceive and communicate IAPT services with patients from low-income communities, nor how the notion of self-referral is understood and responded to by such patients.Aims: This paper examines how IAPT referrals are made by GPs and how these referrals are perceived and acted on by patients from low-income backgroundsMethod: Findings are drawn from in-depth interviews with low-income patients experiencing mental distress (n = 80); interviews with GPs (n = 10); secondary analysis of video-recorded GP-patient consultations for mental health (n = 26).Results: GPs generally supported self-referral, perceiving it an important initial step towards patient recovery. Most patients however, perceived self-referral as an obstacle to accessing IAPT, and felt their mental health needs were being undermined. The way that IAPT was discussed and the pathway for referral appears to affect uptake of these services.Conclusions: A number of factors deter low-income patients from self-referring for IAPT. Understanding these issues is necessary in enabling the development of more effective referral and support mechanisms within primary care.

Understanding healthcare self-referral in Nigeria from the service users' perspective: a qualitative study of Niger state.

BACKGROUND: The by-pass of the primary level of care to the referral facilities has continued to raise concerns for the healthcare delivery system. About 60-90% of patients in Nigeria are reported to self-refer to a referral level of care. Thus, this study sought to identify the factors that influence service-users' decision to self-refer to the secondary healthcare facilities in Nigeria by exploring the perceptions and experiences of the service-users. METHODS: Twenty-four self-referred service-users were interviewed from three selected secondary healthcare facilities (general hospitals) in Niger state, Nigeria. The interviews were tape-recorded, each lasting 20 min on average. This was subsequently transcribed and framework analysis was employed for the analysis. RESULTS: Various reasons were identified to have resulted in the bypass of the primary healthcare facilities in favour of the secondary level of care. The identified themes were organised based on the predisposing, enabling and need component of Andersen's model. These themes included: patients understanding of the healthcare delivery system; perceptions about the healthcare providers; perceptions about healthcare equipment/ facilities; advice from relatives and friends; service-users' expectations; access to healthcare facilities; regulations/ policies; medical symptoms; perceptions of severity of medical symptoms. CONCLUSIONS: The findings from this study call for an evaluation of the current healthcare referral system, particularly in developing settings like Nigeria and consequently the need for developing a contextual model as applicable to individual settings. Therefore, a multifaceted approach is needed to address the current concerns to ensure patients utilise the appropriate level of care. This will ensure the primary healthcare facilities are not undermined and allow the referral levels of care to live up to their mandate.

School-based early intervention for anxiety and depression in older adolescents: A feasibility randomised controlled trial of a self-referral stress management workshop programme ("DISCOVER").

INTRODUCTION: Schools may provide a convenient intervention setting for young people with mental health problems generally, as well as for those who are unwilling or unable to access traditional clinic-based mental health services. However, few studies focus on older adolescents, or those from ethnic minority groups. This study aims to assess the feasibility of a brief school-based psychological intervention for self-referred adolescents aged 16-19 years. METHODS: A two-arm cluster randomised controlled trial was conducted in 10 inner-city schools with block randomisation of schools. The intervention comprised a one-day CBT Stress management programme with telephone follow-up (DISCOVER) delivered by 3 psychology (2 clinical and 1 assistant) staff. The control was a waitlist condition. Primary outcomes were depression (Mood and Feelings Questionnaire; MFQ) and anxiety (Revised Child Anxiety and Depression Scale; RCADS-anxiety subscale). Data were analysed descriptively and quantitatively to assess feasibility. RESULTS: 155 students were enrolled and 142 (91.6%) followed up after 3 months. Participants were predominantly female (81%) and the mean age was 17.3 years, with equal numbers enrolled from Year 12 and Year 13. Over half (55%) of students were from ethnic minority groups. Intraclass correlations were low. Variance estimates were calculated to estimate the sample size for a full RCT. Preliminary outcomes were encouraging, with reductions in depression (d = 0.27 CI-0.49 to -0.04, p = 0.021) and anxiety (d = 0.25, CI-0.46 to -0.04, p = 0.018) at follow-up. CONCLUSIONS: Results support the feasibility of a school-based, self-referral intervention with older adolescents in a definitive future full-scale trial (Trial no. ISRCTN88636606).

Does having a usual primary care provider reduce patient self-referrals in rural China's rural multi-tiered medical system? A retrospective study in Qianjiang District, China.

INTRODUCTION: Within China's multi-tiered medical system, many patients seek care in higher-tiered hospitals without a referral by a primary-care provider. This trend, generally referred to as patient self-referral behavior, may reduce the efficiency of the health care system. This study seeks to test the hypothesis that having a usual primary care provider could reduce patients' self-referral behavior. METHODS: We obtained medical records of 832 patients who were hospitalized for common respiratory diseases from township hospitals in Qianjiang District of Chongqing City during 2012-2014. Logit regressions were performed to examine the association between having a township hospital as a usual provider and self-referring to a county hospital after being discharged from a township hospital, while controlling for patients' gender, age, income, education, severity of disease, distance to the nearest county hospital and the general quality of the township hospitals in their community. A propensity score weighting approach was applied. RESULTS: We found that having a usual primary care provider was associated with a lower likelihood of self-referral (odds ratio = 0.58, 95% confidence interval [CI] =0.41-0.82), and a 9% (95% CI: -14%, - 3%) reduction in the probability of patients' self-referral behavior. DISCUSSION/CONCLUSION: The results suggest that establishing a long-term relationship between patients and primary care providers may enhance the patient-physician relationship and reduce patients' tendency for unnecessary use of medical resources.

A randomized controlled trial comparing self-referral to inpatient treatment and treatment as usual in patients with severe mental disorders.

BACKGROUND: There has been a call for increased patient autonomy and participation in psychiatry. Some Community Mental Health Centres (CMHC) have implemented services called 'self-referral to inpatient treatment' (SRIT) for patients with severe mental disorders. AIMS: To investigate whether SRIT could yield better outcomes after 12 months in use of mental health services for people with severe mental disorders than Treatment As Usual (TAU). METHODS: This was a randomized controlled trial at a CMHC in Norway comparing SRIT and TAU in 12 months. Fifty-four patients with severe mental disorders were included. The patients in the SRIT group could admit themselves as inpatients for up to 5 days for each admission with at least a 2 weeks pause between the admittances. RESULTS: Twenty out of 26 participants (77%) in the SRIT group used the SRIT for a median of 1.5 admissions and 5 inpatient days. With the exception of a somewhat larger number of admissions at the CMHC in the SRIT group, no significant differences were found between the two groups in days as inpatients, admissions, outpatient contacts or coercion. Both groups reduced their inpatients days by 40%. CONCLUSIONS: Both the SRIT and the TAU groups reduced their use of services during the 12 months intervention period. Giving patients with severe mental disorders the possibility to self-refer did not change the use of services. CLINICAL IMPLICATIONS: Self-referral to inpatient treatment for patients with severe mental disorders might increase patient autonomy, but does not seem to save use of inpatient services.

Anticipating the Unintended Consequences of Closing the Door on Physician Self-Referral.

PURPOSE: While physician self-referral has been associated with increased health care use, the downstream effects of the practice remain poorly characterized. Accordingly we identified the relationship between urologist self-referral and downstream health care use in patients with urinary stone disease. MATERIALS AND METHODS: With urologist self-referral status as the exposure of interest, we performed a retrospective cohort study of Medicare beneficiaries from 2008 to 2010 to evaluate the relationship between self-referral and imaging intensity, risk of surgical treatment and time to surgical treatment for urinary stone disease. RESULTS: We identified dose dependent increases in computerized tomography use with increasing stratum of urologist self-referral. Compared to nonself-referring urologists, computerized tomography use was 1.19 times higher (95% CI 1.07-1.34) in episodes ascribed to intermediate frequency (5 to 9) and 1.32 times higher (95% CI 1.16-1.50) in episodes ascribed to high frequency (10+) self-referring urologists. Self-referral was inversely associated with risk of surgical treatment for stone disease. Specifically, patients treated by intermediate and high frequency self-referring urologists were less likely to undergo surgical treatment than those treated by nonself-referring urologists, with HR 0.84 (95% CI 0.71-0.99) and HR 0.81 (95% CI 0.66-0.99), respectively. We identified no statistically significant between-group differences in time to surgical treatment. CONCLUSIONS: Self-referral is associated with increased use of computerized tomography and with decreased use of surgery for stone disease. While policy efforts to further restrict physician self-referral may reduce the use of computerized tomography, they may also result in unintended consequences with respect to patterns of surgical care.

Short time effect of a self-referral to inpatient treatment for patients with severe mental disorders: a randomized controlled trial.

BACKGROUND: Service user participation is a central principle in mental healthcare, and the opportunity to self-refer to inpatient treatment is used to increase service user involvement and activation. The aim of this study was to investigate the short-term effect of a self-referral system in an inpatient rehabilitation unit at a community mental health center on patient activation and recovery in individuals with severe mental disorders. METHODS: A randomized controlled study including 53 patients (41 % females, mean age 40 years). Twenty-six patients in the intervention group were given a contract for self-referral to inpatient treatment, limited to maximum 5 days and a quarantine time of 14 days between each stay. The control group (27 participants) received treatment as usual, and was offered the intervention after 1 year. The Patient Activation Measure was the primary outcome and secondary outcome was the Recovery Assessment Scale. Mixed models were used to assess group differences. RESULTS: During the 4 months period, 15 (58 %) of 26 participants in the intervention group used the contract of self-referral to inpatient treatment. The intervention group had more admissions than the control group but both groups had a similar total use of inpatient days and out-patient consultations. The self-referral to inpatient treatment counted for 11 % of all inpatient days for the intervention group. There were no significant differences in the outcome between the groups on patient activation (estimated mean difference 2.7, 95 % confidence interval = -5.5 to 10.8, p = 0.52) or recovery (estimated mean difference 0.01, 95 % confidence interval = -0.3 to 0.3, p = 0.92). CONCLUSIONS: Giving persons with severe mental disorders the possibility to self-refer to inpatient treatment did not change their level of patient activation and recovery after 4 months and did not lead to increased use of health services. The cost-effectiveness and long-term effect of self-referral to inpatient treatment should be investigated further. TRIAL REGISTRATION: NCT01133587 , clinicaltrials.gov.

A service evaluation of self-referral to military mental health teams.

BACKGROUND: The UK military runs a comprehensive mental health service ordinarily accessed via primary care referrals. AIMS: To evaluate the feasibility of self-referral to mental health services within a military environment. METHODS: Three pilot sites were identified; one from each service (Royal Navy, Army, Air Force). Socio-demographic information included age, rank, service and career duration. Clinical data included prior contact with general practitioner (GP), provisional diagnosis and assessment outcome. RESULTS: Of the 57 self-referrals, 69% (n = 39) had not previously accessed primary care for their current difficulties. After their mental health assessment, 47 (82%) were found to have a formal mental health problem and 41 (72%) were offered a further mental health clinician appointment. The data compared favourably with a large military mental health department that reported 87% of primary care referrals had a formal mental health condition. CONCLUSIONS: The majority of self-referrals had formal mental health conditions for which they had not previously sought help from primary care; most were offered further clinical input. This supports the view that self-referral may be a useful option to encourage military personnel to seek professional care over and above the usual route of accessing care through their GP.

Role of Online Patient Portal Self-Scheduling and Self-Referral Pathways to Decrease Health Disparity for Screening Mammography.

PURPOSE: The aim of this study was to assess the rate of self-scheduling and self-referral for screening mammography and to assess sociodemographic factors associated with their use in an academic health care system in southern California. METHODS: Patients scheduled for screening mammography between February 1, 2021, and September 20, 2022, were included in this retrospective study. Multivariable logistic regression models were used to assess associations among sociodemographic factors, self-referral, and online self-scheduling pathways. RESULTS: In total, 22,306 patients were scheduled for screening mammography (mean age, 59 years; 66.8% White, 20.4% Asian, and 20.6% Hispanic). Overall, 3,566 (16.0%) used online self-scheduling, and 1,232 (5.5%) self-referred for screening mammography. Patients 70 years or older (versus 50 years or younger) (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.34-0.51), Spanish (versus English) speakers (OR, 0.22; 95% CI, 0.16-0.31), and those on Medicaid (versus commercially insured) (OR, 0.71; 95% CI, 0.50-0.99) were less likely to self-schedule. Hispanic patients (versus non-Hispanic) (OR, 1.39; 95% CI, 1.20-1.61), Asian patients (versus White) (OR, 1.64; 95% CI, 1.46-1.85), and patients residing in the most (versus least) disadvantaged neighborhoods (OR, 1.16; 95% CI, 1.02-1.33) were more likely to self-schedule. Furthermore, patients 70 years or older (versus 50 or younger) (OR, 0.70; 95% CI, 0.52-0.93) and Spanish speakers (OR, 0.05; 95% CI, 0.03-0.09) were less likely to self-refer, whereas Black patients (versus White) (OR, 1.89; 95% CI, 1.30-2.75), patients on Medicaid (versus commercially insured) (OR, 3.70; 95% CI, 2.65-5.13), and patients living in the most (versus least) disadvantaged neighborhoods (OR, 1.52; 95% CI, 1.27-1.82) were more likely to self-refer. CONCLUSIONS: Sociodemographic differences in online patient portal use and self-referral for screening mammography suggest that the two pathways have been successful in addressing some of the existing scheduling barriers and are a step toward closing the disparity gap.

What impact do self-referral and direct access pathways for patients have on health inequalities?

BACKGROUND: There is increasing interest in self-referral and direct access as alternatives pathways to care to improve patient access to specialist services. The impact of these pathways on health inequalities is unknown. OBJECTIVES: The purpose of this systematic review is to explore the impact of self-referral and direct access pathways on inequalities in health care use. DESIGN: Three databases (Ovid Medline, Embase, Web of Science) and grey literature were systematically searched for articles from January 2000 to February 2023, reporting on self-referral and direct access pathways to care. Title and abstracts were screened against eligibility criteria to identify studies that evaluated the impact on health inequalities. Data were extracted from eligible studies after full text review and a quality assessment was performed using the ROBINS-I tool. RESULTS: The search strategy identified 2948 articles. Nineteen records were included, covering seven countries and six healthcare services. The impact of self-referral and direct access on inequalities was mixed, suggesting that the relationship is dependent on patient and system factors. Typically self-referral pathways and direct access pathways tend to widen health inequalities. White, younger, educated women from less deprived backgrounds are more likely to self-refer, exacerbating existing health inequalities. CONCLUSIONS: Self-referral pathways risk widening health inequalities. Further research is required to understand the context-dependent mechanisms by which this can occur, explore ways to mitigate this and even narrow health inequalities, as well as understand the impact on the wider healthcare system.

Clinical characterisation of patients diagnosed with cancer following emergency self-referral.

BACKGROUND: Despite their frequency and potential impact on prognosis, cancers diagnosed via self-referral to the emergency department are poorly documented. We conducted a detailed analysis of cancer patients diagnosed following emergency self-referral and compared them with those diagnosed following emergency referral from primary care. Given the challenges associated with measuring intervals in the emergency self-referral pathway, we also aimed to provide a definition of the diagnostic interval for these cancers. METHODS: A retrospective observational analysis was performed on patients diagnosed with 13 cancers, either following emergency self-referral or emergency referral from primary care. We analysed demographics, tumour stage, clinical data (including 28 presenting symptoms categorised by body systems), and diagnostic intervals by cancer site, then testing for differences between pathways. RESULTS: Out of 3624 patients, 37 % were diagnosed following emergency self-referral and 63 % via emergency referral from primary care. Emergency self-referrals were associated with a higher likelihood of being diagnosed with cancers manifesting with localising symptoms (e.g., breast and endometrial cancer), whereas the likelihood of being diagnosed with cancers featuring nonspecific symptoms and abdominal pain (e.g., pancreatic and ovarian cancer) was higher among patients referred from primary care. Diagnostic intervals in self-referred patients were half as long as those in patients referred from primary care, with most significant differences for pancreatic cancer (28 [95 % CI -34 to -23] days shorter, respectively). CONCLUSION: These findings enrich the best available evidence on cancer diagnosis through emergency self-referral and showed that, compared with the emergency referral pathway from primary care, these patients had a significantly increased likelihood of presenting with symptoms that are strongly predictive of cancer. Since the starting point for the diagnostic interval in these patients is their emergency presentation, comparing it with that of those referred from primary care as an emergency is likely to result in biased data.

Development of an Electronic Health Record Self-Referral Tool for Lung Cancer Screening: One-Group Posttest Study.

BACKGROUND: Approximately 14 million individuals in the United States are eligible for lung cancer screening (LCS), but only 5.8% completed screening in 2021. Given the low uptake despite the potential great health benefit of LCS, interventions aimed at increasing uptake are warranted. The use of a patient-facing electronic health record (EHR) patient portal direct messaging tool offers a new opportunity to both engage eligible patients in preventative screening and provide a unique referral pathway for tobacco treatment. OBJECTIVE: This study sought to develop and pilot an EHR patient-facing self-referral tool for an established LCS program in an academic medical center. METHODS: Guided by constructs of the Health Belief Model associated with LCS uptake (eg, knowledge and self-efficacy), formative development of an EHR-delivered engagement message, infographic, and self-referring survey was conducted. The survey submits eligible self-reported patient information to a scheduler for the LCS program. The materials were pretested using an interviewer-administered mixed methods survey captured through venue-day-time sampling in 5 network-affiliated pulmonology clinics. Materials were then integrated into the secure patient messaging feature in the EHR system. Next, a one-group posttest quality improvement pilot test was conducted. RESULTS: A total of 17 individuals presenting for lung screening shared-decision visits completed the pretest survey. More than half were newly referred for LCS (n=10, 60%), and the remaining were returning patients. When asked if they would use a self-referring tool through their EHR messaging portal, 94% (n=16) reported yes. In it, 15 participants provided oral feedback that led to refinement in the tool and infographic prior to pilot-testing. When the initial application of the tool was sent to a convenience sample of 150 random patients, 13% (n=20) opened the self-referring survey. Of the 20 who completed the pilot survey, 45% (n=9) were eligible for LCS based on self-reported smoking data. A total of 3 self-referring individuals scheduled an LCS. CONCLUSIONS: Pretest and initial application data suggest this tool is a positive stimulus to trigger the decision-making process to engage in a self-referral process to LCS among eligible patients. This self-referral tool may increase the number of patients engaging in LCS and could also be used to aid in self-referral to other preventative health screenings. This tool has implications for clinical practice. Tobacco treatment clinical services or health care systems should consider using EHR messaging for LCS self-referral. This approach may be cost-effective to improve LCS engagement and uptake. Additional referral pathways could be built into this EHR tool to not only refer patients who currently smoke to LCS but also simultaneously trigger a referral to clinical tobacco treatment.