Levels of Evidence Table
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s12913-018-3745-y.pdf
RESEARCH ARTICLE Open Access
A categorisation of problems and solutions to improve patient referrals from primary to specialty care James Greenwood-Lee1, Lauren Jewett2, Linda Woodhouse3 and Deborah A. Marshall4,5*
Abstract
Background: Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated.
Methods: We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes.
Results: We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies.
Conclusion: The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.
Keywords: Health system, Chronic illness, Intervention, Primary care, Secondary care, Specialty care, Referral
* Correspondence: [email protected] 4Canada Research Chair, Health Services and Systems Research, Arthur J.E. Child Chair in Rheumatology Outcomes Research, Department of Community Health Sciences, University of Calgary, Calgary, Canada 53C56 Health Research Innovation Centre (HRIC), 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 https://doi.org/10.1186/s12913-018-3745-y
Background In response to the increasing prevalence of chronic condi- tions and the associated shift in the global burden of dis- ease [1] there is pressure to improve chronic care [2–5]. New models for the delivery of care have been proposed, emphasising better integration between primary and spe- cialty care, coupled with systems for better patient self-management. The goal is a patient centric system, easily navigable, with seamless transitions, that ensures patients receive appropriate services in a timely manner [6–8]. Achieving this goal requires reshaping of the health system through health services delivery interventions; transitioning from a compartmentalized system that is structured in terms of health care services, to an inte- grated system that is restructured in terms of patient fo- cused chronic care pathways. Improving access to specialty care, which includes any
specialized medical services that can only be provided by a physician specialist, has been identified as an import- ant system level issue, as patient outcomes may be compromised when disease management is delayed. However, accessibility is not easily decoupled from the broader need for the co-ordination of primary and speci- ality care [9] to ensure that patients are diagnosed and receive timely and effective treatment to manage their conditions, as early as possible. Access to specialty care requires that such services can be provided either locally or remotely. Here, we focus only on the former, as the latter case is deserving of focused consideration. Given that specialty care is locally available, the management of the primary-specialty care interface is important both at a patient level, as a determinant of health outcomes, experience, and satisfaction, and at a systems level as a determinant of patient flows as this interface is prone to inefficiencies [10]. The primary-specialty care interface centres on the re-
ferral. There are many reasons a patient might be re- ferred to specialty care including diagnosis, management advice, and treatment beyond the scope of the primary care physician [11]. With growing demand for specialty care, but limited resources to meet demand, referral quality is increasingly important to ensure efficient pa- tient flow across the primary-specialty care interface; re- ferrals should be necessary, appropriate, timely, and well communicated [12]. In addition, the health system must support the referral process by maintaining efficient in- formation exchange and patient flow, especially given the broader need for the co-ordination of primary and speciality care [9]. The primary-specialty care interface is complex [13],
with a breadth of potential deficiencies impacting the pa- tient journey through the primary-specialty care interface and an equal breadth of interventions. Previous reviews [10, 14, 15] have synthesized evidence on interventions to
improve the primary-specialty care interface. However, while in practice, symptoms of a poorly functioning primary-specialty care interface may be easy to recognize, their causes may not be. In addition, the primary-specialty care interface may be impacted by a breadth of potential deficiencies; with an equal breadth of interventions devel- oped to correct them. The complexity of the primary-spe- cialty care interface requires consideration for both multitude of influencing factors and potential conse- quences of any given intervention, as well as the interac- tions amongst interventions, both synergistic and antagonistic [15]. Theory driven approaches are necessary [16]; approaches that consider mechanisms of causality [17, 18] by mapping out the deficiencies, why they arise, and which strategies can be used to intervene based on evidence showing effectiveness. In this review we deconstruct the primary-specialty
care interface to produce a conceptual map between de- ficiencies that impact access of patients with chronic conditions who are referred to specialty care for non-emergent procedures, interventions and subsequent impacts. The objective is to create an organizational structure that enables system deficiencies to be identified and linked to potential intervention strategies, while considering potential interactions amongst intervention strategies, both synergistic and antagonistic. We focus on the system perspective, where the objective is to optimize the system to improve access to specialty care for non-emergent patients. Consequently, the patient and provider experience are not captured explicitly in this context. The practical outcome is the creation of a resource for health care organizations seeking to optimize the primary care/specialty care interface to im- prove access to specialty care for non-emergent patients.
Methods The categorization was developed through an iterative two staged process.
Stage 1: Narrative literature review Narrative literature reviews provide a flexible method- ology to collect, map and summarize current state of knowledge amongst diverse studies, where a key advan- tage of the narrative review is the ability to examine a wide breadth of literature and to address multiple research topics [19]. This is appropriate here, as we seek to under- stand a wide range of problems that impact the necessity, appropriateness, timeliness and communication of the re- ferral, as well as how the health system supports the refer- ral process by maintaining efficient information exchange and patient flow. It is important to note that an inherent trade-off with narrative reviews is possible subjectivity in study selection that potentially leads to biases and non-replicability. To maintain transparency, the search
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 2 of 16
strategy is appended. However, the goal of our search is not to inform a comprehensive systematic review, but ra- ther serves to capture a representative sample of the litera- ture sufficient to inform our categorization [20]. An iterative search strategy was developed to capture inter- ventions that address deficiencies at the primary-specialty care interface that impact patient access to specialty care. Given our broad focus on the primary-specialty care inter- face we sought to limit our search to ensure a manageable number of results. Specifically, we limited our search to peer-reviewed literature published over the most recent 10 year time frame (from January 1, 2005 until May 31, 2014, at time of search), indexed in the MEDLINE and EMBASE databases (see Additional file 1). Medline and EMBASE were selected due to their broad subject cover- age including clinical care, public health, health policy de- velopment and health services research. Databases such as the CINAHL database, which is a database of nursing and allied health literature, were not included. A grey literature search was also conducted. Studies of interventions meet- ing all inclusion criteria were considered to be eligible for review: 1) in English 2) report on intervention to correct deficiencies that impact the necessity, appropriateness, timeliness and communication of patient transitions across the primary-specialty care interface, and 3) report on human subjects via primary data, secondary data (re- view articles) or data validated computer simulation of a health system. Articles were screened by two reviewers at three sequential levels: title, abstract and full text. Quality criteria were not used as our objective was to be inclusive. Selected articles were categorized to identify broad classes of interventions to improve the necessity, appropriateness, timeliness, and communication of referrals. This initial categorization was completed in December 2014. Follow- ing this initial categorization, we conducted targeted searches of MEDLINE and EMBASE databases to locate peer-reviewed literature up to December 31, 2014, and searched reference lists of included articles to identify additional relevant articles. We captured pertinent information from each selected
article using a data extraction form, including: specialty, intervention strategy, intervention objective, study de- sign, methods, reported impacts, limitations, and conclu- sions. Quality of evidence was not scored. Data extractions were completed by a single reviewer and reviewed by a second.
Stage 2: Categorization development To develop our categorization we described the change process, beginning with contextualizing the need for change, and then detailing the mechanisms for change, including contextual factors which are associated or in- fluence outcomes [21]. The purpose was to assimilate and categorize a broad range of interventions to both
highlight their individual functions as well as their rela- tionships. Our end-goal was to develop a categorization based on the broad types of deficiencies that are ob- served at the primary-specialty care interface. The prac- tical difficulty encountered was that much of the reviewed literature describes the causal mechanisms through which the intervention operates with a forward focus; providing explanations of how the intervention generates change via the intervention’s actions. Explana- tions and evidence as to why the performance of the primary-specialty care interface is failing were not always provided. As such, to achieve our objective, backwards extrapolation was used to identify deficiencies in the primary-specialty care interface and their causes based on the form of intervention and its actions. The process proceeded through four steps. In the first step the intervention objectives and activ-
ities were recorded as reported in the reviewed articles. Accordingly, we described: 1) the context and the ob- jective of the intervention; 2) intervention activities; and 3) intervention outcomes. In the second step, root causes were extrapolated by considering each interven- tion action in the context of its objective and identifying the root causes the identified action served to remedy. The data extracted from the included papers were then synthesized as themes and categorized with a focus on high level deficiencies and their causes thereby creating the categorization scheme [20]. In step three, the previ- ously recorded intervention objectives and activities were remapped within the new categorization scheme. In the final step, a summary of reported impacts were linked to the intervention activities and we finished by discussing potential synergies and conflicts among inter- vention strategies. Although the above process is pre- sented as linear, in practice the four steps were iterative allowing the categorization to evolve to its final form.
Results Stage 1: Narrative literature review The results of the literature search are presented in Fig. 1 (PRISMA diagram). The search returned 4893 records (Medline: 1679, Embase 3010, Articles Identified through targeted and citation searches 204). In total, 4787 records were identified as not meeting the inclusion criteria based on their title. Abstracts were reviewed in the remaining 368 articles. In total, 228 articles were excluded based on the information found in the abstract. 140 articles were extracted and reviewed in full text, with 106 of those in- cluded in this review. Reviewed articles included systematic reviews, data
validated computer simulations and empirical studies ranging from quality improvement reports, to time series analyses, and randomized controlled trials. Given the wide range of studies included in this review, the quality
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 3 of 16
of the evidence reported varies among the reviewed arti- cles. As previously noted, quality of evidence was not formally assessed here, as our objective is to provide an organizational structure that enables system deficiencies to be identified and linked to potential intervention strategies. Once the categories of intervention strategies are identified, evidence demonstrating intervention ef- fectiveness can be reviewed as a next step. In particular, it will be important to determine if available evidence for a given category of intervention is highly context specific, or if there is a broad base of evidence that dem- onstrates the effectiveness of the intervention in variety of health services delivery applications and contexts.
Stage 2: Categorization Four categories of health services delivery deficiencies were identified: deficiencies based in 1) clinical deci- sion making, 2) information management, 3) the sys- tem level management of patient flows between primary and secondary care, 4) quality-of-care moni- toring. Each is detailed below and mapped to inter- vention strategies, and reported impacts. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Figure 2 presents an overview of the categorization, with details cap- tured in Tables 1 and 2.
Fig. 1 PRISMA diagram of included articles
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 4 of 16
Identified deficiencies at the primary-specialty care interface (Table 1) D.1. Deficiencies based in clinical decision making en- compass referral errors that pertain to the necessity, appropriateness, timeliness and communication of re- ferrals. Note that the parameters defining the neces- sity, appropriateness and timeliness of a referral, as well as the information and diagnostics needed to support the referral vary between specialities and are set by current standards of care. Referral errors devia- tions from the defined parameters that are the result of the diagnostic process, which is probabilistic in na- ture and implies uncertainty and error. Four types of error were identified:
1. Unnecessary and inappropriate referrals are the product of false positives, which occur when the patient is inappropriately/unnecessarily identified as needing a referral to specialty care.
2. Delayed referrals are the product of false negatives, which occur when a referral to specialty care is necessary but is not made, resulting in patients not being referred until their condition reaches late stages [22–24].
3. Triaging errors result when patients are improperly prioritized based on the severity of their condition.
4. Communication errors result when sufficient information and diagnostics are not provided [25–27].
D.2. Deficiencies based in information management encompass delays that result due to technological communication breakdowns at the primary-specialist care interface. Traditionally the referral letter has been the principal means of communication and its importance is well recognized [10]. However, un- necessary delays result from the reliance on anti- quated communication technologies as a means of
Fig. 2 Simplified categorization linking deficiencies at the primary-specialty care interface to interventions
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 5 of 16
transmitting referral requests and subsequent com- munications and diagnostics between primary and specialty care. Modern information technologies can
facilitate improved linkages between primary care providers and specialists [28, 29] and help limit communication delays.
Table 1 Deficiencies identified at the primary-specialty care interface
Intervention Context Identified deficiency in Health services delivery •Impact of deficiency •Intervention types and objectives
D.1. Deficiencies based in clinical decision making – Referral error
Deficiency Sub-types and root cause Impact of deficiency Intervention types and Objectives (see Table 1B)
Referral errors as a natural consequence of diagnosis as a probabilistic process.
1. Unnecessary and inappropriate referrals (False positives) - Referral is unnecessary or inappropriate.
Poor patient experience, delay in receipt of diagnosis/care, compromised patient outcome. Impeded patient flows at the primary-specialty care interface and decreased efficiency of the health system. Potential impacts include: access delays, increased short term costs, increased long term costs as a result of a higher proportion of patients with severe conditions
Preventive interventions to reduce the occurrence of Type I errors, Type II errors, triaging errors and communication delays Screening interventions – to detect Type I errors, Type II errors, triaging errors and communication delays that have occurred.
2. Delayed referrals (False negatives) - Referral is warranted, but not made.
3. Triaging Errors - Improper prioritization of patients based on urgency.
4. Communication delays - Referrals are delayed due to missing information and/or diagnostics.
D.2. Deficiencies based in information management- Technologies
Deficiency Root cause Impact of deficiency Intervention types and Objectives (see Table 1B)
Delays due to outdated communication systems
Referrals and subsequent correspondence, forwarding of diagnostics, etc. via standard mail or fax.
Poor patient experience, delay in receipt of diagnosis/care, compromised patient outcome.
Electronic referral systems (e-referrals) and electronic medical records (EMRs) to expedite information sharing
D.3. Deficiencies based in system level management of patient flows between primary and secondary care – Supply and demand management
Deficiency Root cause Impact of deficiency Intervention types and Objectives (see Table 1B)
Delays due to care pathway structure and management
1. Care pathway management Inefficient care pathway structure and resource use hinders patient flows.
Poor patient experience, delay in receipt of diagnosis/care, compromised patient outcome. Impeded patient flows at the primary-specialty care interface and decreased efficiency of the health system. Potential impacts include: access delays, increased short term costs, increased long term costs as a result of a higher proportion of patients with severe conditions
Care pathway management - streamlining
Delays due to human resource management
2. Role management (Inter- professional workload imbalance) Creation of bottlenecks within the care pathway as a result of insufficient specialty care providers (Short term and sustained).
Human resource management - Scope of practice restructuring at primary-specialty care interface to increase supply of services
Delays due to queue/referral management
3. Queue/Referral management Intra-professional workload imbalance Disproportionate allocation of referrals amongst specialists producing an imbalance in specialist utilizations.
Queue/referral management - Centralized intake of referrals to improve access to specialty care.
D.4. Deficiencies based in quality/performance monitoring
Deficiency Root cause Impact of deficiency Intervention types and Objectives (see Table 1B)
Inability for performance improvement due to Insufficient data capture
Lack of a measurement framework to adequately track system performance
Decreased efficacy of operational decision making
Continuous quality improvement frameworks
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 6 of 16
Ta b le
2 In te rv en
tio n st ra te gi es
an d ou
tc om
es
C or e in te rv en
tio n st ra te gi es
Id en
tif ie d H ea lth
se rv ic es
de liv er y in te rv en
tio ns
•S tr at eg
y, ob
je ct iv e, ta rg et
po pu
la tio
n, Ta rg et
im pa ct ,R ep
or te d Im
pa ct s
I.1 .I nt er ve nt io ns
to re du
ce re fe rr al er ro r
1. Pr ev en tiv e in te rv en tio
ns to
re du
ce th e oc cu rr en ce
of fa lse
po sit iv es ,f al se
ne ga tiv es ,t ria gi ng
er ro rs an d co m m un
ic at io n de la ys .
St ra te gy
O bj ec tiv e
Ta rg et
po pu
la tio
n Ta rg et
im pa ct
Re po
rt ed
im pa ct
Re fe rr al G ui de
lin es
C lin ic al G ui de
lin es :g
ui da nc e on
ne ce ss ity ,
ap pr op
ria te ne
ss an d tim
el in es s of
re fe rr al s.
C le ric al gu
id an ce :g
ui da nc e on
co m pl et en
es s
of re fe rr al s.
Re fe rr in g ph
ys ic ia ns
Im pr ov e re fe rr al de
ci si on
s: re du
ce fa ls e
po si tiv es
(u nn
ec es sa ry
an d in ap pr op
ria te
re fe rr al s) ,r ed
uc e fa ls e ne
ga tiv es
(d el ay ed
re fe rr al s) .I m pr ov e th e co m m un
ic at io n of
th e re fe rr al .
Pa ss iv e in tr od
uc tio
n of
gu id el in es
pr od
uc es
lit tle
ch an ge
[3 6– 47 ]. G ui de
lin es
w ith
fe ed
ba ck
m ay
be ef fe ct iv e [4 3, 53 –5 6] .
C oo
rd in at ed
in tr od
uc tio
n of
gu id el in es ,w
ith st an da rd iz ed
re fe rr al pr oc es s ca n im
pr ov e
re fe rr al ap pr op
ria te ne
ss an d po
te nt ia lly
lo w er
w ai t tim
es [6 4– 70 ].
St an da rd iz ed
re fe rr al
pr oc es s
Se t st an da rd s fo r re fe rr al qu
al ity .
A id s in cl ud
e: st an da rd
re fe rr al fo rm
s, cr ite ria
ch ec kl ist s, di ag no
st ic ch ec kl ist s, sc or in g sy st em
s.
Sh ar ed
/S up
po rt ed
pa tie nt
as se ss m en
t Im
pr ov ed
se ns iti vi ty /s pe
ci fic ity
of re fe rr al
de ci si on
th ro ug
h de
ci si on
su pp
or t vi a
pr of es si on
al ne
tw or ks :p
rim ar y ca re
gr ou
ps ,
an d m ul tid
is ci pl in ar y gr ou
ps .
Re fe rr in g ph
ys ic ia ns
an d
al lie d he
al th
w or ke rs
Im pr ov ed
re fe rr al ap pr op
ria te ne
ss w hi le
de ci si on
su pp
or t is av ai la bl e [1 4, 58 –6 1] .
Pr im
ar y ca re
cl in ic al
ed uc at io n pr og
ra m m es
an d cl in ic al sc re en
in g
to ol s
Im pr ov e se ns iti vi ty /s pe
ci fic ity
of re fe rr al de
ci si on
th ro ug
h im
pr ov ed
pr im
ar y ca re
di se as e sp ec ifi c
kn ow
le dg
e an d di ag no
st ic sc re en
in g to ol s
Re fe rr in g ph
ys ic ia ns
Pr im
ar y ca re
ed uc at io n pr og
ra m m es
an d
cl in ic al sc re en
in g to ol s. Re du
ct io n in
nu m be
r of
de la ye d re fe rr al s, an d im
pr ov ed
re fe rr al
ap pr op
ria te ne
ss [4 8, 49 ,6 4– 70 ].
2. Sc re en
in g in te rv en
tio ns
– to
de te ct
fa ls e po
si tiv es ,f al se
ne ga tiv es ,t ria gi ng
er ro rs an d co m m un
ic at io n de
la ys .
St ra te gy
O bj ec tiv e
Ta rg et
po pu
la tio
n Ta rg et
im pa ct
Re po
rt ed
im pa ct
Pu bl ic aw
ar en
es s
ca m pa ig ns ,c om
m un
ity ca se
fin di ng
st ra te gi es ,
co m m un
ity sc re en
in g
pr og
ra m s
Im pr ov ed
pu bl ic aw
ar en
es s as
to w he
n to
se ek
ca re
w ith
pr im
ar y ca re
pr ov id er ,o r di re ct
pu bl ic
ou tr ea ch .
Pa tie nt
po pu
la tio
n. Im
pr ov ed
id en
tif ic at io n of
pa tie nt s in
ne ed
of sp ec ia lis t ca re
an d re du
ct io n in
nu m be
r of
de la ye d re fe rr al s
Im pr ov ed
id en
tif ic at io n of
pa tie nt s in
ne ed
of sp ec ia lis t ca re
an d re du
ct io n in
nu m be
r of
de la ye d re fe rr al s [8 7, 88 ].
C le ric al sc re en
in g of
re fe rr al s
Sc re en
in g of
in co m in g re fe rr al s, to
en su re
re fe rr al
co m pl et en
es s an d tr ia ge
re fe rr al s ba se d on
ur ge
nc y.
Sp ec ia lty
ca re
re fe rr al
ad m in is tr at io n
Id en
tif y in co m pl et e re fe rr al s, an d re qu
es t
m is si ng
in fo rm
at io n fro
m re fe rr in g ph
ys ic ia n.
Re du
ce sc he
du lin g of
in co m pl et e re fe rr al s.
Re du
ct io n of
in co m pl et e re fe rr al s be
in g
sc he
du le d [7 5] .I m pr ov ed
tr ia gi ng
of re fe rr al s
ba se d on
ur ge
nc y [7 7– 80 ].
C lin ic al sc re en
in g of
re fe rr al s
C on
fir m
ne ce ss ity
an d ap pr op
ria te ne
ss of
re fe rr al
ba se d on
pa tie nt ’s di ag no
st ic im
ag es /t es t re su lts
th at
ar e re qu
is ite
fo r th e re fe rr al .T ria ge
ap pr op
ria te
re fe rr al s.
Sp ec ia lis ts /c on
su lta nt s
Id en
tif y an d re di re ct
fa ls e po
si tiv es
(u nn
ec es sa ry
an d in ap pr op
ria te
re fe rr al s) ,
tr ia ge
re fe rr al s ba se d on
ur ge
nc y as
in di ca te d
by di ag no
st ic im
ag es /t es t re su lts .
Re di re ct io n of
un ne
ce ss ar y/
in ap pr op
ria te
re fe rr al s [1 0, 76 ].
C lin ic al sc re en
in g of
pa tie nt s
C on
fir m
ne ce ss ity
an d ap pr op
ria te ne
ss of
re fe rr al
ba se d on
cl in ic al as se ss m en
t of
th e pa tie nt .
Id en
tif y ap pr op
ria te
ca re
al te rn at iv es
w he
n sp ec ia lis t ca re
is no
t re qu
ire d (e .g .c on
se rv at iv e
m an ag em
en t fo r O A no
t re qu
iri ng
ar th ro pl as ty ).
Tr ia ge
ap pr op
ria te
re fe rr al s.
Sp ec ia lis ts /c on
su lta nt s,
re fe rr in g ph
ys ic ia ns
an d
al lie d he
al th
w or ke rs
Id en
tif y an d re di re ct
fa ls e po
si tiv es
(u nn
ec es sa ry
an d in ap pr op
ria te
re fe rr al s) ,
tr ia ge
re fe rr al s ba se d on
ur ge
nc y as
in di ca te d
by cl in ic al as se ss m en
t.
Re di re ct io n of
un ne
ce ss ar y/
in ap pr op
ria te
re fe rr al s
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 7 of 16
Ta b le
2 In te rv en
tio n st ra te gi es
an d ou
tc om
es (C on
tin ue d)
I.2 .I nt er ve nt io ns
to im
pr ov e in fo rm
at io n m an ag em
en t- In fo rm
at io n te ch no
lo gi es
El ec tr on
ic re fe rr al sy st em
s (e -r ef er ra ls )a
nd el ec tr on
ic m ed
ic al re co rd s (E M Rs )t o ex pe
di te
in fo rm
at io n sh ar in g
St ra te gy
O bj ec tiv e
Ta rg et
po pu
la tio
n Ta rg et
im pa ct
Re po
rt ed
im pa ct
El ec tr on
ic re fe rr al
sy st em
s an d El ec tr on
ic M ed
ic al re co rd s
Pr ov id e a st an da rd iz ed
el ec tr on
ic re fe rr al pr oc es s
th at
en su re s co m pl et en
es s of
re le va nt
in fo rm
at io n an d di ag no
st ic s w ith
th e re fe rr al ,
an d tim
el y co m m un
ic at io n.
Sy st em
le ve lc ha ng
e af fe ct in g Pr im
ar y ca re
th ro ug
h sp ec ia lty
ca re .
Im pr ov e ef fic ie nc y of
re fe rr al su bm
is si on
. Re du
ce w ai t tim
e be
tw ee n th e tim
e th e
re fe rr al is m ad e an d th e tim
e it is re ce iv ed
an d ap po
in tm
en t is sc he
du le d.
El ec tr on
ic re fe rr al sy st em
s an d el ec tr on
ic he
al th
re co rd s
Im pr ov ed
w or kf lo w
ef fic ie nc y fro
m re fe rr al
su bm
is si on
,t o sc re en
in g an d sc he
du lin g
re su lti ng
fro m
hi gh
er qu
al ity
re fe rr al ,i m pr ov ed
ac ce ss
to di ag no
st ic s, an d ef fic ie nt
co m m un
ic at io ns
[2 8, 29 ,9 5] .
Im pr ov ed
ne ce ss ity /a pp
ro pr ia te ne
ss of
re fe rr al s
du e im
pr ov ed
re fe rr al qu
al ity
an d en
ab lin g
im pr ov ed
cl er ic al /c lin ic al sc re en
in g of
re fe rr al s
[4 8, 92 –9 4] .
I.3 In te rv en
tio ns
to im
pr ov e sy st em
le ve lp
at ie nt
flo w s be
tw ee n pr im
ar y an d se co nd
ar y ca re
– Su pp
ly an d de
m an d m an ag em
en t
1. C ar e pa th w ay
m an ag em
en t - st re am
lin in g
St ra te gy
O bj ec tiv e
Ta rg et
po pu
la tio
n Ta rg et
im pa ct
Re po
rt ed
im pa ct
D ire ct /o pe
n ac ce ss
to di ag no
st ic s an d
sp ec ia lty
se rv ic es
Pr ov id e di re ct ,o r op
en ac ce ss ,t o sp ec ia lty
se rv ic es
by el im
in at in g on
e or
m or e st ep
s al on
g th e tr ad iti on
al re fe rr al pa th w ay .
Sy st em
le ve lc ha ng
e af fe ct in g pr im
ar y ca re
th ro ug
h sp ec ia lty
ca re .
Im pr ov ed
ac ce ss
to di ag no
st ic s, an d
sp ec ia lty
ca re .
Im pr ov ed
ac ce ss
to di ag no
st ic s an d or
sp ec ia lty
se rv ic es ,r ed
uc ed
w ai tin
g tim
es [9 7– 10 4] .
2. H um
an re so ur ce
m an ag em
en t - Sc op
e of
pr ac tic e re st ru ct ur in g at
pr im
ar y- sp ec ia lty
ca re
in te rfa ce
to in cr ea se
su pp
ly of
se rv ic e
St ra te gy
O bj ec tiv e
Ta rg et
po pu
la tio
n Ta rg et
im pa ct
Re po
rt ed
im pa ct
A lte re d sc op
es of
pr ac tic e
In cr ea se d fo cu s on
sp ec ia lty
se rv ic es
by sp ec ia lis ts su pp
or te d w ith
ex pa nd
ed sc op
e of
pr ac tic e by
no n- sp ec ia lis t ca re
pr ov id er s.
Sp ec ia lis ts an d no
n- sp ec ia lis t ca re
pr ov id er s
su ch
as nu
rs e
pr ac tit io ne
rs ,a lli ed
ca re
an d pr im
ar y ca re .
Im pr ov ed
ac ce ss
to sp ec ia lis ts vi a cr ea tio
n of
ca pa ci ty
th ro ug
h al te rn at iv e se rv ic e de
liv er y
m et ho
ds
N ur se
le d cl in ic s/ se rv ic es :R ed
uc ed
w or kl oa d fo r
ph ys ic ia ns .I nc re as ed
at te nt io n an d tim
el y ca re
to pa tie nt s. Ev id en
ce ha s sh ow
n nu
rs e- le d cl in ic s
ca n pr ov id e eq
ui va le nt
ca re
w ith
no gr ea te r ris k
of po
or er
ou tc om
es [1 13 ,1 14 ,1 16 ]
Si m ila r ou
tc om
es re po
rt ed
fo r Pr im
ar y ca re
ph ys ic ia ns
w ith
ex te nd
ed ro le s [1 19 ,1 20 ].
M ul ti- di sc ip lin ar y te am
ba se d ca re
C oo
rd in at ed
ca re
pr ov id in g pa tie nt
im pr ov ed
ac ce ss
to a br oa d ra ng
e of
co m pl im
en ta ry
ca re
se rv ic es .
Sp ec ia lis ts an d no
n- sp ec ia lis t ca re
pr ov id er s
su ch
as nu
rs e
pr ac tit io ne
rs ,a lli ed
ca re
an d pr im
ar y ca re .
Im pr ov ed
Q ua lit y of
ca re .I m pr ov ed
ac ce ss
to sp ec ia lis ts vi a cr ea tio
n of
ca pa ci ty
th ro ug
h al te rn at iv e se rv ic e de
liv er y m et ho
ds .
M ul ti- di sc ip lin ar y te am
ba se d ca re :B et te r pa tie nt
ac ce ss
to a w id e ra ng
e, bu
t in cr ea si ng
ly sp ec ia liz ed
he al th
ca re se rv ic es
th at m ay
be re qu
ire d
fo re ffe ct iv e di se as e m an ag em
en t[ 12 3, 12 4] .
Ev id en ce
re ga rd in g th e co st -e ffe ct iv en es s
of m ul tid isc ip lin ar y te am
ba se d ca re is la ck in g,
an d fu rth
er st ud ie s ar e re qu ire d [1 48 ].
3. Q ue ue /r ef er ra lm
an ag em
en t - C en
tr al iz ed
in ta ke
of re fe rr al s to
im pr ov e ac ce ss
to sp ec ia lty
ca re .
St ra te gy
O bj ec tiv e
Ta rg et
po pu
la tio
n Ta rg et
im pa ct
Re po
rt ed
im pa ct
Re fe rr al m an ag em
en t
ce nt re s
Po ol ed
in ta ke
an d su bs eq
ue nt
sc he
du lin g of
al l
in co m in g re fe rr al s fo r al ls pe
ci al tie s
Sy st em
le ve li nt er ve nt io n,
re qu
iri ng
cr iti ca lb uy -in
fro m
re fe rri ng
ph ys ic ia ns
an d sp ec ia lis ts .
D ec re as ed
w ai t tim
es .
Sy st em
at ic ev al ua tio
ns of
re fe rr al m an ag em
en t
ce nt re s ar e ne
ed ed
[7 3] .
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 8 of 16
Ta b le
2 In te rv en
tio n st ra te gi es
an d ou
tc om
es (C on
tin ue d)
Sp ec ia lty
sp ec ifi c
tr ia gi ng
cl in ic s
Po ol ed
in ta ke
an d su bs eq
ue nt
sc he
du lin g of
al li nc om
in g re fe rr al s fo r sp ec ifi c sp ec ia lty
(o r
su b- sp ec ia lty )
Sy st em
le ve l
in te rv en
tio n, re qu
iri ng
cr iti ca lb
uy -in
fro m
re fe rr in g ph
ys ic ia ns
an d
sp ec ia lis ts .
D ec re as ed
w ai t tim
es .
Im pr ov ed
re fe rr al pr oc es se s, im pr ov ed
pa tie nt
tr ia gi ng
,i m pr ov ed
ap pr op
ria te ne ss ,i m pr ov ed
w ai t
tim es
to sp ec ia lis t co ns ul t [5 8, 12 1, 13 2– 13 4] ,
un ch an ge d w ai t tim
es to
do w ns tr ea m
be nc hm
ar ks
su ch
as su rg er y [1 35 ,1 36 ], pr ov id er
sa tis fa ct io n m ay
be lo w [1 35 ].
I.4 In te rv en
tio ns
to m on
ito r an d im
pr ov e qu
al ity
an d/ or
pe rfo
rm an ce
C on
tin uo
us qu
al ity
im pr ov em
en t
St ra te gy
O bj ec tiv e
Ta rg et
po pu
la tio
n Ta rg et
im pa ct
Re po
rt ed
im pa ct
Q ua lit y/ pe
rfo rm
an ce
im pr ov em
en t
fra m ew
or ks
Pr ov id e ca pa ci ty
fo r st ra te gi c de
ci si on
m ak in g
us in g in fo rm
at io n th at
re la te s op
er at io na la nd
m an ag em
en t de
ci si on
s to
th ei r ou
tc om
es
Sy st em
,H os pi ta l, C lin ic
le ve lt ar ge
ts Im
pr ov e st ra te gi c de
ci si on
m ak in g,
an d
m an ag em
en t of
op er at io ns .
Pe rfo
rm an ce
m ea su re s of
re fe rr al pr oc es se s an d
ou tc om
es in cl ud
in g th e ad eq
ua cy
an d
ap pr op
ria te ne
ss of
co or di na tio
n of
re fe rr al s
an d th e qu
al ity ,r es ou
rc e us e an d ou
tc om
es of
re fe rr al s ar e la ck in g [1 38 ]
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 9 of 16
D.3. Deficiencies based in the management of patient flows between primary and specialty care (Supply and demand management) encompass both the organization of care pathways traversing the primary-specialty inter- face and their management. The care pathway is a key determinant of the patient flows from primary to specialty care, dictating the options available to primary care pro- viders and influencing how demand is distributed across specialty care providers and diagnostic service providers. Care pathways are designed to incorporates all relevant factors necessary to provide quality care, but should be as efficient as possible, ensuring that patients receive the ap- propriate care as quickly as possible. Three types of issues were identified in the management of patient flows be- tween primary and specialty care:
1. Care pathway management. Inefficient care pathway structure and resource use hinders patient flows.
2. Role management (Inter-professional workload imbalance). Surplus demand placed on specialty care providers, creates bottlenecks within the care pathway (Short term and sustained).
3. Queue/Referral management (Intra-professional workload imbalance). Unmanaged distribution of referrals amongst specialty care providers may create an imbalance in specialist utilizations that unnecessarily increases average wait times.
D.4. Deficiencies in the monitoring of quality-of-care and system performance result when measurement frameworks, needed to provide decision makers the capability for strategic decision making, are lacking. Quality-of-care/performance improvement is promoted as a core value in the healthcare field, with numerous frameworks developed to measure and track the performance of health systems [30–32]. The impact of these four categories of deficiencies is sig-
nificant, creating unnecessary delays to appropriate spe- cialty services. At a system level, such deficiencies impact the efficiency of the health system, creating access delays for all referred patients, increased costs and extra strain on care providers. At a patient level, such errors result in a poor patient experience, and potential delays in diagnosis and therapy initiation compromising patient outcomes (e.g. rheumatoid arthritis [33, 34] and chronic kidney disease [35]). A lack of quality-of-care/performance monitoring compounds these issues, making it difficult to identify, evaluate the severity, and prioritise problems that arise at the primary-specialty care interface.
Intervention strategies and outcomes (Table 2) I.1. Interventions to reduce referral error 1. Preventive interventions to reduce the occurrence of false positives, false negatives, triaging errors and communication delays.
Preventive interventions serve to improve referral qual- ity and reduce the occurrence of referral errors. Referral guidelines [36–47] and education programs [48–52] tar- geting primary care providers generally serve as the foun- dation for such interventions. However, guidelines and education alone may be ineffective without feedback op- portunities [43, 53–56] and relationship building [57]. Similarly, peer review or shared/supported patient assess- ment may also reduce rates of unnecessary/inappropriate or delayed referrals and can be implemented via primary care triage clinics [58, 59], multidisciplinary team based diagnosis [14], and peer consult groups [60, 61]. The intro- duction of a referral process that employs standard referral forms, criteria checklists, diagnostic checklists, scoring systems [14, 62, 63] and assessment tools developed specifically for primary care use [64–72] serves to improve referral quality. Local health services providers should be included in dissemination activities, allowing the interven- tion to adapt to local circumstances [10, 50, 73]. 2. Screening interventions to detect false positives, false
negatives, triaging errors and communication delays. Screening interventions serve to catch referral errors
that do occur. Reassessing patients on wait lists for need and appropriateness can reduce wait lists [74]. Clerical screening of referrals ensures completeness in terms of needed information and diagnostics [75]. Clinical screen- ing of diagnostics prior to a specialist consult may redirect unnecessary or inappropriate referrals [10, 76]. Screening referrals also allows referrals be triaged based on urgency. Triaging may be conducted through various means, from reviewing clinical findings and diagnostic test results to the development of specific scoring systems [77–80, 81, 82]. Previous reviews of triaging systems concluded that further evidence is required regarding the effectiveness and reliability of triaging [83], and whether triaging im- proves patient outcomes [84] and waiting times [83, 85]. It is difficult to identify interventions developed to catch type II errors. Since type II error results when a patient should be referred to specialty care but is not, such errors must be caught by the patient themselves. Improved pa- tient awareness may encourage patients to voice their con- cerns with their primary care provider, or seek a second opinion. Various strategies are outlined for Rheumatoid arthritis [86]. For example, internet based education sites and public awareness campaigns can be used to raise pa- tient awareness. Community screening/outreach pro- grammes provide patients direct access to healthcare professionals and provide alternative means for undiag- nosed patients to enter specialist care [87, 88].
I.2. Interventions to improve information management- electronic referral systems and electronic medical records to expedite information sharing Electronic re- ferral systems (eReferrals), supplemented with electronic
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 10 of 16
medical records (EMRs) enable improved information management, improving workflow efficiency and quality-of-care through better linkages between primary and specialty care, improved dialogue, and better coord- ination of primary and specialty care resources [28, 29, 89]. eReferrals also help facilitate transmision of diag- nostics [28, 90], reduce duplicate testing [91] and in some cases enable referral triaging, which can improve the appropriate use of clinic time and significantly im- prove wait times for patients needing to see specialists [48, 92–94]. While eReferral systems hold great promise, in practice, the successful development and implementa- tion of such systems has been difficult [95]. Barriers in- clude the high cost and extensive strategic planning required for development, privacy and data security, and technical barriers such as interoperability between pro- prietary EMRs [28]. The benefits of eReferrals may well outweigh these costs but further empirical evidence is required.
I.3 Interventions to improve system level patient flows between primary and secondary care 1. Care pathway management - streamlining Patient flows between primary and secondary care
may be improved by the removal of unnecessary gate- keeping along the referral pathway, providing direct or open access. Examples include allowing patients to self-refer for follow up on uncertain diagnoses [96], al- lied health workers to refer directly to specialists [27], and allowing primary care physicians to circumvent pre- liminary specialist assessments in favour of proceeding straight to advanced diagnostics [26, 97–104, 105, 106] and even surgery [107]. A similar strategy involves spe- cialties running rapid access clinics to triage and provide care to urgent patients [108–111]. The inherent trade-off that comes with providing direct or open ac- cess is the potential for increased rate of inappropriate referrals or diagnostic requests. For example, one study found that in an open access system for endoscopic pro- cedures, agreement between GPs and specialists was poor to moderate, with specialists viewing 22.1% of re- ferrals as inappropriate [105]. 2. Human resource management - Scope of practice
restructuring. In systems constrained by workforce shortages, im-
proved patient flows may be achieved by allocating se- lected tasks to alternative health care professionals with similar scopes of practice (e.g. [112]). For example, ex- tending the roles of nurses and nurse practitioners in specialty areas such as rheumatology [113], cardiology [114, 115] and oncology [116] can reduce demand for specialists while providing equivalent care with no greater risk of poorer outcomes. Similar roles may be played by allied health care providers such as
physiotherapists [117, 118], and primary care physicians [119, 120]. The formation of multi-disciplinary care teams (MDTs) that provide an integrated approach to healthcare and may improve load sharing between med- ical and allied health professionals who work collabora- tively (e.g. [121]). MDTs have become the standard of care in Oncology [122], enabling better patient access to a wide range, but increasingly specialized health care services for disease management [123, 124], but are also thought to be an effective model for chronic diseases re- quiring complex management strategies [125]. Current evaluations of MDT care focus on clinical benefit to the patient [126, 127] and information on system level out- comes and cost-effectiveness is lacking [128]. 3. Queue/referral management - Centralized intake of
referrals to improve access to specialty care. Referral management via centralized intake provides a
mechanism for manage demand intra-professionally [121, 129–131] and to mitigate the effects of fluctuations in staffing, facility availability, and caseload (emergent, urgent, non-urgent, etc.). Centralized intake has been implemented through dedicated referral management centres, which are tasked with handling all incoming re- ferrals for all specialties, and specialty based clinical as- sessment clinics. Systematic evaluations of referral management centres are lacking [10, 14]. There is evi- dence showing speciality based clinics offer improved urgency-based access to specialists [58, 121, 132–134]. While specialty based clinics have demonstrated a de- creased wait period from referral to first consult, other wait periods may remain unchanged, such as the wait period from referral to surgery [135, 136]. Specialty tri- age clinics may also reduce the overall rate of unneces- sary and inappropriate referrals, resulting in patients being appropriately diverted from specialist care [137].
I.4 Interventions to monitor and improve quality and/ or performance - continuous quality improvement Guavara et al. [138] review performance measures for the specialty referral process, categorizing performance measures into 4 principle domains: 1) referral initiation (reason and rates of referral), 2) accessibility to specialty care 3) coordination of primary and secondary care, and 4) quality (timeliness and satisfaction), with the majority of measures reporting on referral structures. Perform- ance measures for referral processes and outcomes are lacking, and although most of the reviewed measures included assessments of validity, few reported on reliability.
Synergies and trade-offs We end by identifying potential synergies and conflicts among intervention strategies. Recognizing synergies or trade-offs is important when attempting to manage
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 11 of 16
multiple intervention strategies that may seek to achieve common or conflicting objectives [139]. Potential synergies amongst the reviewed interventions
were identified. For example, centralized intake of referrals may facilitate the introduction of a standardized referral process, with supporting guidelines, especially if imple- mented with eReferrals [93, 140–142] improving workflow efficiency by ensuring the completeness of the referral and providing access to relevant information and diagnostics thus hastening the screening of the referral [28, 90]. In addition, standardized referral forms ensure the patient’s information, history, physical exams, laboratory tests and urgency are communicated to the specialist [143–145], improving triaging. Centralized intake may also facilitate the introduction of both preventive and screening inter- ventions to reduce inappropriate/unnecessary referrals. When coupled with EMRs, referrals can be clinically screened, reducing the need for face-to-face assessment, instead allowing referrals and diagnostics to be reviewed remotely [48, 93, 94]. Triaging may be coupled with rapid access services to reduce wait times between referral and patient assessment [110]. Identifying potential conflicts between intervention
strategies requires an understanding of the mechanisms of causality that explain why deficiencies arise, and how they are corrected via intervention. For example, our discussion of referral errors (false positives and false negatives) and the corresponding corrective interven- tions would not be complete without acknowledging that in many cases a trade-off will need to be made between inappropriate /unnecessary referrals and delayed refer- rals. Indeed, a decreased specificity and increased sensi- tivity will result in fewer false negatives but increased false positives, which will increase the demand for spe- cialty services. Alternatively, an increased specificity and decreased sensitivity will result in fewer false positives but an increased number of false negatives which will in- crease the number of patients remaining undiagnosed and improperly managed. Interventions are needed to not only improve the sensitivity and/or specificity of the decision process, but also to optimise the balance be- tween the sensitivity and specificity. Similarly, interven- tions designed to reduce or catch referral errors (sometimes called gatekeeping) may be in conflict with accessibility. For example, screening interventions to re- duce rates of unnecessary and inappropriate and/or de- layed referrals may introduce additional waiting periods. Such processes must be effective in redirecting inappro- priate referrals in order to offset additional delays and costs that are introduced. If the false positive/negative error rates are sufficiently low, then it may be of benefit to move towards a more direct, or open access, referral system that eliminates one or more screening steps along the traditional referral pathway. Conversely,
removal of screening processes to improve access times to diagnostics and specialty services may increase the frequency of inappropriate/unnecessary referral to these services, increasing wait times for all patients (appropri- ately and inappropriately referred). Finally, balance be- tween system, provider, and patient perspectives is always needed. For example, when assessing referral management strategies such as centralized intake, caution is required not to limit focus purely to system efficiency. Both primary and specialist provider participation is crucial for effective centralized intake systems. Reasons for non-participation include loss of autonomy, loss of primary-specialist care relationships, and loss of control over case-loads [135]. Patients may prefer the option to have input into the scheduling of appointments [146], but appropriateness may decrease [147]. Interestingly our search revealed little if any discussion regarding the stra- tegic balancing of these effects.
Discussion There is a large literature pertaining to interventions that impact the necessity, appropriateness, timeliness and communication of patient transitions across the primary-specialty care interface. The literature is broad and can be difficult to navigate due to complexity of the primary-specialty care interface, the breadth of potential deficiencies, and the equal breadth of interventions de- veloped to correct them. As such, we present a narrative review that describes linkages between deficiencies at the primary-specialty care interface, which impact access to specialty services for non-emergent patients, with in- terventions and subsequent effects. This review was focussed only on deficiencies at the
primary-specialty care interface that impact access to specialty services to address our objective on these spe- cific problems. The review does not consider deficiencies at the primary-specialty care interface that impact the broader patient and service provider experience. While improving access to specialty care is a critical issue in the delivery of health services, more broadly, health sys- tem performance is measured in terms of quality of care criteria in multiple dimensions. Improving access to care must be done in the context of the broader objective of improving the overall quality of care provided to patients suffering from chronic diseases.
Limitations This review is unlikely to be complete, especially given the broad scope of our topic. The literature on health services interventions applied at the primary-specialty care inter- face is vast, spanning many fields from clinical practice to economics and operations research. Inevitably there are bodies of work that will be revealed to have been left out. For example, the omission of CINAHL in our search
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 12 of 16
strategy may have resulted in missed studies pertaining to the roles and impact of allied health care workers and nurse practitioners in reducing wait times for specialist services when the service the patient required could be provided by a nurse practitioner or an allied health care provider. Moreover, as the primary-specialty care interface continues to evolve, new problems will inevitably arise and future research will produce new innovative health system interventions. We did not summarise the context and assess the
quality of each study. Our aim and focus were to note that from a system perspective, the literature is fragmen- ted. Specifically, the studies reviewed were generally highly context specific; developed to document improve- ments to in-use, specialty specific, referral systems ex- periencing specific difficulties (e.g. long wait times). Such an approach does not lend itself to establish the ef- fectiveness of the intervention in the broader health sys- tems context. Consequently, it is not clear if the available evidence pertaining to intervention effective- ness can be taken out of context. The reviewed studies were not developed to demonstrate intervention effect- iveness in variety of applications and contexts.
Value The key strength of this review is its emphasis on the identification and categorization of deficiencies in the primary-specialty care interface by cause. Within the lit- erature, interventions are commonly framed in terms the practical actions taken to create improvements in system performance as measured through specific out- comes such as reduced wait times between referral and consult. However, simply detailing an intervention’s ac- tions and outcomes without describing the deficiencies the intervention is designed to correct can lead to poten- tial mis-application. The potential issue here is one of logical verification; the logic that supports the adaptation and implementation of the reviewed interventions to new contexts can only be verified through an understanding as to why the performance of the primary-specialty care interface is failing in the first place. The intention is that such a causal approach will facilitate the development of complex integrated health system interventions that consist of multiple coordinated intervention components, managing different shortfalls in the referral system that arise at the primary-specialty care interface. The categorization serves as a necessary first step to facilitate the development and evaluation of such complex interventions. The practical outcome is the creation of a resource for health care organizations seeking to optimize the primary care/specialty care inter- face to improve access to specialty care for non-emer- gent patients from a systems perspective.
Conclusion The results of this review demonstrate the breadth of deficiencies that impact access to specialty services for non-emergent patients via primary-specialty care inter- face and an equal breadth of corrective interventions. Although interventions developed to improve the refer- ral process at the primary-specialty care interface hold great promise, much work remains to better understand the potential utility of such interventions. Deficiencies that limit access to specialty care for non-emergency pa- tients, as outlined here, arise independent of context. As such, general intervention strategies that can be adapted and applied in broad range of contexts are needed.
Additional file
Additional file 1: Search strategy. Details of the search strategy used. (DOCX 13 kb)
Abbreviations EMRs: Electronic medical records
Acknowledgements JGL was employed a research associate at the University of Calgary during this project and funded by the PRIHS grant awarded to DM and LW. LJ was employed as a research assistant at the University of Calgary on this project and funded by the A.E Child Chair grant awarded to DM. Thank you to Yoojin Kwon, MLS (Master of Library Science), for her assistance developing the search strategy for this review.
Funding This project was funded by a Partnership for Research and Innovation in the Health System (PRIHS) grant provided by Alberta Innovates Health Solutions DM is supported by a Canada Research Chair, Health Services and Systems Research and the Arthur J.E. Child Chair in Rheumatology Outcomes Research. LJ was supported through the Arthur J.E. Child Chair in Rheumatology Outcomes Research.
Availability of data and materials Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Authors’ contributions JGL had the original idea and led the drafting of the paper. Early drafts were developed between LJ and JGL. DM and LW provided comments and helped refine the categorization. All authors read and approved the final manuscript.
Ethics approval and consent to participate Not Applicable.
Consent for publication Not Applicable.
Competing interests JGL and LJ declare the following interests: None DM declares the following interests: Ad hoc consulting for Optum, a health economics and outcomes research global company. Honoraria and travel expenses as a member of Pfizer HTA Advisory Board, honoraria and travel expenses for a seminar for Abbvie, honoraria and travel expenses for a presentation for Novartis, honoraria and travel expenses for a presentation for Janssen. Unpaid officerships - President and member of Board of Directors, International Society for Pharmacoeconomics and Outcomes Research, and member of Board of Directors, Health Technology Assessment International, Editorial Board
Greenwood-Lee et al. BMC Health Services Research (2018) 18:986 Page 13 of 16
The Patient, Editorial Board, International Society for Technology Assessment in Health Care. LW declares the following interests: Funding from Eli Lilly for myostatin trial design and serving on an advisory board for myostatin development.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Author details 1Centre for Science, Athabasca University, 6th Floor, 345 6 Avenue SE, Calgary, Alberta T2G 4V1, Canada. 2Geography & Planning, University of Toronto, Sidney Smith Hall, Rm 594, 100 St George St., Toronto, Ontario M5S 3G3, Canada. 3Faculty of Rehabilitation Medicine, University of Alberta, 3-10 Corbett Hall, 8205 114 Street, Edmonton, Alberta T6G 2G4, Canada. 4Canada Research Chair, Health Services and Systems Research, Arthur J.E. Child Chair in Rheumatology Outcomes Research, Department of Community Health Sciences, University of Calgary, Calgary, Canada. 53C56 Health Research Innovation Centre (HRIC), 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada.
Received: 23 April 2018 Accepted: 21 November 2018
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- Abstract
- Background
- Methods
- Results
- Conclusion
- Background
- Methods
- Stage 1: Narrative literature review
- Stage 2: Categorization development
- Results
- Stage 1: Narrative literature review
- Stage 2: Categorization
- Identified deficiencies at the primary-specialty care interface (Table 1)
- Intervention strategies and outcomes (Table 2)
- Synergies and trade-offs
- Discussion
- Limitations
- Value
- Conclusion
- Additional file
- Abbreviations
- Acknowledgements
- Funding
- Availability of data and materials
- Authors’ contributions
- Ethics approval and consent to participate
- Consent for publication
- Competing interests
- Publisher’s Note
- Author details
- References
