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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., Plain English summary 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 2015/16–20. 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.

PURPOSE: Musculoskeletal problems are the leading cause of chronic disability. Most patients in the UK seek initial care from general practitioners (GPs), who are struggling to meet demand. Patient direct access to National Health Service physiotherapy is one possible solution. The purpose of this study was to understand the experiences of patients, GPs, physiotherapists and clinical commissioners on direct access in a region in England with it commissioned. \ud \ud METHODS: The study was informed by Normalisation Process Theory (NTP). Data collection was via semi-structured individual face-to-face and telephone interviews with 22 patients and 20 health care professionals (HCPs). Data were analysed thematically using NPT. \ud \ud RESULTS: Three themes emerged: understanding physiotherapy and the direct access pathway; negotiating the pathway; making the pathway viable. HCPs saw direct access as acceptable. Whilst patients found the concept of direct access, those with complex conditions continued to see their GP as first point of contact. Some GPs and patients reported a lack of clarity around the pathway, reflected in ambiguous paperwork and inconsistent promotion. Operational challenges emerged in cross-disciplinary communication and between HCPs and patients, and lack of adequate resources. \ud \ud CONCLUSION: Direct access to NHS musculoskeletal physiotherapy is acceptable to patients and HCPs. There is need to ensure: effective communication between HCPs and with patients, clarity on the scope of physiotherapy and the direct access pathway, and sufficient resources to meet demand. Patient direct access can free GPs to focus on those patients with more complex health conditions who are most in need of their care.

Context: Thailand subsidizes health-care costs, allowing citizens access to health care without out-of-pocket expenses. However, some citizens still spend large amounts of money on treatment provided at tertiary care hospitals. Aim: To identify the proportion of patients whose visits are not covered by national health insurance at the tertiary hospital and their reasons for visiting. Settings and Design: Prospective, descriptive study in patients visiting Srinagarind hospital outpatient department from July to September 2019. Subjects and Methods: We gathered and analyzed the data regarding demographics, hospital visits, and illness severity using a questionnaire. Statistical Analysis Used: Descriptive analyses and logistic regression were performed as appropriate. Results: Of the 700 participants, 40% (95% confidence interval 36.3–43.7) was not covered for their visits. The three common reasons visiting this hospital were desire of treatment from a specialist (42.9%), the reputation of the hospital (31.4%), and service satisfaction (26.6%). Conclusions: Although the national health-care system provides a gratis service pathway, some people still pay out-of-pocket unnecessarily. Officials should work to better raise the level of public confidence in the primary and secondary care units.

Purpose: Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy. Methods: An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy. Results: Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30–59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems. Conclusions: The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story. Graphical abstract: [Figure not available: see fulltext.]

Evidence is lacking on how to manage imminent suicidality in adolescents with self-harm. Brief Admission by Self-referral (BA) is a crisis-management intervention, developed for adults with self-harm at risk for suicide. Structured, individualized and based on responsible autonomy, BA aims to provide a respite while minimizing negative effects of hospitalization. This qualitative interview study illuminates adolescents’ experiences of BA, adapted for this target group. Nineteen adolescents aged 14 to 19 years, described BA as helpful for timely rest and recovery to save themselves from impulses to self-harm. The individual contract, which is a prerequisite for access to BA, was perceived to give access to professional support in a safe environment, also among adolescents not using their contract. Being trusted with responsibility to self-admit was also hard work with struggles of self-doubt. Challenges included experiencing distrust from staff and fear of not being able to abstain from self-harm, which BA is conditioned upon. However, this condition was also perceived to induce self-motivation and growth. BA appeared well-adapted to the target group, fulfilling needs of predictability, autonomy, and opportunity for recovery to prevent self-harm. Suggestions for improvement included continually informing staff about important features of BA. To further evaluate benefits and challenges of BA, future research may evaluate clinical and health-economic outcomes and perspectives from parents and caregivers.

Resumen La meditación de atención plena es una técnica ampliamente usada en la actualidad, con origen en la cultura budista, que permite desarrollar la habilidad de dirigir la atención sin prejuicios a las experiencias del momento presente, tratando de disminuir el procesamiento autorreferencial narrativo o de experiencias y la prospección en el futuro. Los estudios en el área han demostrado la utilidad de la meditación de atención plena para aumentar el bienestar psicológico y físico en términos generales, pero los mecanismos neurofisiológicos asociadas a estos cambios aún están sin dilucidarse. En la presente revisión se recopila información de estudios que han utilizado neuroimagen y electroencefalograma para valorar los mismos, con énfasis en aquellos estudios que permiten discutir la propuesta de la meditación de atención plena como un estímulo que disminuye el procesamiento de tareas autorreferenciales y favorece los estados de tareas cognitivas y tareas asociativas sensoriales, incluida la interocepción. Estos estudios evidencian cambios estructurales y funcionales en sectores como corteza prefrontal, ínsula, el hipocampo, el giro cíngulo, la corteza visual primaria y el estriado, que son discutidos en este artículo a la luz del conocimiento actual. Abstract Mindfulness meditation is a technique widely used today, originating in Buddhist culture, which allows developing the ability to direct attention without prejudice to the experiences of the present moment, trying to reduce narrative or experience self-referential processing and prospecting in the future. Studies in the area have shown the usefulness of mindfulness meditation to increase psychological and physical well-being in general terms, but the neurophysiological mechanisms associated with these changes remain to be elucidated. In this review, information is collected from studies that have used neuroimaging and electroencephalography to assess them, with emphasis on those studies that allow discussing the proposal of mindfulness meditation as a stimulus that decreases the processing of self-referential tasks and favors states of cognitive tasks and sensory associative tasks, including interoception. These studies show structural and functional changes in sectors such as prefrontal cortex, insula, hippocampus, cingulate gyrus, primary visual cortex and striatum, which are discussed in this article in the light of current knowledge.

Objective: To compare the characteristics of the emergency medical services (EMS) brought COVID-19 patients versus self-referred walk-in patients. Methods: This was a Cross-sectional study of COVID-19 infected cases in Jahrom, south of Iran. Age, sex, the symptoms of beginning days’ passing, respiratory distress, PO2 at arrival, admission length and inhospital death were retrieved for confirming COVID-19 cases in the whole 2020 year. Respiratory distress was considered as the sign that agitates the patient to call EMS care. Survival analysis was used to evaluate the possible difference of the hospitalization outcome in EMS brought or Self-referred walk-in (SRW) patients. Results: There was 704 (27.1%) registries patients transfer to the hospital by EMS and 1895 (72.9%) cases with SRW referred to the hospital. The survival distributions for the EMS group were statistically significant and lower than SRW group (p

Objectives Self-referred imaging has grown rapidly, raising concerns about increased costs and compromised quality of care. A quality improvement program using imaging interpretation criteria was designed by a national payer to ensure that noninvasive diagnostic images are interpreted by appropriately trained physicians. The objective of this program evaluation was to compare self-referral rates before and after institution of the imaging interpretation criteria program. Methods The imaging interpretation criteria program allocated privileges to bill for advanced imaging interpretation according to physician specialty. Nonradiologist physicians could obtain exemptions by appeal. Some physicians were not restricted in their billing because of successful appeals of the restrictions or the timing of their contract renewals. Self-referral rates were compared between the period 12 months before and 25 months after the program was initiated using t tests. The preprogram and postprogram self-referral rate for computed tomography and magnetic resonance imaging in aggregate was calculated both for the physicians that came into contact with the program and nationally, and then was stratified based on physician appeal status and reimbursement restrictions. Results The program was associated with significantly less frequent self-referrals by physicians whose appeals were denied (17.4%–8.2%; P = 0.0011) and by physicians notified of the program but not subject to it (24.8%–18.5%; P = 0.026). Self-referrals in the program states declined from 19.9% to 13.7% (P < 0.01). Conclusions A significant reduction in image interpretations billed by physicians working outside of the scope of their training occurred after the implementation of the imaging interpretation criteria program.

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.

OBJECTIVES: This study examined the real-world impact of patient direct access to NHS physiotherapy (self-referral) on (a) general practice consultations for musculoskeletal (MSK) conditions and (b) specified clinical management for patients with MSK conditions. \ud \ud DESIGN AND SETTING: Natural experiment in four general practices and the associated physiotherapy service. \ud \ud METHODS: Anonymised routinely collected data were obtained. MSK coded GP consultations, recorded fit notes, MSK-related prescription medication, X-rays and MRI requests, and referrals to secondary care for patients consulting with MSK conditions were identified and trends described across a 6-year period (June 2011 to June 2017). Joinpoint regression analysis was used to identify any significant changes in GP MSK consultation trends before and after the introduction of self-referral to physiotherapy. Physiotherapy service data examined access methods used by patients (GP referred, GP recommended self-referral, true self-referral) and the number of physiotherapy sessions. \ud \ud RESULTS: Direct access resulted in inconsistent impact on general practices. In one arm of the experiment a significant increase in GP consultations was observed and in one arm was stable. Exploratory examination of clinical management showed only requests for X-rays (arm 1) and possibly requests for MRI (arm 2) changed over time. Physiotherapy service referrals showed a low uptake of true self-referral (10% and 6%) in each arm respectively. \ud \ud CONCLUSION: This is the first study to examine the real-world impact of patient direct access to physiotherapy at general practice level. We found no consistent impact of patient direct access on GP MSK workload. Impact on some clinical management was observed but not consistently in the direction suggested by previous studies.

Objective While adherence is an important factor influencing the effectiveness of internet interventions, many studies operationalize adherence only by the number of sessions and do not report adherence to specific treatment components. The goal of this study was to investigate adherence to treatment components as well as outcome in outpatients and self-referred participants who participated in an internet intervention targeting anxiety. Method Outpatients (N = 50) were compared to self-referred (N = 37) participants and a matched outpatient waitlist sample (based on nearest neighbor matching): Using t-test and χ2 tests adherence to treatment components based on the number of completed exercises was compared between participant groups. A 2 × 2 repeated measures ANOVA was used to compare pre-to post symptom change between participant groups. Primary measures included the Generalized Anxiety Disorder Scale-7 (GAD-7) and the Mini Social Phobia Inventory (Mini-SPIN). Using nonparametric bootstrap analyses number of sessions and adherence to treatment components were investigated as potential mediators of the relationship between participant group and outcome. Finally, predictors of adherence to treatment components in outpatient participants were investigated using LASSO and logistic regression. Results Self-referred participants were more adherent than outpatient participants, however the groups did not differ significantly in outcome. Outpatient participants who adhered to relaxation showed greater improvement during the waiting period than the matched outpatient waitlist sample. The effect of participant group on outcome was mediated via adherence to exposure and number of sessions. Conclusions In internet interventions adherence to treatment components differs between participant groups and has a mediating effect on treatment outcome. Therefore, it should be fostered, especially when participants are not self-referred. In line with these findings more studies should investigate relevant participant characteristics in more depth., Highlights • Self-referred participants are more adherent than outpatient participants. • Impact of adherence on outcome varies across treatment components. • Self-efficacy predicts adherence to relaxation.

Background Elderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process. Aim To investigate the effect of screening patients at risk for post-acute care needs by social workers on time with respect to social workers’ notification, length of stay and delays in discharge compared to usual care. Methods Cluster randomized stepped wedge trial design for five clusters (wards) and two steps (control to intervention) was used. A total of 400 patients (200 per period) with high risk of post-acute care needs (defined as Post-Acute Care Discharge score, PACD ≥ 7) were included. Social workers performed a screening to decide about self-referral to their services (intervention period), which was compared to a highly structured standard SW notification by physicians and nurses (control period). A Generalized Estimating Equations model adjusted the clustering and baseline differences. Results A total of 139 patients were referred to social services (intervention: n = 76; control: n = 63). Time to social workers’ notification was significantly shorter in the intervention period when adjusted for all the differences in baseline (Mdn 1.2 vs 1.7, Beta = -0.73, 95%-CI 1.39 to -0.09). Both the length of stay and the delayed discharge time in nights showed no significant differences (Mdn 10.0 vs 9.1, Beta = -0.12, 95%-CI 0.46 to .22 nights 95%-CI, resp. Mdn 0.0 vs 0.0, Beta = .11, 95%-CI -0.64 to 0.86). Conclusion Screening speeded up social workers’ notification but did not accelerate the discharge processes. The screening by social workers might show process improvement in settings with less structured discharge planning.

Contains fulltext : 196791.pdf (Publisher’s version ) (Open Access) 4 p.

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. Electronic supplementary material The online version of this article (10.1186/s12913-017-2673-6) contains supplementary material, which is available to authorized users.

Hintergrund: Die Anzahl ambulanter Behandlungsfälle in Notaufnahmen steigt seit Jahren. Trotz der zentralen Stellung von Hausärztinnen und Hausärzten in der Versorgung ist bisher wenig untersucht worden, wie die Primärversorger die Inanspruchnahme von Notaufnahmen wahrnehmen und beurteilen. Die vorliegende qualitative Studie befasst sich daher mit der hausärztlichen Sicht auf Konsultati-onsmotive, Entscheidungsprozesse und Gesundheitskompetenzen von Notaufnahmepatientinnen und Notaufnahmepatienten sowie mit hausärztlich initiierten Notaufnahmevorstellungen. Methodik: Durchführung qualitativer Experteninterviews mit 15 Hausärztinnen und Hausärzten mittels semi-strukturiertem Leitfaden. Die Auswertung erfolgte auf Grundlage der qualitativen Inhaltsanalyse. Die vorliegende qualitative Studie ist Teil des Mixed-Methods-Forschungsprojektes EMACROSS, eine Studie des Berliner Versorgungsforschungsnetzwerkes EMANet. Ergebnisse: Hausärztlicherseits vermutete patientinnen- und patientenseitige Beweggründe und Entschei-dungsprozesse entsprechen in weiten Teilen den Begründungen von Hausärztinnen und Hausärzten für ärztlich veranlasste Notaufnahmevorstellungen. So wird die zeitnahe Verfügbarkeit eines erweiterten Spektrums diagnostischer und therapeutischer Möglichkeiten von den Befragten für beide Seiten als relevant hervorgehoben, zudem wird die Abklärung von patientinnen- und patienten-seitig subjektiv beunruhigenden Beschwerden betont. Ärztlicherseits befürchtete Versorgungslücken, z. B. an Wochenenden, und Zugangsbarrieren im ambulanten Bereich werden ebenfalls prominent thematisiert, zentral erscheinen Terminprobleme in der fachärztlichen Versorgung. Die Gesundheitskompetenz der Patientinnen und Patienten wird von den Hausärztinnen und Hausärzten als begrenzt wahrgenommen. Als bedeutsame Einflussfaktoren und Informationsquellen werden Medien (z. B. Internet) sowie die hausärztliche Beratung diskutiert. Schlussfolgerungen: Hinsichtlich einer Verminderung nicht-dringlicher Notaufnahmekonsultationen weisen die Ergebnisse darauf hin, dass eine Reduzierung organisatorischer Engpässe in der ambulanten Versorgung (begrenzte Sprechstunden, Terminproblematik) einen wichtigen Ansatzpunkt auf Seiten des Angebots darstellt. Nachfrageseitig erscheint eine Stärkung der individuellen Gesundheitskompetenz bedeutsam. Bei letzterer kommt der hausärztlichen Beratung eine relevante Rolle zu., Background: The number of outpatient consultations in emergency departments (EDs) has been rising for years. Despite the central role of general practitioners (GPs) in health care, it has not been extensively studied how primary care physicians perceive ED utilization. This qualitative study therefore examines the view of GPs on consultation motives, decision processes and health literacy of ED pa-tients as well as ED visits initiated by GPs. Methods: Qualitative expert interviews with 15 GPs based on a semi-structured interview guide were conducted. Qualitative content analysis was performed. This qualitative study is part of the mixed methods research project EMACROSS, a study of the Berlin health services research network EMANet. Results: Patient motives and decision processes assumed by GPs correspond in wide parts to the GPs’ reasoning in cases of physician-initiated ED consultations. The timely availability of an extended spectrum of diagnostic and therapeutic options is stressed by the interviewees as relevant for both patients and GPs, and diagnostic investigation in case of subjectively worrying symptoms on the patient side is also emphasized. Care gaps feared by the physicians, e.g. on weekends, and access barriers in the ambulatory sector are also prominently thematized, with a seemingly central role of appointment problems in specialist care. Patients’ health competence is experienced by the GPs as limited. Media information sources (e.g. internet) and counseling by the GP are discussed as important influencing factors in this context. Conclusion: In order to decrease non-urgent ED consultations, the results suggest that a reduction of organizational shortages in ambulatory care (limited consultation hours, appointment difficulties) could constitute a meaningful leverage point on the care provision side. On the demand side, strengthening individual health competence seems important. Counseling by the GP plays an important role in this regard.

The International Criminal Court’s (ICC) policy and practice of self-referrals has attracted some degree of academic criticism. This has been due partly because the procedure itself was, according to some opinions, never quite envisaged in the original Rome Statute, and partly because the concept of a State self-referral appears to contradict the Rome Statute objective of the ICC as a Court of complementarity. Following Gabon’s self-referral in 2016, and in view of the recent termination of the ICC Prosecutor’s Preliminary Examinations in Gabon, this paper argues that African States’ self-referral practice continues to represent a step backwards for African local justice and accountability. The fact that in this particular situation the necessary threshold was not met is actually not relevant for the argument put forward in this paper, namely that this practice should now be put under scrutiny rather than accepting, at face value, a self-referral whenever an (African) State proposes it. The strengthening of local accountability and the transformation of the local justice landscape should be considered as the ICC long-term objectives, and more dialogue (as well as political pressure) should be contemplated in order to gently coerce States to take on investigations and prosecutions of international crimes.

The file attached to this record is the author's final peer reviewed version. Background: The distortion of the pyramidal structure of the healthcare delivery system due to by-passing 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 minutes on average. This was subsequently transcribed verbatim 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.

Introduction\ud 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.\ud \ud Methods\ud 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.\ud \ud Results\ud 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.\ud \ud Conclusions\ud Results support the feasibility of a school-based, self-referral intervention with older adolescents in a definitive future full-scale trial (Trial no. ISRCTN88636606).

Background Severe health anxiety is a chronic and costly disorder if untreated. Patient self-referral may lower barriers to treatment and decrease diagnostic delay. Aims This study evaluated the accuracy of self-referral for severe health anxiety and compared characteristics of patients self-referred to internet-delivered treatment with patients referred by a clinician to face-to-face treatment. Method Two trials in the same clinic employed different referral methods for health anxiety, namely self-referral and clinician-referral (trial registration: clinicaltrials.gov: NCT01158430 and NCT02735434). The trials were conducted at different time points but with largely comparable eligibility criteria. The accuracy of the recruitment methods was compared by looking at the number of eligible patients in the two trials. Patients completed a baseline questionnaire and subsequently underwent a diagnostic interview by experienced clinicians. Mean differences in self-report and clinical data explored between-group demographic and clinical characteristics. Results In total, 101/151 (67%) self-referred patients were eligible compared with 126/254 (50%) clinician-referred patients (P = 0.001). Self-referred patients were 3.4 years older (P = 0.008) and had a somewhat higher educational level (P = 0.030). Patients who self-referred reported significantly higher levels of health anxiety, emotional distress and somatic symptoms compared with clinician-referred patients. Yet, they had less clinician-assessed comorbid anxiety disorders (PP Conclusions Self-referral was found to be an accurate method to recruit highly relevant patients with treatment-demanding health anxiety. Thus, both self-referral and clinician-referral seem feasible and valid referral methods, but they may recruit patients with slightly different characteristics. Declaration of interest None.

OBJECTIVES: Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals. DESIGN: Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis. SETTING: GP practices in Berlin, Germany. PARTICIPANTS: 15 GPs (female/male: 9/6; mean age 53.6 years). RESULTS: The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy. CONCLUSIONS: Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals. TRIAL REGISTRATION NUMBER: DRKS00011930.

Aims and methodAs part of a larger clinical trial concerning the use of transcranial magnetic stimulation (TMS) for treatment-resistant depression, the current study aimed to examine referral emails to describe the clinical characteristics of people who self-refer and explore the reasons for self-referral for TMS treatment. We used content analysis to explore these characteristics and thematic analysis to explore the reasons for self-referral.ResultsOf the 98 referrals, 57 (58%) were for women. Depressive disorder was the most commonly cited diagnosis, followed by bipolar affective disorder. Six themes emerged from the thematic analysis: treatment resistance, side-effects of other treatments, desperation for relief, proactively seeking information, long-term illness and illness getting worse.Clinical implicationsTMS has recently been recommended in the UK for routine use in clinical practice. Therefore, the number of people who self-refer for TMS treatment is likely to increase as its availability increases.Declaration of interestNone.

Objectives Access to psychological treatments has been defined by Gulliford as comprising supply, effectiveness, equity and uptake. In the UK, a recent national programme “Improving Access to Psychological Treatments” has significantly increased supply and assessed effectiveness, but paid less attention to uptake and equity. The model developed by Gask et al. delineating processes relevant to improving access for ‘hard-to-engage’ groups in the UK, including black and minority groups seems relevant. This paper presents studies of a large-scale ‘community workshop’ intervention model developed by Brown to improve access for adults in the UK, designed to improve uptake and equity. We describe two ‘community workshop’ interventions for common mental health problems to which people have been able to self-refer and where uptake and equity have been high. Key components of this model are a ‘group-sensitive engagement’ ethos which includes self-referral, non-diagnostic titles of the intervention, a non-mental health setting, face-to-face presentation as well as a brief intervention and an acceptable format. Conclusion The model of community workshops with its ‘group-sensitive engagement’ ethos to which adults can self-refer may be very relevant in providing access for people with mental health needs in national and international settings. Trial registration Classic ISRCTN26634837

Background: Most people experience low back pain (LBP) at least once in their life and for some patients this evolves into a chronic condition. One way to prevent acute LBP from transiting into chronic LBP, is to ensure that patients receive the right interventions at the right moment. We started research in the design of a clinical decision support system (CDSS) to support patients with LBP in their self-referral to primary care. For this, we explored the possibilities of using supervised machine learning. We compared the performances of the three classification models -i.e. 1. decision tree, 2. random forest, and 3. boosted tree - to get insight in which model performs best and whether it is already acceptable to use this model in real practice.Methods: The three models were generated by means of supervised machine learning with 70% of a training dataset (1288 cases with 65% GP, 33% physio, 2% self-care cases). The cases in the training dataset were fictive cases on low back pain collected during a vignette study with primary healthcare professionals. We also wanted to know the performance of the models on real-life low back pain cases that were not used to train the models. Therefore we also collected real-life cases on low back pain as test dataset. These cases were collected with the help of patients and healthcare professionals in primary care. For each model, the performance was measured during model validation - with 30% of the training dataset -as well as during model testing -with the test dataset containing real-life cases. The total observed accuracy as well as the kappa, and the sensitivity, specificity, and precision were used as performance measures to compare the models.Results: For the training dataset, the total observed accuracies of the decision tree, the random forest and boosted tree model were 70%, 69%, and 72% respectively. For the test dataset, the total observed accuracies were 71%, 53%, and 71% respectively. The boosted tree appeared to be the best for predicting a referral advice with a fair accuracy (Kappa between 0.2 and 0.4). Next to this, the measured evaluation measures show that all models provided a referral advice better than just a random guess. This means that all models learned some implicit knowledge of the provided referral advices in the training dataset.Conclusions: The study showed promising results on the possibility of using machine learning in the design of our CDSS. The boosted tree model performed best on the classification of low back pain cases, but still has to be improved. Therefore, new cases have to be collected, especially cases that are classified as self-care cases. This to be sure that also the self-care advice can be predicted well by the model.

The law of collective proceedings for clearing off depts which replaces the former bankruptcy law pursues an economic objective the reason why it carries certain exceptions to the common procedure law. As such, the judge of collective proceedings has powers of initiative in the institution and conduct of the trial. He can thus of his own initiative open the collective proceeding. The aim of this study is to confront the judge's office powers with the cardinal principles of the trial. The expected result should help verify the compatibility of those powers with the requirements of a fair trial. A hypothesis emerges that automatically powers that deviate somewhat to the cardinal principles of the trial, are justified by the aim of safeguarding collective interests pursued by the insolvency judge.

Background There are enormous problems in recruiting depressed people into randomised controlled trials (RCTs), with numerous studies consistently failing to recruit to target (Sully et al., Trials 14:166, 2013). Given the high prevalence of—and disability associated with—depression, it is important to find ways of effectively recruiting to RCTs evaluating interventions. This study aimed to test the feasibility of using a self-referral system to recruit to a brief intervention in a multi-site trial, the CLASSIC trial of self-confidence workshops for depression. In that trial, participants referred themselves to a depression intervention with a positive non-diagnostic title of ‘self-confidence’, given the close relationship of depression and self-esteem (Horrell et al., Br J Psychiatry 204:222–233, 2014). Method We analysed uptake and retention rates by recruitment to the study, attendance at the workshops and follow-up rates. However, because of the rapid rate of recruitment, we decided to pause the trial and revise our original single-site research protocol in months 5–6. We report findings under three main headings: recruitment rates for the 12 months of the project before and after the pause; data regarding attendance at the workshops before and after the pause; and the follow-up rates before and after the pause. Results We recruited 459 participants within 12 months, representing 38 participants recruited per month. Improved uptake of the intervention and retention after the development of multi-site research protocols are reported. Discussion Based on previous evidence from RCT recruitment among depressed participants, our recruitment rate demonstrates that a self-referral system using a non-diagnostic title of self-confidence is a successful recruitment method. The implications of rapid recruitment using a self-referral system are described, including the impact on uptake of the intervention as well as participant retention. Because of the potential for recruiting many participants quickly, research teams need to be adequately resourced and the oversight committees prepared to meet at shorter intervals with RCTs of brief interventions. Short conclusion Self-referral to a brief intervention for depression with a non-diagnostic title can be a very effective way of recruiting depressed people into trials. However, there are also some challenges. Trial registration ISRCTN, ISRCTN26634837. Registered on 10 June 2010.

"Self-referral" as a specific type of conflict of interest, could potentially interfere with the integrity of an "appropriate referral" which should be practiced based on the unique needs of each patient. Referring patients to health facilities where the traditional therapist or physician "has investment interests or is part/full owner of such facilities" is ethically unacceptable and considered to be a kind of self-referring. We, in line with international community and as a professional duty, are obliged to abstain from such a problem. Considering the fast-growing global request for natural products, this ethical and professional issue needs crucial considerations respecting legislation, legal and professional detection and controls. In this way, potentiate the Traditional Pharmacy specialty (Ph.D), practical education of interested pharmacists regarding traditional medications, defining standards for traditional herbal preparations, cessation of preparation of traditional remedies by physicians are among the suggestions could be followed for professional handling of the problem. It is also the right time for compiling ethical codes covering global concerns for ethical prescription of traditional medications.

Background: Non-compliance with designated referral pathways has ramifications such as increased patient waiting time, overburdening of higher levels of care and increasing healthcare costs on patients and the healthcare system. The purpose of this study was to assess the determinants of self-directed referrals amongst patients attending hospitals in the eThekwini district of KwaZulu-Natal. Methods: An analytic, cross-sectional study was conducted at the Medical Outpatient Departments across five district hospitals in eThekwini using interviewer-administered questionnaires. Descriptive statistics were used to determine the proportion and the most frequent factors contributing towards patient self-referral. The likelihood of patients to self-refer was tested using chi-square (X2) and a multivariate regression model. Results: There were 315 patients interviewed with 35% (n = 109/315) having self-referred. The majority (51%; 55/107) of self-referrals were male and were of African race (74%; n = 80/107). Five institutional factors, namely: availability of medication at the pharmacy (98%); quality of care at the facility (93%); waiting time at facility (92%); services provided (90%); and attitude of healthcare workers (87%), were ranked as the main drivers of self-referral. Multivariate logistic regression established a significant positive association between patient self-referral and male gender (OR 1.73; CI 1.04–2.87, p < 0.05). Age < 39 years (OR 0.96; CI 0.94–0.99, p < 0.05); and patient awareness of a referral letter (OR 0.28; CI 0.09–0.86, p < 0.05) emerged as protective factor against self-referrals. Conclusion: Males patients tend to bypass the referral pathway whilst younger patients and patients who were aware of a referral letter were less likely to bypass the referral system. In addition to addressing the systemic challenges of waiting times, quality of care and availability of medication, a patient-oriented approach that comprises education, encouragement and increased patient awareness is an important strategy to improve referral pathway compliance.

INTRODUCTION: primary health care is widely accepted as the first point of care seeking; yet, individuals requiring healthcare engage in self-referrals to higher levels of care thereby by-passing primary care. Little is known of the extent to which self-referrals are carried out when care is needed. This study thus sought to determine the prevalence of self-referral, its patterns and factors influencing self-referrals amongst federal civil servants in Southwestern Nigeria. METHODS: a cross-sectional study was carried out among 300 federal civil servants who were interviewed using validated and pre-tested interviewer-administered semi structured questionnaires. Data was analyzed using univariate and Chi-square test at level of significance set at P

Self-referral practice has been the main source of cases before the International Criminal Court (icc) to date. This practice provokes significant questions as to its roots, legality and implications on the jurisdiction of the Court in general and the principle of complementarity in particular. Thus, the article, after considering the legal, factual and political considerations attached to self-referral, argues that self-referral, as utilized and encouraged by the icc since its inception, signals a departure of the purposive rationale of the principle of complementarity as the drafting history and the current wording of the Statute reveals, and this could have a detrimental effect on the credibility and impartiality of the Court.

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. (c) 2016 The Nordic Psychiatric Association. This is the authors' accepted and refereed manuscript to the article.

Low back pain (LBP) is the most common cause for activity limitation and has a tremendous socioeconomic impact in Western society. In primary care, LBP is commonly treated by general practitioners (GPs) and physiotherapists. In the Netherlands, patients can opt to see a physiotherapist without referral from their GP (so called ‘self-referral’). Although self-referral has improved the choice of care for patients, it also requires that a patient knows exactly how to select the best next step in care for his or her situation, which is not always evident. This paper describes the design of a web-based clinical decision support system (CDSS) that guides patients with LBP in making suitable choices on self-referral. We studied literature and guidelines on LBP and conducted semi-structured interviews with 3 general practitioners and 5 physiotherapists on the classification of LBP with respect to the best next step in care: visit a GP, visit a physiotherapist or perform self-care. The interview results were validated by means of an online survey, which resulted in a select group of key classification factors. Based on the results, we developed an ontology and a decision tree that models the decision making process of the CDSS.

Background Several community mental health centres and mental hospitals in Norway now allow users with a diagnosis of severe mental illness to self-refer for admission. This give a group of service users who are well-known to service providers the opportunity to refer themselves for short inpatient stays without contacting their doctor, a duty doctor or emergency department. Evidence on self-referral admissions is lacking. Aim To explore service users’ experiences of having the opportunity to refer themselves for a short inpatient stay. Methods Forty-two qualitative semi-structured interviews were undertaken between 2010 and 2014 in a group of 28 service users with serious mental illness and with or without substance abuse problems. All respondents had a contract which allowed them to self-refer for inpatient treatment. Systematic text condensation was applied in the analyses. Results Self-referral inpatient admission is more than just a bed. It was perceived as a new, unconventional health service, which differed substantially from earlier experiences of inpatient care and was characterised by different values and treatment principles. The differences were related to the content, quality and organisation of treatment. Having the option to decide about admission for oneself and having access to services focusing on individual needs seem to enhance service users’ confidence, both in the services they use and in their own ability to cope with everyday life. Conclusions Self-referral inpatient admission is a concrete example of how a user involvement policy can be implemented in mental health services. It is important to emphasise that the self-referral admission process described here is an offer in development and that we are awaiting findings from a larger RCT study. More evidence is needed to determine what aspects of the service are helpful to service users, the long-term effects, appropriateness and cost-effectiveness, and how the service can be integrated into the mental health system.

Background Musculoskeletal problems are common, accounting for up to 30 % of general practitioner (GP) consultations and are a major cause of chronic disability worldwide. Demand for health care for musculoskeletal conditions is likely to continue to rise given the ageing population and the increasing impact of these common painful conditions. Physiotherapists are well equipped to deliver evidence-based management for these conditions. Direct access allows patients to access physiotherapy without seeing their GP or another referring practitioner first; however, for most patients in the UK, access to National Health Service physiotherapy is controlled through GP referral. Methods/Design The aim of this pilot, pragmatic, cluster trial is to assess the feasibility of a future large trial to compare the clinical and cost-effectiveness of the additional offer of direct access to physiotherapy versus continuing with usual GP-led primary care alone for adults with common musculoskeletal problems. The pilot will focus on process outcomes to assess feasibility, although performance of the likely outcomes of a main trial will also be assessed. This is a two-arm parallel, cluster RCT where GP practices are the units of randomisation (the clusters), yet data are collected from individual patients with musculoskeletal problems (the participants). A direct access service will be set up in the participating physiotherapy service to provide the option of direct access to patients of the intervention arm practices. Inclusion criteria are broad to reflect the ‘real-world’ operation of an NHS physiotherapy direct access service for patients with musculoskeletal pain. Data collection will be through patient self-reported questionnaires at baseline, 2, 6 and 12 months and medical record review. Discussion No previous trials have been conducted into direct access to physiotherapy for patients with musculoskeletal problems. The strengths of the STEMS pilot trial are its size, the length of follow-up, and collection of process, clinical and cost outcomes to fully inform a future main trial to meet calls to provide robust trial evidence of the impact on clinical outcomes, work loss and costs to provide clinicians and service funders with the high quality trial data they need to guide decisions on the best models of care. Trial registration The STEMS pilot trial is registered at Current Controlled Trials: ISRCTN23378642 Electronic supplementary material The online version of this article (doi:10.1186/s40814-015-0020-4) contains supplementary material, which is available to authorized users.

L’auto-référencement en physiothérapie, soit le fait pour un professionnel de la santé de référer un patient vers une clinique privée de physiothérapie dans laquelle ce même professionnel possède des intérêts financiers, comporte des implications éthiques importantes de nature organisationnelle. Cet article propose des pistes de solutions à cette pratique éthiquement condamnable. En plus de miser sur des stratégies législatives et déontologiques, les cliniques privées doivent adopter des balises et des activités formelles visant à améliorer la culture éthique de leur entreprise, en impliquant les propriétaires, les actionnaires et les employés., Self-referral in physiotherapy, that is, a healthcare professional referring a patient to a private physiotherapy clinic in which the same professional has a financial interest, presents significant organizational ethical implications. This article offers potential solutions to this ethically reprehensible practice. In addition to focusing on legislative and ethical strategies, private clinics should adopt guidelines and formal activities to improve the ethical culture of their company, by involving owners, shareholders and employees., Commentaire / Commentary

Background: Several hospitals in Norway provide short self-referral inpatient treatment to patients with severe mental diagnosis. No studies have compared the experiences of patients who have had the opportunity to selfrefer to inpatient treatment with patients who have received treatment as usual. This qualitative study was nested within a randomised controlled trial investigating the effect of self-referral to inpatient treatment. The aim was to explore how patients with severe mental diagnosis coped four months after signing a contract for self-referral, as compared to patients receiving treatment as usual. Methods: Data was collected using qualitative individual interviews with patients with severe mental diagnosis, conducted four months after being randomised either to a contract for self-referral (intervention group) or to treatment as usual (control group). Results: Twenty-five patients participated in interviews - 11 from the intervention group and 14 from the control group. Results four months after randomisation showed that patients with a contract for self-referral appeared to have more confidence in strategies to cope with mental illness and to apply more active cognitive strategies. Patients with a contract also expressed less resignation, hopelessness and powerlessness than patients without a contract. In addition, patients with a contract seemed to be closer to the ideal of living a “normal” life and being a “normal” person. Conclusion: The results indicate that the patients who had a contract for self-referral had come further in the recovery process and should possibly be better off during treatment. Keywords: Mental health services, Self-referral, Mental illness, Psychiatry, Psychosis, Bipolar disorder. © 2014 Rise et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. 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.

Daniel Gologorsky1, Scott H Greenstein2 1Dartmouth Medical School, Hanover, NH, USA; 2Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA Abstract: Patients choose to seek a second opinion in matters related to their health for a variety of reasons, and the total cost associated with these second opinion visits is estimated to be billions of dollars annually. Understanding the reasons behind second opinion self-referrals is key to improving patient satisfaction and reducing redundancy in delivered health care. This study represents a retrospective analysis of the records from a single provider at the Massachusetts Eye and Ear Infirmary (MEEI) Comprehensive Ophthalmology Service in order to determine the various reasons that patients self-refer to an ophthalmology clinic seeking second opinions. A total of 174 patients presenting for a second opinion were identified over a one-year period. Patients presented for second opinions for two primary reasons: 60% presented in order to seek a confirmation of a diagnosis from an outside ophthalmologist (54%) or optometrist (6%), and 40% presented due to a previous adverse experience with an outside provider, such as perceived treatment failure (26%), poor bedside manner (3%), distrust of the provider (5%), and poor provider communication skills (7%). This study strives to reiterate that the reduction of adverse patient experiences through effective communication of expected treatment options and outcomes, with a realistic time course of therapy, could significantly improve patient satisfaction and reduce costly second opinion visits. Keywords: referral, self-referral, second opinion, comprehensive ophthalmology

Rationale, aims and objectives: The inappropriate use and overcrowding of emergency departments (EDs) by walk‐in patients are well‐known problems in many countries. The current study aimed to determine whether ambulatory walk‐in patients could be treated more efficiently in a new hospital‐integrated general practice (HGP) for emergency care services compared to a traditional ED. Methods: We conducted a pre‐post comparison before and after the implementation of a new HGP. Participants were walk‐in patients attending the ED of a city hospital in Zurich. Main outcome measures were differences in total process time, time intervals between stages of care and diagnostic resources used. Results: The median process time from admission to discharge was 120 minutes in the ED [interquartile range (IQR): 80–165] versus 60 minutes in the HGP (IQR: 40-90) (P

Purpose: Secondary prevention programmes have traditionally employed mass screening approaches to assess for asymptomatic signs of cancer. It has been suggested that early detection strategies involving public education and self-referral may prove more cost-effective with low risk populations for cancers with symptomatic presentation. This study, which was commissioned to inform the development of a cancer awareness campaign, examines public perceptions of the early detection of cancer, the psycho-social barriers to self-referral amongst a key at-risk population and the implications for patient education. Methodology: An exploratory study using qualitative focus groups with an at-risk population of older people living in deprived communities in west-central Scotland. Findings: The findings reveal broad support for initiatives designed to raise symptom awareness. However fear of cancer can lead to apparently irrational responses to symptoms and subsequent delay , particularly amongst men who are less likely to seek support from lay networks. Implications: Early detection messages need to take account tone and symptom description to allay fears and ensure appropriate presentation. Consideration also needs to be given to the role played by lay and professional opinion formers to informing and supporting patients decision to present with suspicious symptoms, particularly when targeting harder to reach patients of men, older people, and people living in deprived communities.