Consensus among clinicians on referrals' priority and use of digital decision-making support systems.

The growing demand for referrals is a main policy concern in health systems. One approach involves the development of demand management tools in the form of clinical prioritization to regulate patient referrals from primary care to specialist care. For clinical prioritization to be effective, it is critical that general practitioners (GPs) assess patient priority in the same way as specialists. The progressive development of IT tools in clinical practice, in the form of electronic referrals support systems (e-RSS), can facilitate clinical prioritization. In this study, we tested if higher use of e-RSS or higher use of high-priority categories was associated with the degree of agreement and therefore consensus on clinical priority between GPs and specialists. We found that higher use by GPs of the e-RSS tool was positively associated with greater degree of priority agreement with specialists, while higher use of the high-priority categories was associated with lower degree of priority agreement with specialists. Furthermore, female GPs, GPs in association with others, and GPs using a specific electronic medical record showed higher agreement with specialists. Our study therefore supports the use of electronic referrals systems to improve clinical prioritization and manage the demand of specialist visits and diagnostic tests. It also shows that there is scope for reducing excessive use by GPs of high-priority categories.

Priority and appropriateness of upper endoscopy out-patient referrals: Two-period comparison in an open-access unit.

BACKGROUND: In the early 2000s we introduced a prioritization model for referrals based on involvement of primary care physicians (PCPs) and specialists. AIMS: Assess the application of that model of prioritisation, comparing gastroscopies performed 8 years apart, with respect to priority level, appropriateness and relevant endoscopic findings (REFs). METHODS: The studies included 247 and 354 out-patients, who had undergone gastroscopy in 2006 and in 2014, respectively. To reduce interspecialists variability, both studies were performed by the same specialist as investigator. RESULTS: In both years, most patients were assigned low-priority referral by PCPs (78.6% and 75.1% respectively). The agreement PCPs versus specialist on referral priority was moderate in 2006 (0.60, Landis-Koch scale 0.41-0.60) and high in 2014 (0.81, Landis-Koch scale 0.81-1.00). In both years we observed a similar rate of inappropriateness: 27.5% and 27.1%, respectively. Due to multiple logistic regression, the odds ratio (OR) for REF increased when: (i) very high-priority referral versus nopriority referral was indicated (8.813 OR, p = 0.0012), (ii) referral followed the guidelines (9.29 OR, p<0.0001), and (iii) agreement of priority occurred (1.911 OR, p = 0.0308). CONCLUSIONS: Our findings highlighted that the issues of low-priority referrals should be addressed in order to discontinue gastroscopy overusing and reduce related operational costs.

Improving the appropriateness of referrals and waiting times for endoscopic procedures.

OBJECTIVE: There is a lack of standard methods for determining the clinical priority of patients referred by general practitioners (GPs) for specialist outpatient consultations. We introduced a system of progressive involvement by general practitioners and specialists with 80 diagnostic procedures. The aim of this study was to evaluate this new method of prioritization of patients suffering from significant gastroenterological disorders needing rapid access to diagnostic procedures. METHODS: The study included 438 outpatients who were referred for and underwent a gastroscopy or colonoscopy. GPs used a ranking of waiting times for different levels of clinical priority, called 'homogeneous waiting groups'. Specialists also assigned a priority level for each patient as well as evaluating the appropriateness of the referral and the presence of significant endoscopic disorders. Agreement between GPs' and specialists' priority assessments was evaluated by the kappa statistic. RESULTS: Most referrals (74.4%) were deemed low priority by GPs, with no maximum waiting time assigned. The level of agreement between GPs and specialists as regards patients' priorities was poor or moderate: for gastroscopy the kappa was 0.31 (weighted kappa 0.47) and for colonoscopy 0.44 (weighted kappa 0.46). There was an association between the proportion of significant disorders identified with endoscopy and the priority assigned to the referral (chi2 = 18.9, 1 df, p < 0.001). The overall proportion of referrals deemed inappropriate by specialists was 22.1%. CONCLUSIONS: There is value in liaison between GPs and specialists for achieving timely referrals and avoiding delayed diagnosis though higher levels of agreement need to be achieved.

Waiting time prioritisation for specialist services in Italy: the homogeneous waiting time groups approach.

The demand for referrals and diagnostic procedures in Italy has been rising constantly in recent years, making access to diagnostic services increasingly difficult with significant waiting times. A number of Health Authorities (known as Local Health Units) have responded by implementing formalised waiting-time prioritisation tools, giving rise to what are known as Homogeneous Waiting Groups (HWGs). The study describes the implementation of the HWG approach in Italy. This represents a promising tool for improving the prioritisation of patients waiting to see a specialist or to receive a diagnostic test. The study of the Italian HWG experience provides useful insights to improve the outpatient referral process for those countries where the demand prioritisation policies have focused more on inpatient care than outpatient specialist care and diagnostic services.

Improving referral activity on primary-secondary care interface using an electronic decision support system.

OBJECTIVE: Our main aim was to evaluate the ability of electronic feedback and of an electronic referral decision support system (ERSS) to enhance agreement between primary care physicians (PCPs) and specialists in priority assignment in clinics. METHOD: 62 PCPs used a ranking system of waiting times based on different categories of clinical priority called 'Homogeneous Waiting Groups' (HWGs), which was also used by specialists to assign a priority category for each patient. From the year 2001, all PCPs had to use a paper-based manual (group 1); instead from 2008, specialists began to use a computer-based tool, whereby the priority category reassigned to each patient by specialists promptly appeared on PCPs' computers (group 2). During the course of 2010, the manual was incorporated in ERSS and was used by a subgroup of PCPs (group 3). Agreement between PCPs and specialists' priority assignments was evaluated by the kappa statistic. RESULTS: In group 1, the kappa statistic was 0.564 (95% CI=0.526-0.602); in group 2, the kappa statistic was 0.668 (95% CI=0.619-0.716); whereas in group 3 (that used ERSS) a very high kappa statistic emerged of 0.883 (95% CI=0.854-0.912). There was a significant difference in the proportion of agreement among the three groups (χ(2)=182.5, 2df, p<.0001). A significant difference in statistics was also observed in the proportion of priority levels used by PCPs over the years. CONCLUSIONS: Our results emphasize the positive effect of feedback and ERSS for improving referral activity and agreement between PCPs and specialists.