A model for understanding diagnostic imaging referrals and complex interaction processes within the bigger picture of a healthcare system

Using experiences from the South African public healthcare system with limited resources, this review proposes a model that captures a holistic perspective of diagnostic imaging services embedded in a network of negotiated decision-making processes. Professional interdependency and interprofessional collaboration, cooperation and coordination are built around the central notion of integration in order to achieve a seamless transition through the continuum of various types of services needed to come to a diagnosis. Health-system role players interact with patients who enter the system from the perspective of their life-world. The distribution of diagnostic imaging services – within one setting or at multiple levels of care – demonstrates how fragments of information are filtered, interpreted and transformed at each point of care. The proposed model could contribute to alignment towards a common goal: services providing holistic quality of care within and beyond a complex healthcare system.     

“一站式”预约系统的设计与研究

目前就诊排队是普遍的社会问题，为提高服务质量，减少候诊时间，设计完成“一站式”预约系统。结合不同检验检查的预约规则、预约模式，建立数学模型，对非抢占有限优先权的预约模式进行结合实际情况的比对分析。在模式设计中，利用简单工厂模式与策略模式相结合的方法，减少代码重用，使系统更加强壮。同时利用数学模型，通过系统给用户一系列的理论值，使用户感受更加直观。理论值与实际情况相比较，进行误差分析，结合门诊预约等多种模式，做到“一站式”预约，即有排队等待的地方就有预约。     

Colles’ fractures and osteoporosis—A new role for the Emergency Department

PurposeIn Denmark, guidelines from the Danish Orthopedic Society recommend that patients older than 65 years who sustain a Colles’ fracture should be referred to assessment of underlying osteoporosis. An assessment of referral rates at our hospital during the period October 2010–September 2013 showed that none were referred. Due to this, an automatic out-patient referral system for assessment of underlying osteoporosis was established. With this system, patients are referred directly from the Emergency Department (ED). The purpose of this study was to assess how effective this new referral system was at improving referral rates for assessment of osteoporosis and to evaluate how many more cases of osteoporosis that was identified with this practice during the period October 2013–September 2014.MethodThe automatic referral system for evaluation of osteoporosis in patients 65 years and above without known osteoporosis, living in the catchment area and sustaining a low energy distal forearm fracture was established in October 2013. With the new system, patients were referred directly from the ED for evaluation of osteoporosis at the osteoporosis out-patient department at the hospital. The system was evaluated for the period October 2013–September 2014. For comparison data was collected on the same patient group for the 3 years preceding the system.ResultsBefore the automatic system none were referred for evaluation of osteoporosis and thus none were diagnosed. After introduction of the system 100% were referred, 73.26% were examined and 65.08% of these were found to have osteoporosis. Anti-osteoporotic treatment was initiated in all but 4.88% of the patients.ConclusionThe results show that this type of automatic referral system can be an effective way of increasing the number of patients diagnosed with and treated for osteoporosis. It also shows that involvement of the ED in the screening for osteoporosis can be an effective way of increasing referral rates leading to higher rates of diagnosed osteoporosis. The early identification and initiating of treatment might result in a lower rate of secondary and potentially more severe osteoporotic fractures.     

深化家庭医生首诊职能的分析与实践

目的深化家庭医生首诊职能的实施。方法设立激励机制，赋予家庭医生使用三级医疗机构资源的权限，对通过家庭医生首诊的患者给予优先处理措施，向家庭医生反馈患者就诊信息。结果接受家庭医生首诊的55名患者对服务的评价较为积极。结论三级医疗机构和社区卫生服务中心均能够通过家庭医生首诊的实施获益。     

A novel methodology to measure waiting times for community-based specialist care in a public healthcare system

BackgroundMonitoring waiting time (WT) in healthcare systems is essential, since long WT are associated with adverse health outcomes, reduced patient satisfaction and increased private financing.ObjectiveTo describe a methodology developed for routine national monitoring of WT for community-based non-urgent specialist appointments, in a public healthcare system.MethodsThe methodology is based on data from computerized appointment scheduling systems of all Health Maintenance Organizations (HMOs) in Israel. Data included first 50 available appointments for community-based specialists and actual number of visits. Five most frequent specialties: orthopedics, ophthalmology, gynecology, dermatology and otolaryngology, were included.WT offered to HMO members for non-urgent care was calculated for two scenarios: "specific" physician and "any" physician in the region. Distribution of offered WT was calculated separately for each specialty and geographical region, combined to create the nationwide distribution.ResultsThe methodology was tested on data extracted between December 2018-June 2019. Estimated national median WT for "specific" physician, ranged from 9 days (ophthalmology/gynecology) to 20 days (dermatology), with large variation between geographic regions. WT were 26–56 % shorter for "any" than for "specific" physician.ConclusionsThis novel method offers a solution for ongoing national WT measurement, using computerized scheduling systems. It integrates two scenarios for appointment scheduling and allows identification of differences between specialties and regions, setting the ground for interventions to strengthen public healthcare systems.     

Impact of Delayed Time to Advanced Imaging on Missed Appointments Across Different Demographic and Socioeconomic Factors

PurposeThe aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors.MethodsAn institutional review board–approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics.ResultsA total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers.ConclusionsIncreased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.     

Risk factors in an HIV-infected population for refraining from specialist care

Background: To obtain maximal benefit of combination antiretroviral therapy (cART), HIV-infected patients should be retained in medical care. Missed clinical visits are independently associated with all-cause mortality among HIV-infected patients. Our objective was to identify risk factors and patient-reported reasons for nonattendance at outpatient clinic appointments. Design and methods: We conducted a cross-sectional case-control study among 447 HIV-infected patients attending the outpatient clinic between March and July 2014. Patients with missed appointments from January 2013 onwards were included as cases and compared to a random selection of same-day controls without missed appointments during the same period. Clinical and socio-demographic characteristics were collected from clinical records and an interviewer-administered questionnaire. Additionally, reasons for nonattendance and possible solutions for future better attendance were addressed in the questionnaire. Multivariable logistic regression analysis was used to determine independent risk factors for nonattendance. Results: A total of 224 cases and 223 controls were included. Independent risk factors for nonattendance were: (i) age <30 years (odds ratio (OR) 7.2; 95% CI: 3.2–16.3 versus ≥50 years); (ii) African region of origin (OR 2.8; 95% CI: 1.5–5.0 versus Western origin); (iii) having children <12 years of age (OR 2.1; 95% CI: 1.1–4.1); (iv) history of drugs- or alcohol abuse (OR 4.4; 95% CI: 1.8–10.8); (v) no cART (OR 2.5; 95% CI: 1.1–5.3) or HIV-RNA >400 copies/ml while receiving cART (OR 3.5; 95% CI: 1.3–9.6). The main reason given for nonattendance was failure to remember the appointments (44%). Most patients would prefer to receive an appointment reminder by SMS (80% of the cases and 55% of the controls). Conclusion: Missing outpatient clinic appointments were associated with available clinical characteristics. Nonattendance may be prevented by sending routine SMS reminders prior to the next appointment.     

个性化健康教育对原发性青光眼患者复诊率的影响

目的观察个性化健康教育对原发性青光眼患者复诊率的影响。方法将100例原发性青光眼患者按就诊次序分为对照组和观察组各50例。对照组采用常规护理,观察组在此基础上采取个性化健康教育,比较两组患者出院半年内的复诊率。结果两组患者复诊率比较,观察组优于对照组,差异有统计学意义(P0.01)。结论个性化健康教育增强了原发性青光眼患者的复诊意识,提高了复诊率,有利于及时发现病情变化,挽救视功能。     

Old boys’ network in general practitioners’ referral behavior?

We analyzed the impact of social networks on general practitioners’ (GPs) referral behavior based on administrative panel data from 2,684,273 referrals to specialists made between 1998 and 2007. For the definition of social networks, we used information on the doctors’ place and time of study and their hospital work history. We found that GPs referred more patients to specialists within their personal networks and that patients referred within a social network had fewer follow-up consultations and less inpatient days thereafter. The effects on patient outcomes (e.g. waiting periods, days in hospital) of referrals within personal networks and affinity-based networks differed. Specifically, whereas empirical evidence showed a concentration on high-quality specialists for referrals within the personal network, suggesting that referrals within personal networks overcome information asymmetry with respect to specialists’ abilities, the empirical evidence for affinity-based networks was different and less clear. Same-gender networks tended to refer patients to low-quality specialists.