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Cancer will affect more than one in three U.S. residents in their lifetime, and although the diagnosis will be made efficiently in most of these cases, roughly one in five patients will experience a delayed or missed diagnosis. In this integrative review, we focus on missed opportunities in the diagnosis of breast, lung, and colorectal cancer in the ambulatory care environment. From a review of 493 publications, we summarize the current evidence regarding the contributing factors to missed or delayed cancer diagnosis in ambulatory care, as well as evidence to support possible strategies for intervention. Cancer diagnoses are made after follow-up of a positive screening test or an incidental finding, or most commonly, by following up and clarifying non-specific initial presentations to primary care. Breakdowns and delays are unacceptably common in each of these pathways, representing failures to follow-up on abnormal test results, incidental findings, non-specific symptoms, or consults. Interventions aimed at ‘closing the loop’ represent an opportunity to improve the timeliness of cancer diagnosis and reduce the harm from diagnostic errors. Improving patient engagement, using ‘safety netting,’ and taking advantage of the functionality offered through health information technology are all viable options to address these problems. [ABSTRACT FROM AUTHOR]

Copyright of Revista Científica de Enfermería (2071-5080) is the property of Colegio de Enfermeros del Peru and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: In healthcare systems prioritizing care of older adults, resource limitations and escalating demand often impede access to outpatient specialized geriatric services. Objectives: This study, theoretically guided by the Consolidated Framework for Implementation Research (CFIR), aimed to explore barriers and facilitators in implementing a centralized "Geri-Hub." The Geri-Hub is a centralized intake system established within 2 hospital systems to coordinate outpatient and community-based services for older adults, aiming to connect them with the most appropriate care in a timely manner. Methods: Qualitative insights were gathered from healthcare professionals at 2 academic institutions in the process of consolidating services. Through open-ended surveys and semi-structured interviews, we solicited feedback on referral management, waiting times, and overall work experiences. Results: Thirteen frequently referring providers and a cohort of 9 geriatricians, along with 4 administrators, contributed to the study. Geriatricians emphasized streamlined referrals, flexible scheduling for urgent cases, and a target wait time of 3 months. Administrators stressed standardized referral procedures, defined roles, and accessible referral information. Discussion: The findings underscored the need for straightforward referral processes, enhanced communication on referral statuses, and reduced wait times. Optimizing these processes could potentially mitigate resource utilization issues and improve patient outcomes in healthcare systems. This research highlights the critical role of timely access to geriatric services during transformative phases in healthcare delivery. [ABSTRACT FROM AUTHOR]

Background The COVID-19 pandemic has made neurology clinic waiting times longer. To prevent a build-up of patients waiting, we introduced a neurology advanced referral management system (NARMS) to deal with new referrals from GPs, using advice, investigations, or the telephone, as alternatives to face-to-face (FF) assessment. Methods For six months, electronic referrals from GPs were triaged to the above categories. We recorded the numbers in each category, patient satisfaction, inter-consultant triage variation, re-referrals, and calculated CO2 emissions. Results There were 573 referrals. Triage destinations were advice 33%, investigations 27%, telephone 17%, and FF 33%. Of patients referred for MRI, 95% were happy not to be seen if their investigation was normal. Less-experienced consultants triaged 20% and 30% respectively, to advice or investigations, compared with 40% by a triage-experienced neurologist. Four percent were re-referred. Numbers on the waiting list did not increase. CO2 emissions were reduced by 50%. Discussion Two thirds of neurological referrals from GPs did not need to be seen FF and 50% were dealt with without the neurologist meeting the patient. Carbon emission was halved. This system should be employed more, with FF examination reserved for those patients who need a neurological examination for diagnosis and management. [ABSTRACT FROM AUTHOR]

Background: There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers.Objective: Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers.Design: Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers.Patients: Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community.Intervention: Specialist referral management program implemented by Crossover Health employer-sponsored clinics.Main Measures: Rates and costs of specialist referrals.Key Results: The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001).Conclusions: Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed. [ABSTRACT FROM AUTHOR]

Care coordination involves shaping patient care activities and sharing information among all participants concerned with a patient's care to achieve safe and effective care. The objectives of care coordination are to promote sharing of patients' clinical information, keep patients and families informed, and manage effective referrals and care transitions. Failures in care coordination account for a large amount of waste per year in the United States. Many innovative healthcare organizations have recently recognized the danger of poorly coordinated care and have implemented analytics to improve it. Therefore, more analytics‐based research (especially combining explanatory analytics with predictive analytics) is needed to direct efforts to improve care coordination. This paper focuses on systematically studying the extant literature to understand how analytics play a role in improving care coordination. Our goal is to identify a set of key research questions that would lead to new research areas in the use of analytics for care coordination. Based on these questions, we offer new analytics solution pathways to care coordination problems. [ABSTRACT FROM AUTHOR]

In business-to-business markets, suppliers often ask an existing customer to provide a referral for them (i.e., a supplier-selected referral), in which the supplier selects a referrer to influence a specific potential customer favorably. The selection of the referrer is important because the right referrer providing the right message can generate business for the supplier. To study supplier-selected referrals, the authors extend the dyadic source message-recipient communication framework to propose a framework that incorporates the supplier and the supplier's management of the communication between the referrer and the potential customer. They label this framework the Managed Triadic Communication (MaTriC) framework. The authors conduct three experimental studies in which they apply the MaTriC framework to the domain of supplier-selected referrals and focus on the contingent role of supplier uncertainty. The authors find that the benefits of a supplier-selected referral are contingent on supplier uncertainty. For example, their findings imply that an out supplier should focus on selecting a referrer that would give an all-positive evaluation (vs. a balanced evaluation), whereas an in supplier should focus on selecting a highly credible referrer, even if that referral does not provide an all-positive evaluation of the supplier. [ABSTRACT FROM AUTHOR]

Abstract Background A specialist primary care oral surgery service combined with an electronic referral management and triage system was developed in response to concerns raised around overburdened secondary care services in the UK. Whilst the system has the potential to manage conflicting demand for oral surgery services against an objective need, the new pathway represents a number of challenges to existing working practices and could compromise the sustainability of existing hospital services. The aim of this research was to carry out a qualitative exploration of implementation of a new intervention to gain insight into how these challenges have manifested and been addressed. Methods Views were sought from stakeholders (dentists, hospital staff, commissioners and patients) at various time points over 3 years during and after implementation using semi-structured interviews. Normalization Process Theory informed a qualitative thematic analysis which was carried out using data from interview transcripts to identify important emerging issues. Results Themes emerging from the data were; amenability to change and assimilation into practice (primary care dentists), compliance and governance, changing perceptions of impact (secondary care staff and commissioners) understanding change in service provision and priorities for treatment (patients). The new pathway impacted stakeholders at different stages of implementation. Conclusion Electronic referral management with a primary care advanced service for oral surgery was successfully implemented in a specific area of the UK. The service model evaluated has the potential to be expanded across a wider geographical footprint and to support demand management in other specialist services.

Abstract Background A primary care oral surgery service was commissioned alongside an electronic referral management system in England, in response to rising demand for Oral Surgery services in secondary care. It is important to ensure that standards of quality and safety are similar to those in existing secondary care services, and that the new service is acceptable to stakeholders. The aim of this study is therefore to conduct an in depth case study to explore safety, quality, acceptability and implementation of the new service. Methods This case study draws on multiple sources of evidence to report on the commissioning process, implementation, treatment outcomes and acceptability to patients relating to a new oral surgery service in a primary care setting. A combination of audit data and interviews were analysed. Results Most referrals to the new service consisted of tooth extractions of appropriate complexity for the service. There were issues with lack of awareness of the new service in a primary care setting within referring primary care practices and patients at the start of implementation, however over time the service became a fully integrated part of the service landscape. Complications reported following surgery were low. Conclusion Patients liked the convenience of the new service in terms of shorter waiting time and geographical location and their patient reported experience measures and outcomes were similar to those reported in secondary care. Providing appropriate clinical governance was in place, oral surgery could safely be provided in a primary care setting for patients without complex medical needs. Attention needs to be paid to communication with general dental practices around changes to the service pathway during the early implementation period to ensure all patients can receive care in the most appropriate setting.

Objective: This study explores geographic, system, and organizational constructs that predict medical care teams’ willingness to administer fluoride varnish and conduct oral health risk assessments. Methods: A cross-sectional survey of voluntary health professionals attending trainings on interprofessional oral health practice was completed at ten meetings across the United States from April through September, 2016. Bivariate and multivariate analyses were used to examine unknown correlates of oral health prevention and intervention at geographic, organizational, and system levels relating to the impact of referral mechanisms and systems as well as health information technology on fluoride varnish administration and risk-based oral evaluations. Results: A convenience cohort (n = 560) from 44 states was examined. Most (68.7%, n = 385) agreed with the dependent variable “medical providers at our site, or part of our network, are administering fluoride varnish and identifying oral health risk factors in the majority of patients seen.” In bivariate analysis, organization type (P = 0.0067), having successful referral systems (P < 0.0001), and electronic health record (EHR) utility (P < 0.0001) were associated with the dependent variable. No geographic indicators were significant. All referral system indicators were significant in multivariate analysis. Dependable referrals (P < 0.0001), EHR utility (P = 0.0054), and type of referral (P = 0.0009) were predictors of the dependent variable. The odds of those reporting a dependable referral system and dependent variable agreement were 4.5 times greater than for those who lacked dependable referral systems (odds ratio 4.54, confidence interval 2.79–7.39). The odds of those who had dependable EHRs and dependent variable agreement were 2.4 times greater than for those who lacked useful EHRs (odds ratio 2.4, confidence interval 1.29–4.37). Conclusion: The dependability of medical-to-dental referral systems and processes impacts the administration of fluoride varnish and identification of oral health risk factors by motivated primary care teams. Additionally, the ease of EHR use and the availability of electronic information exchange were found to impact primary care oral health practice.

Objective: This study explores geographic, system, and organizational constructs that predict medical care teams' willingness to administer fluoride varnish and conduct oral health risk assessments. Methods: A cross-sectional survey of voluntary health professionals attending trainings on interprofessional oral health practice was completed at ten meetings across the United States from April through September, 2016. Bivariate and multivariate analyses were used to examine unknown correlates of oral health prevention and intervention at geographic, organizational, and system levels relating to the impact of referral mechanisms and systems as well as health information technology on fluoride varnish administration and risk-based oral evaluations. Results: A convenience cohort (n = 560) from 44 states was examined. Most (68.7%, n = 385) agreed with the dependent variable "medical providers at our site, or part of our network, are administering fluoride varnish and identifying oral health risk factors in the majority of patients seen." In bivariate analysis, organization type (P = 0.0067), having successful referral systems (P < 0.0001), and electronic health record (EHR) utility (P < 0.0001) were associated with the dependent variable. No geographic indicators were significant. All referral system indicators were significant in multivariate analysis. Dependable referrals (P < 0.0001), EHR utility (P = 0.0054), and type of referral (P = 0.0009) were predictors of the dependent variable. The odds of those reporting a dependable referral system and dependent variable agreement were 4.5 times greater than for those who lacked dependable referral systems (odds ratio 4.54, confidence interval 2.79-7.39). The odds of those who had dependable EHRs and dependent variable agreement were 2.4 times greater than for those who lacked useful EHRs (odds ratio 2.4, confidence interval 1.29-4.37). Conclusion: The dependability of medical-to-dental referral systems and processes impacts the administration of fluoride varnish and identification of oral health risk factors by motivated primary care teams. Additionally, the ease of EHR use and the availability of electronic information exchange were found to impact primary care oral health practice. [ABSTRACT FROM AUTHOR]

Purpose: Leakage (out-of-network referral) is undesirable because it limits ability to control costs of services. Clinical decision support (CDS) systems seek to ensure appropriate imaging of patients but theoretically could drive leakage if ordering providers attempt to circumvent CDS recommendations and obtain studies from other imaging providers. This study assessed the incidence of leakage of imaging studies that had low appropriateness scores.Methods: We queried our outpatient CDS system over a three-year period (2011-2013) for studies that received a low CDS appropriateness score and were canceled by the ordering physician. For patients meeting these criteria and participating in risk-shared contracts, we cross-referenced their imaging utilization reports in the risk-contract insurance payment database to determine if they received outpatient imaging within 60 days of the index order, contrary to the decision support recommendation.Results: The risk-shared insurance database contained an average of 63,378 patients who had 18,008 MRIs and 18,014 CTs. A total of 11,234 (31.2%) studies were leaked: 3,513 (9.8%) to affiliated institutions; 7,721 (21.4%) to unaffiliated imaging facilities. Overall, 111 imaging studies received a low appropriateness score in the risk-shared patient population and were performed within 60 days despite the low score. Of these studies, 106 of 111 (95.5%) were ultimately performed within our hospital system (104 at the home institution; 2 at affiliated institutions); only 5 of 111 (4.5%) were performed outside of our hospital system.Conclusions: Decision support systems for ordering providers do not seem to drive imaging referrals out of hospital systems to other institutions. Hospital systems can implement decision support without fear of this occurring. [ABSTRACT FROM AUTHOR]

Background There is increasing interest in innovative methods to carry out systematic reviews of complex interventions. Theory-based approaches, such as logic models, have been suggested as a means of providing additional insights beyond that obtained via conventional review methods. Methods This paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesise a broad range of literature. The potential value of the model produced was explored with stakeholders. Results The review identified 295 papers that met the inclusion criteria. The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles. A logic model was systematically built from these studies. The model outlines interventions, short term outcomes, moderating and mediating factors and long term demand management outcomes and impacts. Interventions were grouped into typologies of practitioner education, process change, system change, and patient intervention. Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge, beliefs or attitudes and also interventions related to changed doctor-patient interaction. A range of factors which may influence whether these outcomes lead to long term change were detailed. Demand management outcomes and intended impacts included content of referral, rate of referral, and doctor or patient satisfaction. Conclusions The logic model details evidence and assumptions underpinning the complex pathway from interventions to demand management impact. The method offers a useful addition to systematic review methodologies. [ABSTRACT FROM AUTHOR]

Background: Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care. This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters. Methods: Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral). Results: Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of 'past medical history' (from 71% to 84%, p < 0.001) and 'medication history' (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods. Conclusion: Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement. [ABSTRACT FROM AUTHOR]

Referrals of ‘people you know’ to Child and Adolescent Mental Health Services (CAMHS) raise issues around anxiety, equity and confidentiality. Research in this area is limited. The framework approach was used to analyse interviews with CAMHS teams across Yorkshire. Issues identified included choice (and whose choice this is), power and perceived imbalances of power and relative lack of ‘professional distance’. The notion that health staff should receive preferential treatment by right was not widespread, but nevertheless existed. Standard procedure has to be flexibly applied to offer the best quality care. Families should not be inappropriately advantaged by ‘knowing us’, but disadvantage should be recognised and kept to a minimum. [ABSTRACT FROM PUBLISHER]

This article describes the experiences of running a referral management centre using clinical triage together with the development of primary care-based oral surgery services after 3 years. The benefits have been reduced waiting times for patients, improvements in access to oral surgery services, engagement of oral surgery specialists in a general practice setting and considerable ongoing savings to the NHS. A sustained increase in demand for oral surgery has been fully met by the flexible response of primary care-based oral surgeons and National Health Service (NHS) commissioners. However, the continued rise in referral numbers remains a concern. [ABSTRACT FROM AUTHOR]

With the growing availability of health information on the web, people are becoming more knowledgeable on their health conditions and treatment options, and more patients seek specialists by themselves. To aid patients in requesting self-referrals, we have developed and evaluated a web-based self-referral system in three specialty clinics at the University of Washington. Two clinics adopted the system for routine clinical use, while the third clinic decided not to. A major difference between these two groups was in how fast online requests from patients were handled, which significantly influenced patients’ satisfaction. Clinic's preparedness for handling the temporarily increased workload due to the introduction of a new health information system played a role as well. Also, we noticed that the physician leadership/championship made a difference in the acceptance of our system. [ABSTRACT FROM AUTHOR]

Navigate Your Health is a place-based, co-designed model that will improve the health and wellbeing of children in out-of-home care (OOHC) in the Brisbane Region. The model defines the process and pathways for initial health screening, subsequent comprehensive health and developmental assessments, the provision of ongoing healthcare needs, and will be supported by the creation of four individual Health Navigator positions. Research consistently shows that children and young people in care are likely to have poorer health and wellbeing outcomes than those who are not in care, including poorer physical, developmental, behavioural and mental/emotional health. The Queensland Child Protection Commission of Inquiry report highlighted that children and young people in the care system also have higher rates of earlier onset of sexual activity, higher rates of sexually transmitted infections and higher rates of earlier pregnancy and parenting. Since late 2016, Children's Health Queensland (CHQ), Department of Communities, Child Safety and Disability Services' Brisbane Region, and Brisbane Aboriginal and Torres Strait Islander Community Health Service (Brisbane ATSICHS) have jointly led a co-design process with partners - including non-government agencies, Primary Health Networks (PHNs), children and young people and foster carers. Stakeholders contributed their vast experience and expertise to assist in the development of a best practice model. The proposed elements of the model include: Health Screening: Children and young people will receive a preliminary health check, followed by a comprehensive health and developmental assessment covering the domains of physical, developmental and mental/emotional health. Referral coordination: The most appropriate pathways for the child/young person will be determined - dependent on the outcome of the preliminary and comprehensive assessments, age, cultural status, disability status, care and health history. Referrals to required services or additional assessments are progressed and will be monitored to ensure the timeliness of follow up and the development of a Health Management Plan. Health care coordination: Children and young peoples' healthcare will continue to progress in an integrated way, and in line with the recommendations of their Health Management Plan. A higher emphasis and priority for meeting their healthcare needs is in place and Child Safety Officers (CSOs) are provided with support in healthcare coordination. Change to be implemented: The trial implementation of a place-based, co-designed response in Brisbane that will deliver improved health outcomes for children and young people in OOHC Funding for four Health Navigator roles to support the trial The use of the Navigate Your Healthmodel as outlined above The Health Navigators will have capacity to be co-located between existing CHQ facilities and Child Safety Service Centres on an as needs basis to assist in development of relationships with Health and Child Safety staff, and to establish professional linkages. Fostering partnerships with PHNs and Brisbane ATSICHS will also enable flexibility for Health Navigators to co-locate with these services, as required. Evaluation of Navigate Your Healthwill encompass three outcome categories: implementation, clinical and economic outcomes. [ABSTRACT FROM AUTHOR]

Background: A specialist primary care oral surgery service combined with an electronic referral management and triage system was developed in response to concerns raised around overburdened secondary care services in the UK. Whilst the system has the potential to manage conflicting demand for oral surgery services against an objective need, the new pathway represents a number of challenges to existing working practices and could compromise the sustainability of existing hospital services. The aim of this research was to carry out a qualitative exploration of implementation of a new intervention to gain insight into how these challenges have manifested and been addressed.Methods: Views were sought from stakeholders (dentists, hospital staff, commissioners and patients) at various time points over 3 years during and after implementation using semi-structured interviews. Normalization Process Theory informed a qualitative thematic analysis which was carried out using data from interview transcripts to identify important emerging issues.Results: Themes emerging from the data were; amenability to change and assimilation into practice (primary care dentists), compliance and governance, changing perceptions of impact (secondary care staff and commissioners) understanding change in service provision and priorities for treatment (patients). The new pathway impacted stakeholders at different stages of implementation.Conclusion: Electronic referral management with a primary care advanced service for oral surgery was successfully implemented in a specific area of the UK. The service model evaluated has the potential to be expanded across a wider geographical footprint and to support demand management in other specialist services. [ABSTRACT FROM AUTHOR]

Background: A primary care oral surgery service was commissioned alongside an electronic referral management system in England, in response to rising demand for Oral Surgery services in secondary care. It is important to ensure that standards of quality and safety are similar to those in existing secondary care services, and that the new service is acceptable to stakeholders. The aim of this study is therefore to conduct an in depth case study to explore safety, quality, acceptability and implementation of the new service.Methods: This case study draws on multiple sources of evidence to report on the commissioning process, implementation, treatment outcomes and acceptability to patients relating to a new oral surgery service in a primary care setting. A combination of audit data and interviews were analysed.Results: Most referrals to the new service consisted of tooth extractions of appropriate complexity for the service. There were issues with lack of awareness of the new service in a primary care setting within referring primary care practices and patients at the start of implementation, however over time the service became a fully integrated part of the service landscape. Complications reported following surgery were low.Conclusion: Patients liked the convenience of the new service in terms of shorter waiting time and geographical location and their patient reported experience measures and outcomes were similar to those reported in secondary care. Providing appropriate clinical governance was in place, oral surgery could safely be provided in a primary care setting for patients without complex medical needs. Attention needs to be paid to communication with general dental practices around changes to the service pathway during the early implementation period to ensure all patients can receive care in the most appropriate setting. [ABSTRACT FROM AUTHOR]