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Background: Access to surgery is a challenge for low-income countries like Malawi due to shortages of specialists, especially in rural areas. District hospitals (DH) cater for the immediate surgical needs of rural patients, sending difficult cases to central hospitals (CH), usually with no prior communication., Methods: In 2018, a secure surgical managed consultation network (MCN) was established to improve communication between specialist surgeons and anaesthetists at Queen Elizabeth and Zomba Central Hospitals, and surgical providers from nine DHs referring to these facilities., Results: From May to December 2018, DHs requested specialist advice on 249 surgical cases through the MCN, including anonymised images (52% of cases). Ninety six percent of cases received advice, with a median of two specialists answering. For 74% of cases, a first response was received within an hour, and in 68% of the cases, a decision was taken within an hour from posting the case on MCN. In 60% of the cases, the advice was to refer immediately, in 26% not to refer and 11% to possibly refer at a later stage., Conclusion: The MCN facilitated quick access to consultations with specialists on how to manage surgical patients in remote rural areas. It also helped to prevent unnecessary referrals, saving costs for patients, their guardians, referring hospitals and the health system as a whole. With time, the network has had spillover benefits, allowing the Ministry of Health closer monitoring of surgical activities in the districts and to respond faster to shortages of essential surgical resources.

Objectives: Reliable referral systems are essential to the functionality and efficiency of the wider health care system in low- and middle-income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under-researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned., Methods: We conducted a prospective analysis of all inter-hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014-2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process., Results: 1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely., Conclusions: Our findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present., (© 2020 John Wiley & Sons Ltd.)

Background: Surgical conditions represent up to 30% of the global burden of diseases. The aim of this study was to assess the delays in patients transferred to a tertiary referral hospital from district hospitals (DHs) in Rwanda with emergency general surgery (EGS) conditions., Methods: We performed a prospective review of all EGS patients referred from DH over a 3-month period to assess delays in transfer and accessing care. We then surveyed general practitioners to define their perspective on delays in surgical care., Results: Over a 3-month period, there were 86 patients transferred from DH with EGS conditions. The most common diagnoses were bowel obstruction (n = 22, 26%) and trauma (n = 19, 22%). The most common performed operations were laparotomy (n = 21, 24%) and bowel resection (n = 20, 23%). The mortality rate was 12%, and the intensive care unit admission rate was 4%. In transfer to the referral hospital, 5% patients were delayed for financial reasons and 2% due to lack of insurance. After reaching CHUK, 5% patients were delayed due to laboratory and radiology issues. Other delays included no operating theater available (4%) and no surgeon available (1%). Providers' perceptions for not performing surgeries at DH were predominantly the lack of a competent surgical provider or anesthesia staff., Conclusion: EGS patients represent a broad range of diagnoses. Delays were noted at each step in the referral process with multiple areas for potential improvement. Expanding surgical access at the DH has the potential to decrease delays and thereby improves patient outcomes.

Introduction: Self-referrals to inappropriate levels of care result in an increased patient waiting time, overburdening of higher levels of care, reduced primary healthcare utilisation rate and increasing healthcare costs. Furthermore, self-referral places an additional encumbrance on various levels of care as allocation of resources and infrastructure cannot be accurately planned, based on the facility catchment population. The aim of this study was to determine the prevalence and determinants of patient self-referral at the out-patient department of Stanger Hospital, KwaZulu-Natal between January and June 2017., Methods: A cross-sectional study was conducted at the out-patient department in Stanger Hospital, using interviewer administered questionnaires to collect information from 385 patients, through convenience sampling, between January and June 2017. Multivariable regression analysis was used to test for factors associated with self-referral., Results: of the 385 patients interviewed 36% (n = 138) were self-referrals. Most of the self-referrals were male (51.5%) and of the African race (57.2%). Five institutional factors namely: care received from healthcare workers (91.3%); waiting times (88.4%); help offered (87%); treatment and attitude of healthcare workers (63%) and availability of medication (55.8%) were considered as the main drivers of self-referral. Multivariable regression analysis established a significant positive association between patient self-referral and age (40 years and below), attitude of healthcare workers, quality of care received form healthcare workers, waiting times and the availability of diagnostic tests., Conclusion: This study indicates that most patients attending Stanger Hospital do comply with the prescribed referral pathway, however a significant proportion still bypass the referral system., Competing Interests: The authors declare no competing interests.

Introduction: The Indian National Mental Health Survey (NMHS) of 2015-2016 has estimated 13.7% lifetime and 10.6% point prevalence for mental illnesses. It has identified that the treatment gap for mental illnesses ranges between 70% and 92%. Tele-Psychiatric consultations could be an alternative and innovative approach to bridge this gap in low resource settings., Aims: To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Psychiatric consultations across district hospitals in Karnataka, India., Methodology: We performed a retrospective review of case files of patients who have received collaborative Tele-Psychiatric consultations from January 2013 to June 2017 through video-conferencing. A total of 139 consultations were provided to patients in the state of Karnataka., Results: The mean age of the sample is 31 (±15.5) years. 61.8% were male and 79.8% were aged more than 18 years. In total, 25.9% of them had schizophrenia and other psychotic disorders, 14.4% had mental retardation, 13.7% had a mood disorder and 14.4% had a substance use disorder. 67.6% of patients had been advised pharmacotherapy, 7.9% had been advised rehabilitation along with pharmacotherapy and 24.4% were advised further evaluation of illness and inpatient care at a higher centre., Conclusion: Collaborative tele-psychiatric consultations to district hospitals from an academic tertiary care hospital can be feasible and are likely to benefit patients from rural areas. There is a need for more studies to elucidate their acceptability by patients, caregivers and professionals., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: We conducted an assessment of orthopaedic surgical capacity in the following countries in East, Central, and Southern Africa: Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe., Methods: We adapted the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care with questions specific to trauma and orthopaedic care. In May 2013-May 2014, surgeons from the College of Surgeons of East, Central and Southern Africa (COSECSA) based at district (secondary) and referral (tertiary) hospitals in the region completed a web-based survey. COSECSA members contacted other eligible hospitals in their country to collect further data., Findings: Data were collected from 267 out of 992 (27%) hospitals, including 185 district hospitals and 82 referral hospitals. Formal accident and emergency departments were present in 31% of hospitals. Most hospitals had no general or orthopaedic surgeons or medically-qualified anaesthetists on staff. Functioning mobile C-arm X-ray machines were available in only 4% of district and 27% of referral hospitals; CT scanning was available in only 3% and 26%, respectively. Closed fracture treatment was offered in 72% of the hospitals. While 20% of district and 49% of referral hospitals reported adequate instruments for the surgical treatment of fractures, only 4% and 10%, respectively, had a sustainable supply of fracture implants. Elective orthopaedic surgery was offered in 29% and Ponseti treatment of clubfoot was available at 42% of the hospitals., Interpretation: The current capacity of hospitals in sub-Saharan Africa to manage traumatic injuries and orthopaedic conditions is significantly limited. In light of the growing burden of trauma and musculoskeletal impairment within this region, concerted efforts should be made to improve hospital capacity with equipment, trained personnel, and specialist clinical services., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background:   Wirral University Teaching Hospital is a large district general hospital situated on the Wirral peninsula, UK. Because of the district's geographical and demographic characteristics, Wirral is an ideal location for population-based studies. Information on paediatric referrals, case mix and outcomes are scarce. We took advantage of our situation to conduct an epidemiological study of referrals to general paediatrics in Wirral in 1988 and again in 2006. A companion paper examines referrals to community paediatricians in the Department during the same period., Methods:   A prospective observational study of general paediatric outpatient referrals between 1 Feb and 31 May 2006 compared with the same period in 1988, using the same methodology. We included all children under the age of 15 offered a new patient appointment during the study period., Results:   The referral rate had increased significantly from 15.5 to 25.7 per thousand children under 15 per annum (P < 0.01; Chi Squared). The most common conditions referred in 2006 were constipation (10.5%) and enuresis (7%) compared with asthma (15%) and heart murmurs (13.8%) in 1988. There were significantly fewer wasted appointments (5% vs. 12%), shorter waiting times (5% vs. 12% waited more than 12 weeks), faster treatment times (25% vs. 14% started treatment after the first appointment) and more discharges (41.2% vs. 30.5%) (all P < 0.01; Chi Squared)., Conclusions:   More children were referred to paediatricians in 2006 compares with 1988. Services worked more efficiently, with better attendance, access and time to treatment. We provide information on changes in case mix that is not available elsewhere. This population-based study thus gives a unique insight into changes in referrals to UK general paediatricians., (© 2011 Blackwell Publishing Ltd.)

Objective: To investigate whether requests for standard paediatric electroencephalograms accord with guideline recommendations, subsequent changes in clinical management according to reported results, and extent to which the service meets waiting time targets., Design: Case series., Setting: Regional hospital, Hong Kong., Patients: All patients aged less than 18 years who underwent electroencephalography between December 2009 and February 2010., Main Outcome Measures: Appropriateness of the electroencephalogram request and the impact of its findings on clinical management., Results: A total of 109 patients were recruited, but requests for standard electroencephalograms were considered 'inappropriate' with respect to guidelines in 44% of the patients, of which 50% were made to diagnose 'funny turns'. The standard electroencephalogram contributed to the diagnosis or management in only 28% of patients. In all of the latter, the request for an electroencephalogram had been appropriate. Nonspecialists made referrals for 86% of the patients. Inadequate information was provided in 66% of the requests. Standard electroencephalograms were performed within guideline targets, the wait being less than 4 weeks in 95% of requests., Conclusion: An effective electroencephalogram service was being provided, though abuses were common. These were mainly because of misconceptions regarding the role and limitations of standard electroencephalograms. Through an educative, non-confrontational approach, and with time to explain guideline recommendations to clinicians, sustainable change in practice could be achieved so as to benefit patients, clinicians, and service provision.

Background: India has one of the most extensive health infrastructures- a three-tier hierarchical referral system- for the provision of effective and efficient health services to the majority of its population. In this study we have tried to evaluate the utilization of such a wide health infrastructure and the various factors affecting it. We have also tried to find the factors that motivated the patients to visit the present health facility and the key persons who motivated them to do so., Methods: Time bound cross-sectional study., Setting: Three types of referral health facilities in Lucknow District., Participants: A total of 1265 patients were interviewed during the four months of the period of survey from these three types of referral health facilities., Results: The present study revealed that majority of the patients coming to all the three referral centres were the new patients (89%), about two-thirds of whom had come there directly. Overall, only one tenth of the patients attending the secondary and tertiary level public health facilities were referred by someone. Most of the indirect patients had self referred themselves. About eight and nine percent of the indirect and referred patients could reach the present site of treatment only after more than two years of rummaging and about 13% and 11% had spent more than ten thousand rupees respectively, which in some cases even amounted to lakh rupees., Conclusions: The utilization of the referral system of the health care delivery in India needs to be augmented. Before planning future reforms such as decentralization, incorporation of the Indian system of Medicine, and other steps we need to develop mechanisms to see that the plans are materialized.

Introduction: Multi-Professional Triage Teams (MPTTs) were created to reduce the caseload of hospital orthopaedic clinics and this prospective study evaluated referrals made to a district general hospital orthopaedic department from a lower limb MPTT clinic., Patients and Methods: Over 9 months, 277 referrals to a lower limb hospital orthopaedic clinic were assessed. The temporal delay to hospital clinic review between patients seen at the MPTT clinic and those referred directly by their general practitioner (GP) was analysed using an ANOVA test. A qualitative assessment of diagnoses given to patients reviewed at the MPTT clinic was performed., Results: The 132 patients initially reviewed at the MPTT clinic and subsequently referred to a hospital consultant waited significantly longer (140 days compared to 62 days by direct GP referral; P < 0.05) to see an orthopaedic consultant. Over three-quarters of this patient cohort incorrectly identified the healthcare professional conducting their consultation at the MPTT clinic. One-third of cases (31%) had no diagnosis made and 22% were assessed as having an incorrect diagnosis., Conclusions: Time delays, patient confusion regarding professional roles and diagnostic indecision are significant problems for patients referred to hospital orthopaedic clinics from MPTT clinics. This risks sub-optimal patient care and may lead to future medicolegal implications.

Objectives: To review the referral of patients to a tertiary centre for urgent angiography and to determine if there are differences in invasive treatment strategies for patients with acute coronary syndrome (ACS)., Methods: There were 2 parts to the study, a retrospective part over 3.5 years from a computerised cardiac laboratory booking data base and a prospective part over 3 months., Results: There were 1190 urgent in-patient angiograms performed with 499 (42%) admitted initially to the tertiary centre while the remaining 691 (58%) were admitted to district general hospitals (DGH), with no on-site access to a cardiac laboratory, and subsequently transferred to the tertiary centre. Once referred, DGH patients waited longer for their angiogram (2.7 +/- 3.2 vs 2.0 +/- 2.8 days, p < 0.0001). Interestingly, DGH patients appear to spend an average of 4 days in hospital prior to referral for angiography. DGH patients were more likely to have a higher Thrombosis in Myocardial Infarction (TIMI) risk score at presentation and following angiography were more likely to have coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) and less likely to have angiographically normal arteries., Conclusions: Our findings are consistent with previous studies demonstrating that access to coronary angiography varies considerably between hospitals. However, we have demonstrated that patients in DGHs wait on average 4 days before referral for coronary angiography suggesting that there may be triage based on initial responses to medical therapy. Further research is needed to determine whether this has a direct effect on outcomes.

Background: The main objective of this study is to establish a benchmark for referral rates in rural Niger so as to allow interpretation of routine referral data to assess the performance of the referral system in Niger., Methods: Strict and controlled application of existing clinical decision trees in a sample of rural health centres allowed the estimation of the corresponding need for and characteristics of curative referrals in rural Niger. Compliance of referral was monitored as well. Need was matched against actual referral in 11 rural districts. The referral patterns were registered so as to get an idea on the types of pathology referred., Results: The referral rate benchmark was set at 2.5 % of patients consulting at the health centre for curative reasons. Niger's rural districts have a referral rate of less than half this benchmark. Acceptability of referrals is low for the population and is adding to the deficient referral system in Niger. Mortality because of under-referral is highest among young children., Conclusion: Referral patterns show that the present programme approach to deliver health care leaves a large amount of unmet need for which only comprehensive first and second line health services can provide a proper answer. On the other hand, the benchmark suggests that well functioning health centres can take care of the vast majority of problems patients present with.

Aims: To evaluate the applicability and the clinical impact of the European Society of Cardiology (ESC) Guidelines' recommendations for hospital admission of patients with syncope in a District Hospital Emergency Department (ED)., Methods and Results: From September 2002 to August 2004, 1124 patients with syncope [out of 1308 with transient loss of consciousness (TLC)] were evaluated according to the ESC Guidelines. Overall, 566 patients with syncope (50.1%) were admitted and 558 (49.9%) were discharged. Out of the 1124 patients with syncope, 440 (39.1%) presented at least one ESC Guidelines' criterion for hospitalization. Out of the 440, 393 (89.3%) were admitted, whereas 511 out of the 684 (74.7%) without indication for admission were discharged. A significant difference was found between the adherence rates for admission and for discharge (P<0.001). The appropriateness of the ED medical decision was 69.4% for hospital admission and 91.6% for discharge (P<0.001)., Conclusion: Although an acceptable ED adherence to the guidelines' indications was attained, better implementation strategies are still advisable. The ESC Guidelines' indications are applicable to the majority of patients entering the ED for a TLC. In addition, when the guidelines' indications are observed, a high percentage of patients with syncope have still to be hospitalized.

Problem: The hospital based musculoskeletal service in northwest Wales was unable to cope with the demand for referrals from general practitioners. Waiting times were long, duplicate referrals to other departments were common, and general practitioners were reluctant to refer patients with common problems because of the perceived lack of service. Many referrals were made to the inappropriate specialty, especially orthopaedics. At least part of this problem was due to a lack of coordination between the four hospital departments providing musculoskeletal services and the emphasis on district general hospital based rather than community provision., Design: Review over 18 months of impact of the targeted early access to musculoskeletal services (TEAMS) programme on accessibility to musculoskeletal services., Setting: Northwest Wales., Key Measures for Improvement: Number of patients referred and seen with musculoskeletal problems, waiting times, number of duplicate referrals, and surgery conversion rates in orthopaedic clinics., Strategies for Change: Establishing with central clinical triage a common pathway for all musculoskeletal referrals so that patients attend the appropriate department. A back pain pathway led by extended scope physiotherapists was developed, and general practitioners with special interests and extended scope physiotherapists were trained to provide services for patients with uncomplicated musculoskeletal problems in the community., Effects of Change: Over 18 months the number of referrals more than doubled. Despite this, waiting times for musculoskeletal services fell; this was noticeable for rheumatology and pain management. Duplicate referrals were abolished. Surgery conversion rates did not, however, change. Questionnaires from the clinics showed a high level of patient satisfaction., Lessons Learnt: Integration of hospital services that traditionally have worked in isolation can result in greatly improved access to musculoskeletal services. Community based multidisciplinary clinics run by specially trained general practitioners with special interests and extended scope physiotherapists are an effective way of managing patients with uncomplicated musculoskeletal problems and have been well received by patients and general practitioners. The huge unmet burden of need was reflected by the great increase in musculoskeletal referrals. Other approaches are needed to meet this, including better education of general practitioners and methods for identifying and modifying psychosocial risk factors for chronic pain at an early stage.

Background: The district hospital is considered essential for delivering basic, cost-effective health care to children in resource poor countries. We aimed to investigate the performance of these facilities in Kenya., Methods: Government hospitals providing first referral level care were prospectively sampled from 13 Kenyan districts. Workload statistics and data documenting the management and care of admitted children were obtained by specially trained health workers., Findings: Data from 14 hospitals were surveyed with routine statistics showing considerable variation in inpatient paediatric mortality (range 4-15%) and specific case fatality rates (eg, anaemia 3-46%). The value of these routine data is seriously undermined by missing data, apparent avoidance of a diagnosis of HIV/AIDS, and absence of standard definitions. Case management practices are often not in line with national or international guidelines. For malaria, signs defining severity such as the level of consciousness and degree of respiratory distress are often not documented (range per hospital 0-100% and 9-77%, respectively), loading doses of quinine are rarely given (3% of cases) and dose errors are not uncommon. Resource constraints such as a lack of nutritional supplements for malnourished children also restrict the provision of basic, effective care., Interpretation: Even crude performance measures suggest there is a great need to improve care and data quality, and to identify and tackle key health system constraints at the first referral level in Kenya. Appropriate intervention might lead to more effective use of health workers' efforts in such hospitals.

Objective: To determine the effectiveness and efficiency of the Department of Health's new general practitioner referral guidelines for bowel cancer., Design: One year prospective audit., Setting: District general hospital serving a population of 550 000., Subjects: All patients with bowel cancer; all patients referred on the basis of the two week standard and to a routine colorectal surgical outpatient clinic., Main Outcome Measures: Proportion of cancers referred on the basis of the two week standard and to other colorectal clinics; the proportion with the higher risk criteria and their diagnostic yields; stage of cancers diagnosed in outpatient clinics; and time to treatment., Results: A total of 249 cancers were diagnosed in the index year. Sixty five (26.1%) were referred to two week standard clinics, 40 (16.1%) to routine colorectal surgical outpatient clinics, 54 (22%) to other clinics, and 88 (35.3%) were emergencies. Thirteen patients per week were referred to the two week standard clinics and 85% (54/65) of cancers so referred were seen within two weeks. The diagnostic yield of cancer in the two week standard clinic was 9.4% (65/695) compared with 2.2% (40/1815) in the routine colorectal surgical outpatient clinic (p<0.0001). Eighty five per cent of patients with cancer referred to outpatients matched the guidelines for the two week standard clinics. Only 46% of this group were so referred. Overall, delay to treatment and Dukes' stage were not improved in patients diagnosed in the two week standard clinics., Conclusions: Most patients with bowel cancer were not referred on the basis of the two week standard although most fulfilled the referral criteria, which had higher diagnostic yields. The two week standard clinics did not shorten the overall time to treatment or improve the stage of disease because the time lags before referral and after the outpatient appointment are the major causes of delay in the bowel cancer patient's journey.

The aim of our study was to audit dysphagia referrals received by a specialist gastroenterology unit during an entire year. We used a prospective audit carried out over a 12-month period at the District General Hospital gastroenterology unit. The audit included 396 consecutive patients who were referred with swallowing difficulties. We found that 60 referrals (15.2%) were inaccurate and the patients had no swallowing problem. Of the 336 patients with genuine dysphagia, only 29 (8.6%) were new cancer cases. The large majority of subjects had benign disease mostly related to acid reflux. Weight loss was significantly associated with malignancy but also occurred in one third of patients with reflux alone. The temporal pattern of dysphagia was not significantly predictive of cancer. All the cancer patients were above the age of 50 years. Although patients were in general assessed rapidly after hospital referral, the productivity, in terms of early tumor diagnosis, was extremely low. We conclude that there is a substantial rate of inaccurate referrals of dysphagia patients. Most true cases of swallowing difficulty relate to benign disease. Even the devotion of considerable resources to the early diagnosis of esophago gastric malignancy in an attempt to conform with best practice guidelines results in a very low success rate in terms of the detection of potentially curable tumors.

The purpose of this study was to identify differences between referral patterns and the clinical conditions of patients referred to consultant-led Restorative Dentistry clinics in a district general hospital and a London dental teaching hospital. The Index of Restorative Dental Treatment Need was used to classify patients into those patients whose treatment was appropriate for any dental graduate in general practice, for an experienced dentist in general practice, and for a dentist with specialist training. Demographic and clinical details were recorded for one hundred patients at each hospital. The results of the study showed that the proposed treatment of 21% of the patients seen at the district general hospital and 16% of the patients seen at the teaching hospital was appropriate for specialist care. The results support the expansion of specialist restorative dentistry services in district general hospitals.

Purpose: Pediatric uveitis is rare and has been reported to cause increased rates of visual loss compared with adult patients. The reasons for this are unclear. Only one study has been population-based, so the effect of referral bias is not known. We examined the pattern of disease in primary and referral centers to establish the unique characteristics of uveitis in children., Design: Case control study., Methods: Retrospective, multicenter, observational study of uveitis starting before the age of 20 years. Two hundred forty-nine patients were recruited from three primary and two referral ophthalmic units. Age-related differences in types of uveitis and systemic disease between hospitals were characterized, as were associations with visual loss., Results: The incidence of uveitis in district hospitals at less than 16 years of age was 4.9/100,000: the most frequent diagnosis was idiopathic uveitis (78%). In referral cohorts the most frequent diagnosis was juvenile idiopathic arthritis-associated uveitis (67%). Other systemic diseases were rare. The most frequent type of uveitis at 0 to 7 years of age was chronic anterior uveitis, posterior uveitis in 8- to 15-year-olds, and acute anterior uveitis in 16- to 19-year-olds. Visual loss (any eye < 6/12) occurred in 17% and was not associated with age, sex, or hospital cohort. It was most frequent in posterior uveitis (25%). Treatment variables were independent predictors of visual loss: systemic treatment 2.2 (1.1- 4.6), surgical intervention 8.2 (3.8-17.6)., Conclusions: Idiopathic uveitis was three times more common in district hospitals. Visual loss was similar to adult uveitis in this study. The increased frequency of severe chronic anterior uveitis in children aged 0 to 7 years and posterior uveitis in older children aged 8 to 15 years accounts for the rate of visual loss seen in previous studies.

Objectives: The Department of Health had recently introduced guidelines so that all suspected colorectal cancer patients could be seen by a specialist within two weeks of referral by their general practitioners. The usefulness and practicality of such a decision had been questioned. The aims of this study were to measure the compliance to the guidelines and evaluate the effectiveness of such referrals., Methods: All patients who were referred to the rapid access colorectal clinic between August 2000 and July 2001 were included., Settings: Darlington Memorial Hospital and Bishop Auckland General Hospital, both under South Durham Health Care Trust, were considered for the study., Measures: Date of referral, referring practitioner, time of appointment, reasons for referral, and diagnosis., Results: A total of 239 referrals were made; 96.2% of patients were given appointments within two weeks. Rectal bleed was the commonest (32%) cause for referral. Diverticular disease was the most frequent (29%) condition diagnosed. Altogether 97.4% of referrals were incomplete and 37.6% did not comply with the guidelines. Twenty one colorectal cancers (8.9%) were diagnosed. The early cancer detection rate was 4.6%., Conclusions: This audit showed that compliance to the guidelines was associated with a higher cancer detection rate. The majority of patients received appointments within two weeks. Contrary to some speculations, the number of referrals was not limitless. However a high number of referrals failed to adhere to the guidelines. The cancer (particularly early cancer) detection rate was disappointingly low. This does not reflect an efficient system of referral and potential benefits to patients remain questionable.

Objective: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital., Methods: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis., Results: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved., Conclusions: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.

Formal referral systems have been proposed as a strategy to improve access to secondary care, yet their implementation can be problematic. This paper describes data from referrals in one rural district in Nepal over a 4-year period. Whilst the characteristics of those patients attending hospital after referral were similar to those described in other developing countries, the rate (1.0/1000 population/year) is much lower, especially when compared to estimated need. Geographical and other barriers to access to secondary care in rural Nepal are discussed.

Aim: To assess the impact that a test-and-treat policy with open-access urea breath testing (UBT) has had on the referral rates for endoscopy in a district hospital. Additionally, we examined for any change in the proportion of serious pathology detected endoscopically after adopting the policy., Methods: Analysis of data on all open-access endoscopy referrals in a 12-month period before (October 1994 to September 1995) and 2 years after (October 1997 to September 1998) the introduction of the UBT service. This was compared with the same service in our sister hospital, which had not provided a UBT service. Results of patients attending the UBT service during the period of study were also examined., Results: A total of 798 patients attended for endoscopy (18% aged < 40 years, 82% aged > 40 years) in the pre-UBT year compared with 1905 patients (16% aged < 40 years, 84% aged > 40 years) in the post-UBT year. The standardized referral ratios were significantly higher for both age groups in the post-UBT year: 210 in the < 40 years group (95% CI 187 to 235) and 244 in the > 40 years group (95% CI 233 to 257). Six per cent of the < 40 years group in the post-UBT year had serious pathology compared with 7% pre-UBT (P < 0.1). However, the proportion of serious pathology decreased from 37 to 27% in the > 40 years group (P < 0.01). The total number of open-access endoscopies had increased steadily over the 3 years, despite the introduction of the UBT service. This trend was mirrored in our sister hospital. A total of 457 patients attended the UBT service during the 12 months. Of these, 24.5% were Helicobacter pylori positive, with a 66.3% eradication rate., Conclusions: A test-and-treat policy has not saved endoscopy workload in this non-referral hospital. We feel that results from centres with an H. pylori interest cannot be generalized for the vast majority.

We defined the pattern and appropriateness of GPs' new-patient referrals to a large district general hospital gastroenterology department, and assessed the implications for workload in the context of the recently introduced 'two-week target'. Prospective data were collected on all new referrals over a two-month period and 426 new appointments were included, from which data were available on 390. Only six referrals were deemed inappropriate. Sixty-nine patients had a functional disorder, and GPs were less likely to diagnose this group at referral than the gastroenterologist was after the initial consultation. Nineteen per cent of all GP referrals were classified as urgent and 6% of these had a malignancy. Fifty per cent of patients with malignancy were not perceived as meriting an urgent referral by the GP Gastroenterology outpatient facilities are already overstretched and the implementation of the two-week target will add considerable strain to the current resources, with little gain in identifying malignancy.

We studied the frequency of referring newborns to special care in Finland and its variation between hospitals. Data was obtained from the nationwide Finnish Birth Register for 1991 and 1994. Newborns who during their first week of life had been in special care, in another hospital, in a respirator, or who had received a blood exchange were defined as having been in special care. This applied to 7% of newborns in 1991 and to 8% in 1994. The proportions of newborns in special care varied notably between hospitals of the same level. The differences could be explained by varying patient mixtures and different thresholds for referral to care. The indications for referring newborns into special care, especially in hospitals with high rates of referral, requires scrutiny.

Objective: To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners., Design: Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995., Setting: District health authority in south-west England., Subjects: 10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients., Main Outcome Measures: Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times., Results: In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5., Conclusions: Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients.

Patients with chronic pain may benefit from referral to a pain specialist. This study describes the delay between referral and first appointment of 3386 new referrals seen in ten outpatient pain clinics between 1990 and 1992. We then assess the follow-up patterns of the pain clinics and how these relate to waiting times. Patients wait in pain for long periods before being seen in a pain clinic. In 1992 about half of patients waited more than 3 months for an appointment at a teaching hospital pain clinic; and half waited 9 weeks or longer to be seen at a district general hospital pain clinic. In many clinics the situation is worsening. Pain clinics differ widely in their patient follow-up, with patients averaging more than twice as many visits in some clinics than others. Clinic practice on reappointing patients largely determines the number of new referrals who can be accepted for management, and hence affects waiting lists. Thus our data suggest that pain clinics themselves can help reduce waiting times, by changing the extent and nature of patient follow-up. Ultimately, however, additional consultant sessions may be needed to enable pain clinics to meet the increasing demands placed on them.

The recent re-organization of the National Health Service has placed a new emphasis on reexamining the services that hospitals provide to General Practitioners (GPs). To assess the positive findings from an existing open access ultrasound service for GPs in a metropolitan District General Hospital, a retrospective study was performed of 300 consecutive patients referred by GPs compared with 300 consecutive patients referred from the general medical, surgical and geriatric Outpatient Departments--specifically with regard to upper abdominal ultrasound. The frequency with which the clinical indication for referral was associated with an ultrasound finding which could explain the patient's symptoms was measured and the similarities and differences in the two groups are discussed. The study did not attempt to assess the complete value of this service since that would have necessitated assessment of the importance of negative findings. In the two groups the total number of ultrasound abnormalities was similar. A total of 25.3% of GP referrals had an abnormality which could account for their symptoms. The corresponding figure for hospital outpatients was 33.6%. On this criterion, the provision of open access for abdominal ultrasound to GPs is justified.

An important strategy to make a better use of the scarce resources available to the health sector in developing countries should focus on strengthening the referral system. Hospitals overcrowded with patients who could be more cheaply treated in smaller facilities is a common feature of poorly functioning referral systems. After defining what is meant by referral system, the paper discusses the main problems affecting its implementation within a primary health care strategy in developing countries. The essential prerequisites for an effective referral system are then discussed, emphasizing the need for a clear division of tasks between the different levels of the health delivery system. The paper concludes that efficiency gains and improvement of access are the most likely outcomes of a well-functioning referral system.

A study was undertaken to determine if inappropriate general practitioner out-patient referrals have increased. Out-patients referred to an otolaryngology unit in north-east England were analysed. Patient, diagnosis, waiting time and outcome of consultation details of new attenders for a two-month period in 1981 and 1989 were compared. New out-patient attenders without evidence of otolaryngological disease, who required no treatment, investigation or follow-up, were defined as inappropriate referrals. A total of 2200 new attendances were studied, 819 in 1981 and 1381 in 1989. In all, 125 referrals (15%; 95% confidence interval, 12-18%) in 1981 and 180 patients (13%; 11-15%) in 1989 were inappropriate. There was no increase in the proportion of inappropriate referrals.

Objective: To measure the effect on hospital radiology referral practice of introducing a strategy for change involving guidelines of good practice, monitoring, and peer review., Design: Prospective data collection over a continuous 21-24 month period at each centre some time between January 1987 and December 1990., Setting: Five district general hospitals and one district health authority., Subjects: 314,663 inpatient discharges, deaths, and day cases and 1,706,781 outpatient attendances under the care of 722 consultants from 25 clinical specialties., Main Outcome Measures: Number of referrals for x ray examination per 100 inpatient discharges, deaths, and day cases and per 100 new outpatient attenders., Results: Most doctors were prepared to accept standards of clinical practice set by peers and also the monitoring and review of their practice with respect to these standards by local colleagues. 18% of firms were identified before guidelines were instituted as having persistently high referral rates. Appreciable, and often dramatic reductions in referral rates for individual x ray examinations were recorded by a substantial number of firms in every centre and in every specialty after guidelines were instituted. The major part of this reduction was achieved by some of the firms whose initial practice did not meet "high referral" criteria. Important variations in compliance with agreed standards of good practice were observed., Conclusions: The study offers strong experimental evidence to support a recent suggestion that at least a fifth of radiological examinations carried out in NHS hospitals are clinically unhelpful. The problem of how to assure compliance with agreed standards of practice needs to be resolved. Until this happens medical audit alone is unlikely to translate good practice into common practice.

Objective: A baseline audit of radiology referral practice before the introduction of a strategy for change involving guidelines of good practice, monitoring, and peer review., Design: Prospective data collection over a continuous 12 months period at each centre sometime between January 1987 and December 1989., Setting: Five district general hospitals and one district health authority., Subjects: 159,421 inpatient discharges, deaths, and day cases and 861,370 outpatient attendances under the care of 722 consultants from 25 clinical specialties., Main Outcome Measures: Monitoring of x ray examination referrals per 100 inpatient discharges, deaths, and day cases and per 100 new outpatient attenders after establishment of a computerised data collection system., Results: Referral rates for all x ray examinations varied between firms in the same specialty or sub-specialty by as much as eightfold for inpatients and 13-fold for outpatients, and for chest x ray examination by as much as ninefold for inpatients and 25-fold for outpatients. There was no consistent relation between high referral and teaching status of the centre or specialty or subspecialty., Conclusions: The variation that persisted at all levels of disaggregation of the data supports a recent suggestion that at least a fifth of x ray examinations carried out in Britain may be clinically unhelpful. An intervention study that examines the effect of guidelines of good practice and attendant peer review procedures on the baseline referral levels described above is needed to test this hypothesis further.

The number of referrals made to a district psychiatry service by each of the local general practitioners over a five year period was counted and a large variation in general practitioner referral rate was found. Ten referral letters from each of the general practitioners were independently assessed for the amount of detail included and a mean score for each general practitioner obtained. A significant negative correlation was found between referral rate and amount of detail in referral letters, that is low referrers wrote very detailed letters. The procedure was repeated over an 18 month period including referrals to the district psychology service. Referral rate to the psychologists was positively correlated with detailed referral letters, that is those who referred many patients to the psychologists wrote detailed letters. This study has indicated a wide variation in the use of the psychiatry and psychology services by general practitioners which cannot be explained solely on the basis of a general referral tendency. It is likely that constructive liaison between psychiatrists and general practitioners, especially those who refer a large number of patients, could enhance the care of patients with psychiatric disorder in general practice.

This paper presents the results of a study into some specific aspects of the management of coronary heart disease within one district health authority. In particular, it is concerned with the appropriate balance of inpatient coronary care between the district general hospital and community hospitals in the light of current and potential changes in the clinical management of coronary cases. The study is an example of a multidisciplinary approach to local health planning which is beginning to emerge within the Exeter Health District, the methodology of which may be applicable to client groups within the medical specialties other than coronary cases, such as strokes or respiratory disorders. It also illustrates the use of spatial analysis and diagnosis-related groups in local planning.

The surgical aspects of 12 years' involvement with a combined consultative gastroenterology clinic at a district general hospital are reviewed. In this time the overall number of patients subjected to surgery has gradually fallen and the average age of patient referral has gradually increased and the logistical implications are considered. Trends for the common diagnoses encountered are discussed and the educational benefit of the clinic is stressed.