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Background/Objectives: the timely and effective management of acute myocardial infarction (AMI) is crucial to improve patient outcomes. 'Self-Referral' is defined as instances either where patients arrive at the hospital by their own means or are transported by someone else, rather than through professional emergency medical services. This approach can lead to treatment delays and potentially worsen outcomes. This study aims to identify the factors associated with the choice of self-referral among patients with AMI in Saxony-Anhalt, Germany. Methods: We used the data from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA), which included 4044 patients with confirmed acute myocardial infarction (AMI), including 48.7% from urban areas (city of Halle) and 51.3% from rural areas (Altmark). The gender distribution was 65% male and 35% female, covering an age range from 25 to over 80 years. Multivariable logistic regression identified factors associated with self-referral and its impact on reaching a hospital with percutaneous coronary intervention (PCI) capability. Results: Rural residents were more likely to self-refer compared to those in urban settings (adjusted odds ratio 2.43 [95% CI: 2.00–2.94]). Odds of self-referral decreased with age, while metabolic factors, including hypertension, high body mass index (BMI), and diabetes, as well as sex were not associated with self-referral. Self-referral did not increase the odds of arriving in a hospital without PCI capability. (Adjusted odds ratio 1.12 [95% CI: 0.85–1.47]). Furthermore, in cases of self-referral, women did not have a disadvantage in reaching a hospital with PCI (0.91; 0.59–1.41) compared to men. However, in medically attended transports, women were at a disadvantage (odds ratio: 1.33; 95% CI: 1.06–1.67). Conclusions: These findings highlight the need for public education on self-referral and for medical personnel training to prevent gender bias in AMI transport to PCI-capable hospitals. [ABSTRACT FROM AUTHOR]

Abstract Background Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors. Methods This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients’ mode of referral (self-referral or institutional referral) was considered the outcome variable. Results Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p

Background: Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors. Methods: This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients' mode of referral (self-referral or institutional referral) was considered the outcome variable. Results: Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p < 0.001). Among patients attending the study sites through institutional referral, approximately 10% were referred from community clinics, 6% from union sub-centers, 25% from upazila health complexes, 22% from district hospitals, 22% from other tertiary care hospitals, and 42% from private clinics. Patients visiting the outpatient department (adjusted odds ratio [aOR] 3.3, 95% confidence interval [CI] 2.28–4.82, p < 0.001), residing in urban areas (aOR 1.29, 95% CI 1.04–1.64, p = 0.007), belonging to middle- and high-income families (aOR 1.34, 95% CI 1.03–1.62, p = 0.014, and aOR 1.98, 95% CI 1.54–2.46, p = 0.005, respectively), and living within 20 km of healthcare facilities (aOR 3.15, 95% CI 2.24–4.44, p-value < 0.001) exhibited a higher tendency for self-referral to tertiary care facilities. Conclusions: A considerable number of patients in Bangladesh, particularly those from affluent urban areas and proximity to healthcare facilities, tend to self-refer to tertiary care centers. Inadequacy of facilities in primary care centers significantly influences patients to opt for self-referral. [ABSTRACT FROM AUTHOR]

Addiction is a complex and difficult issue, with relapses occurring in about 50 to 70 percent of addicts after quitting. To better understanding the factors associated with relapse, we conducted a study from the perspective of drug abusers in self-referral centers affiliated with the Welfare Organization of Bandar-e Anzali. Our sample consisted of 181 men referred to addiction treatment centers in Bandar-e Anzali in 1400. We used a researcher-made questionnaire to collect data on demographic information and factors related to relapse. Our findings revealed that associating with addicted and deviant friends (2.62%) was the most important factor associated with relapse from the perspective of addicts. Based on our results, we suggest that training and intervention for assertiveness (the skill of saying no) in front of friends and changing clients’ lifestyles, as well as teaching interpersonal relationships and moderation to family members after quitting drug use, are necessary.

The aim of this study was to assess the rate of self-scheduling and self-referral for screening mammography and to assess sociodemographic factors associated with their use in an academic health care system in southern California. Patients scheduled for screening mammography between February 1, 2021, and September 20, 2022, were included in this retrospective study. Multivariable logistic regression models were used to assess associations among sociodemographic factors, self-referral, and online self-scheduling pathways. In total, 22,306 patients were scheduled for screening mammography (mean age, 59 years; 66.8% White, 20.4% Asian, and 20.6% Hispanic). Overall, 3,566 (16.0%) used online self-scheduling, and 1,232 (5.5%) self-referred for screening mammography. Patients 70 years or older (versus 50 years or younger) (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.34-0.51), Spanish (versus English) speakers (OR, 0.22; 95% CI, 0.16-0.31), and those on Medicaid (versus commercially insured) (OR, 0.71; 95% CI, 0.50-0.99) were less likely to self-schedule. Hispanic patients (versus non-Hispanic) (OR, 1.39; 95% CI, 1.20-1.61), Asian patients (versus White) (OR, 1.64; 95% CI, 1.46-1.85), and patients residing in the most (versus least) disadvantaged neighborhoods (OR, 1.16; 95% CI, 1.02-1.33) were more likely to self-schedule. Furthermore, patients 70 years or older (versus 50 or younger) (OR, 0.70; 95% CI, 0.52-0.93) and Spanish speakers (OR, 0.05; 95% CI, 0.03-0.09) were less likely to self-refer, whereas Black patients (versus White) (OR, 1.89; 95% CI, 1.30-2.75), patients on Medicaid (versus commercially insured) (OR, 3.70; 95% CI, 2.65-5.13), and patients living in the most (versus least) disadvantaged neighborhoods (OR, 1.52; 95% CI, 1.27-1.82) were more likely to self-refer. Sociodemographic differences in online patient portal use and self-referral for screening mammography suggest that the two pathways have been successful in addressing some of the existing scheduling barriers and are a step toward closing the disparity gap. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Direct access to physiotherapy has been introduced in several countries. In France, the healthcare system is evolving towards its introduction; however, no study has described the ability of physiotherapists in this context. Objective: To describe the ability of physiotherapists practicing in France to formulate correct diagnostic hypotheses and make appropriate management decisions using clinical vignettes. Methods: Pre‐existing validated clinical vignettes were used and integrated into a numerical questionnaire. The percentages of correct answers were calculated from the results concerning the choice of diagnostic hypothesis and the management decision, both overall and for the three different patient categories: musculoskeletal, non‐critical medical, and critical medical. Results: Four hundred eighty‐two participants (1.7%) responded to the study. For the formulation of a diagnostic hypothesis, there were 43.0% (415/964), 26.6% (128/482), and 17.8% (86/482) correct answers respectively for the musculoskeletal, non‐critical medical, and critical medical categories. For management decisions, there were 60.8% (586/964), 61.6% (297/482), and 85.1% (410/482) correct answers respectively for the same categories. Conclusions: Our results related to the management decision were better than those for the diagnostic hypothesis, especially for the critical medical category. There is still room for improvement. It might be interesting to support this initial study by using more clinical vignettes validated in a French context. [ABSTRACT FROM AUTHOR]

Tuberculosis remains a significant public health concern worldwide, with approximately 8 million new cases being reported every year. In the past decade, there has been a worsening of the epidemiological situation surrounding tuberculosis, characterized by increased incidence and more severe disease progression. One of the factors contributing to this situation in our country is the change in the method of detection. With a reduction in preventive fluorographic screenings of the population, over 50% of tuberculosis cases are now diagnosed based on patient self-referral to general healthcare institutions. This often leads to delayed diagnosis of the disease. Late detection is associated with an increased burden of tuberculosis and comorbidities, including dental pathology, which further impairs the quality of mechanical food processing. Previous studies have shown that dental diseases among patients with pulmonary tuberculosis are widespread and tend to worsen, leading to tooth loss and complicating the course of the tuberculosis process. [ABSTRACT FROM AUTHOR]

Background: Brief Admission by self-referral is a preventive intervention here intended for individuals who recurrently self-harm and have a history of contact with emergency psychiatric services. Individuals with access to Brief Admission are empowered to self-admit to inpatient care for up to three days per stay and are encouraged to do so before experiencing crisis. Brief Admission was implemented relatively recently in child and adolescent psychiatric settings in Sweden. The purpose of this study was to phenomenologically explore the lived experience of parents whose teenagers, who recurrently self-harm and experience suicidal thoughts, use Brief Admissions. Methods: This is a qualitative study using phenomenological psychological analysis. We interviewed 17 parents who had experienced their teenagers using Brief Admissions. The interviews were recorded and transcribed verbatim and analyzed to arrive at the essential meaning structure of the phenomenon of Brief Admissions for the parent. Results: We identified two essential meaning structures of the parent's experience of their teenager's use of Brief Admissions: being gifted relief and hope or being robbed of everything you believed in. The experience of Brief Admissions as a gift was structured by the following constituents: 'a sense of safety and containment', 'liberation from a hostage situation', 'a return to wellbeing', and 'catalysts for relational shifts'. In contrast, the constituents of the experience of being robbed included 'a tug of war for control', 'an unworthy wasteland', 'abandonment and collapse of authority', and 'no sense of purpose and plan'. Conclusions: Brief Admissions may come across as challenging, futile and painful in the life of the parent, yet they may also support a process of recovery and healthy development for the entire family. To realize the full potential of the intervention, mental health professionals providing Brief Admission must be mindful of the challenges the parent may face as their teenager starts self-admitting, tactfully and sensitively preparing the parent for a new parental role. [ABSTRACT FROM AUTHOR]

The decisions of two patients each who nominated their own schedule of care to minimise recurrence of a chronic non-musculoskeletal condition raises questions about how the experiences of patient-facing Chiropractors may better be conveyed to the discipline's researchers and academics. The matter deserves thought to ascertain the best way to study this phenomenon, using a method which controls for confounders such as placebo or ideomotor effect, regression to the mean, coincidental or casual patient interpretation to treatment response and many others. Patients with self reported positive unexpected non-musculoskeletal outcomes to Chiropractic care or those patients who are self referring themselves for Chiropractic care for wellness or non-musculoskeletal care, deserve to be considered with a view to determining whether we can develop a prediction instrument for this subset of nonmusculoskeletal patients who beneficially respond to chiropractic care. [ABSTRACT FROM AUTHOR]

Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists' characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261. [ABSTRACT FROM AUTHOR]

Study Design.: Retrospective chart review. Objective: The objective of this study was to elucidate the demographics of patient referrals from different sources and identify factors that affect a patient's likelihood of undergoing surgery. Summary of Background Data.: Despite baseline factors for surgical consideration, such as attempting conservative management, surgeons encounter many patients who are not surgically indicated. Overreferrals, that is, a patient referred to a surgeon that does not need surgery, can result in long wait times, delayed care, worse outcomes, and resource waste. Materials and Methods.: All new patients at a single academic institution seen in the clinic by eight spine surgeons between January 1, 2018, and January 1, 2022, were analyzed. Referral types included self-referral, musculoskeletal (MSK), and non-MSK provider referral. Patient demographics included age, body mass index (BMI), zip code as a proxy for socioeconomic status, sex, insurance type, and surgical procedures undergone within 1.5 years postclinic visit. Analysis of variance and a Kruskal-Wallis test was used to compare means among normally and non-normally disturbed referral groups, respectively. Multivariable logistic regressions were run to assess demographic variables associated with undergoing surgery. Results.: From 9356 patients, 84% (7834) were self-referred, 3% (319) were non-MSK, and 13% (1203) were MSK. A statistically significant association with ultimately undergoing surgery was observed with MSK referral type compared with non-MSK referral [odds ratio (OR)=1.37, CI: 1.04–1.82, P =0.0246]. Additional independent variables observed to be associated with patients undergoing surgery included older age (OR=1.004, CI: 1.002–1.007, P =0.0018), higher BMI (OR=1.02, CI: 1.011–1.029, P <0.0001), high-income quartile (OR=1.343, CI: 1.177–1.533, P <0.0001), and male sex (OR=1.189, CI: 1.085–1.302, P =0.0002). Conclusions.: A statistically significant association with undergoing surgery was observed with a referral by an MSK provider, older age, male sex, high BMI, and a high-income quartile home zip code. Understanding these factors and patterns is critical for optimizing practice efficiency and reducing the burdens of inappropriate referrals. [ABSTRACT FROM AUTHOR]

Access to specialty care can be challenging for patients, often involving multiple evaluations, laboratory tests, and referrals. To better understand the different pathways to specialty care, we examined the outcomes of patients evaluated for surgical thyroid disease at a single tertiary referral clinic. We reviewed 691 patients seen in the endocrine surgery clinic for thyroid disease (2018-2021). Patient demographics, referral source, referral reason, and reason for not receiving an operation were collected. The number of days from referral to initial clinic visit and from initial clinic visit to an operation were also collected. The Chi-square test, the independent t -test, the Kruskal–Wallis test, the Dunn-Bonferroni post hoc test, and multiple logistic regression tests were performed using SPSS. The top reasons for referral were thyroid nodules (54.4%), hyperthyroidism (26.5%), and multinodular goiter (10.3%). Specialty clinic referrals came from endocrinologists (56.0%), self-referrals (15.5%), and primary care physicians (PCP; 14.4%). Self-referred patients had a shorter waiting time for an appointment than those referred by endocrinologists and PCPs. [median (IQR) (days) 12 (6-17) versus 16 (9-24) versus 16 (9-25), P < 0.001]. Overall, 450 (72.7%) patients underwent thyroid surgery. For those who underwent thyroidectomy, self-referred patients had a shorter time between initial clinic visit and the operation compared to those referred by endocrinologists and PCPs [median (IQR) (days) 2 (1-19) versus 19 (8-33) versus 16 (1-48), P < 0.001]. Patients referred for hyperthyroidism (odds ratio [OR] = 2.2, 95% confidence interval [CI] 1.3-10.5, P = 0.012 were more likely to undergo an operation than those referred for other reasons. Access to specialty care for thyroid disease is facilitated and optimized when self-referrals are permitted. Reducing or eliminating the requirement for a provider referral may improve patients' access. • Most patients seen in thyroid surgical clinic were referred by endocrinologists, self-referrals, and primary care physicians. • Self-referred patients had significantly shorter wait times from referrals to clinic visits and from clinic visits to operations. • Referral sources, sex, and referral reasons were independent predictors of undergoing operations. • Patients who were referred by specialists were more likely to receive operations than self-referrals and PCP referrals. However, there was no difference in operation rate between self-referrals and PCP-referrals. [ABSTRACT FROM AUTHOR]

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

Abstract 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.

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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.

Despite the high prevalence of psychological distress in primary care, only a limited number of individuals can benefit from early and evidenced-based psychological approach. Barriers to help-seeking attributable to stigma, lack of proper care pathway to evidence-based psychological interventions, and a high volume of primary care attendees are among the factors that contribute to the inadequate psychological treatments. This study examined the implementation of a change process using a brief cognitive behavioral therapy (b-CBT) workshop as a potential approach in managing psychological distress among 73 primary care self-referrals using purposive sampling. One-way repeated-measures multivariate analysis of variance (ANOVA) was used to analyze changes in psychological distress within a non-randomized quasi-experimental study. Results revealed significant differences in psychological distress using Depression, Anxiety, and Stress Scale-21 items at three time points (pre-intervention, post-intervention, and 1-month follow-up). Implementation of the b-CBT workshop showed positive changes for psychological distress, suggesting the possibility of integrating brief, non-stigmatized, and evidence-based psychological approach at the primary care level. However, the self-referral characteristics of the attendees remain unknown. Factors such as potential feasibility, participant's usability and satisfaction, and implementation of b-CBT workshop to improve psychological distress are discussed in this study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The demand for outpatient hospital appointments has risen steadily over recent years, almost doubling since 2008; now standing at 120 million appointments per year. Initiatives to reduce unnecessary appointments are a key area of interest, as they can be an effective way of both improving patient care and satisfaction, as well as reducing NHS costs. Patient Initiated Follow-Up (PIFU) provides an alternative to traditional hospital instigated follow-up, by which patients have autonomy in their future care, allowing them to make appointments based on their own perception of need. PIFU has proved successful when implemented in Rheumatology, Inflammatory Bowel Disease and Oncology, with trends towards reduced burden on outpatient appointments, improved patient satisfaction and lower costs. To-date, the use of PIFU in women's health has been limited to gynaecological oncology, where observations include high patient satisfaction and fewer appointments than traditional follow-up. This study aims to undertake a systematic review of the literature relating to PIFU in Obstetrics and Gynaecology in order to identify evidence-based indications for PIFU in the specialty, as well as form a foundation for a subsequent service evaluation. The project was registered with Prospero, University of York. Using the OVID platform, a literature search was conducted using the terms "patient initiated follow up", "gynaecology", "women's health", and "follow up care". Papers were then screened in accordance with the PRISMA protocol, and relevant articles identified based on our inclusion criteria. The quality of the studies was assessed using the Newcastle-Ottawa Scale, and data from the studies were extracted and compared. Eight papers were identified as relevant, two were randomised controlled trials, three were retrospective cohort studies, and the remaining three were prospective cohort studies. The majority of these studies (5/8) were of good quality, scoring 6 or more points on the Newcastle-Ottawa Scale. Four of the eight studies examined cost-effectives; all reported cost-savings relating to PIFU. Seven of the eight studies also reported an association between PIFU and greater patient satisfaction, fewer overall appointments and reduced non-attendance. One study reported no effect on patient satisfaction. Five studies related to gynaecological oncology, two were obstetric and one urogynaecology. The studies which investigated PIFU use in selected gynaecological oncology patients reported that PIFU did not have a negative impact on detection of cancer recurrence, but evidence regarding the psychological impact of PIFU on cancer survivors was conflicting. PIFU was received largely positively and was well accepted by women across these studies. It was also shown to be cost-effective, without a negative impact on health outcomes. PIFU also has the potential to offer additional benefits including reducing diagnostic delay and increasing patient engagement with their own health status. This review found a paucity of data for PIFU in Obstetrics and Gynaecology, with the exception of gynaecological oncology, and further evaluation is required before more widespread implementation. [ABSTRACT FROM AUTHOR]

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.

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. [ABSTRACT FROM AUTHOR]

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Abstract Background The by-pass of 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 min on average. This was subsequently transcribed 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.

Abstract 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.

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Physicians are often dissatisfied with their own medical care. Self-prescribing is common despite established guidelines that discourage this practice. From a pilot study, we know primary care physicians' (PCP) preferences, but we lack information regarding other specialties and work places.Objectives: The goal of this study was to examine whether physicians are satisfied with their personal primary care and how this could be improved.Methods: We distributed an electronic survey to all physicians registered with the Israeli Medical Association. The questionnaire examined satisfaction with medical care, preferences for using formal care versus informal care, self-prescribing and barriers to using formal care.Results: Two thousand three hundred and five out of 24 360 invited physicians responded. Fifty-six per cent of the respondents were satisfied with their personal primary care. Fifty-two per cent reported initiating self-treatment with a medication during the last year. Five and four per cent initiated treatment with a benzodiazepine and an antidepressant, respectively, during the last year. This was despite the fact that most physicians did not feel competent to treat themselves. Having a personal PCP was correlated with both a desire to use formal care and self-referral to formal care in practice. Regression analysis showed that the highest odds ratio (OR) for experiencing a large gap between desired and actual care were for physicians who had no personal PCP (OR = 1.92).Conclusions: Physicians frequently engage in self-treatment and in informal medical care. Whether the root cause is the health care system structure that does not meet their needs or the convenience of self-treatment is not known. [ABSTRACT FROM AUTHOR]

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.

Abstract 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

Elderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process.

Background: Improving Access to Psychological Therapies (IAPT) constitutes a key element of England's national mental health strategy. Accessing IAPT usually requires patients to self-refer on the advice of their GP. Little is known about how GPs perceive and communicate IAPT services with patients from low-income communities, nor how the notion of self-referral is understood and responded to by such patients. Aims: This paper examines how IAPT referrals are made by GPs and how these referrals are perceived and acted on by patients from low-income backgrounds Method: Findings are drawn from in-depth interviews with low-income patients experiencing mental distress (n = 80); interviews with GPs (n = 10); secondary analysis of video-recorded GP-patient consultations for mental health (n = 26). Results: GPs generally supported self-referral, perceiving it an important initial step towards patient recovery. Most patients however, perceived self-referral as an obstacle to accessing IAPT, and felt their mental health needs were being undermined. The way that IAPT was discussed and the pathway for referral appears to affect uptake of these services. Conclusions: A number of factors deter low-income patients from self-referring for IAPT. Understanding these issues is necessary in enabling the development of more effective referral and support mechanisms within primary care. [ABSTRACT FROM AUTHOR]

Background: Induced abortion is a common procedure. However, there is marked variation in accessibility of services across England. Accessing abortion services may be difficult, particularly for women who live in remote areas, are in the second trimester of pregnancy, have complex pre-existing conditions or have difficult social circumstances.Objective and Rationale: This article presents a two-part review undertaken for a new National Institute of Health and Care Excellence guideline on abortion care, and aiming to determine: the factors that help or hinder accessibility and sustainability of abortion services in England (qualitative review), and strategies that improve these factors, and/or other factors identified by stakeholders (quantitative review). Economic modelling was undertaken to estimate cost savings associated with reducing waiting times.Search Methods: Ovid Embase Classic and Embase, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), PsycINFO, Cochrane Library via Wiley Online, Cinahl Plus and Web of Science Core Collection were searched for articles published up to November 2018. Studies were included if they were published in English after 2001, conducted in Organization for Economic Co-operation and Development (OECD) countries and were: qualitative studies reporting views of patients and/or staff on factors that help or hinder the accessibility and sustainability of a safe abortion service, or randomized or non-randomized studies that compared strategies to improve factors identified by the qualitative review and/or stakeholders. Studies were excluded if they were conducted in OECD countries where abortion is prohibited altogether or only performed to save the woman's life. One author assessed risk of bias of included studies using the following checklists: Critical Appraisal Skills Programme checklist for qualitative studies, Cochrane Collaboration quality checklist for randomized controlled trials, Newcastle-Ottawa scale for cohort studies, and Effective Practice and Organization of Care risk of bias tool for before-and-after studies.Qualitative evidence was combined using thematic analysis and overall quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual). Quantitative evidence was analysed in Review Manager 5.3 and overall quality of evidence was assessed using GRADE.Outcomes: Eight themes (service level barriers; financial barriers; logistical barriers; personal barriers; legal and policy barriers; privacy and confidentiality concerns; training and education; community prescribing and telemedicine introduce greater flexibility) and 18 subthemes were identified from 23 papers (n = 1016) included in the qualitative review. The quality of evidence ranged from very low to high, with evidence for one theme and seven subthemes rated as high quality. Nine studies (n = 7061) were included in the quantitative review which showed that satisfaction was better (low to high quality evidence) and women were seen sooner (very low quality evidence) when care was led by nurses or midwives compared with physician-led services, women were seen sooner when they could self-refer (very low quality evidence), and clinicians were more likely to provide abortions if training used an opt-out model (very low quality evidence). Economic modelling showed that even small reductions in waiting times could result in large cost savings for services.Wider Implications: Self-referral, funding for travel and accommodation, reducing waiting times, remote assessment, community services, maximizing the role of nurses and midwives and including practical experience of performing abortion in core curriculums, unless the trainee opts out, should improve access to and sustainability of abortion services. [ABSTRACT FROM AUTHOR]

Background: Although previous research has demonstrated high rates of inappropriate diagnostic imaging, the potential influence of several physician-level characteristics is not well established.Objective: To examine the influence of three types of physician characteristics on inappropriate imaging: experience, specialty training, and self-referral.Design: A retrospective analysis of over 70,000 MRI claims submitted for commercially insured individuals. Physician characteristics were identified through a combination of administrative records and primary data collection. Multi-level modeling was used to assess relationships between physician characteristics and inappropriate MRIs.Setting: Massachusetts PARTICIPANTS: Commercially insured individuals who received an MRI between 2010 and 2013 for one of three conditions: low back pain, knee pain, and shoulder pain.Measurements: Guidelines from the American College of Radiology were used to classify MRI referrals as appropriate/inappropriate. Experience was measured from the date of medical school graduation. Specialty training comprised three principal groups: general internal medicine, family medicine, and orthopedics. Two forms of self-referral were examined: (a) the same physician who ordered the procedure also performed it, and (b) the physicians who ordered and performed the procedure were members of the same group practice and the procedure was performed outside the hospital setting.Results: Approximately 23% of claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists. Self-referral was not associated with higher rates of inappropriate MRIs.Limitations: Classification of MRIs was conducted with claims data. Not all self-referred MRIs could be detected.Conclusions: Inappropriate imaging continues to be a driver of wasteful health care spending. Both physician experience and specialty training were highly associated with inappropriate imaging. [ABSTRACT FROM AUTHOR]

Abstract 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.

BackgroundSevere health anxiety is a chronic and costly disorder if untreated. Patient self-referral may lower barriers to treatment and decrease diagnostic delay.AimsThis 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.MethodTwo 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.ResultsIn 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 (P

Patient self-referral is a condition when patients refer themselves to higher level health facilities without having to see anyone else first. Despite the expansion in the number of health facilities, it has been seen when patients routinely accessed referral hospitals without a formal referral. The study aims to evaluate cost of treatment among self-referred outpatients at referral hospitals compared to primary health care facilities. Comparative cross-sectional study design was used and the required sample size for the study was determined by using formula of double populations mean comparison cost of treatment for diseases leading to outpatient visits. A total of 794 participants (397 from referral hospital and 397 from primary health facilities) were included in the study. Data was collected using face-to-face interview from December 1 to 30, 2017. Data entry and analysis were made using SPSS version 20. Descriptive statistics and independent samples t-test were performed. A total of 783 outpatients responded to the interview of the study and 391 of them were from referral hospital and 392 from primary health facilities. The mean of outpatient visit cost per visit for the treatment of diseases leading to outpatient visits was significantly higher at referral hospitals compared to primary health facilities [95% CI=6.13 (5.07-7.18)] USD. The mean cost of outpatient visits for the treatment of all type of diseases leading to outpatient visits was significantly higher at referral hospitals and at least two times of primary level health facilities. Health care providers should create awareness in the community about referral linkages to inform patients and their families the additional costs they incur when they bypass the proximal primary health facilities.

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 chisquare (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 selfreferrals 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.

Purpose: Previous studies demonstrated rapid growth in payments to nonradiologist providers (NRPs) for MRI and CT in their private offices. In this study, we re-examine the trends in these payments.Methods: The nationwide Medicare Part B master files from 2004 to 2016 were accessed. They provide payment data for all Current Procedural Terminology codes. Codes for MRI and CT were selected. Global and technical component claims were counted. Medicare specialty codes identified payments made to NRPs and radiologists, and place-of-service codes identified payments directed to their private offices.Results: Medicare MRI payments to NRPs peaked in 2006 at $247.7 million. As a result of the Deficit Reduction Act, there was a sharp drop to $189.5 million in 2007, eventually declining to $101.6 million by 2016 (-59% from peak in 2006). The NRP specialty groups with the highest payments for MRI ownership include orthopedists, neurologists, primary care physicians, and hospital-based specialists (pathology, physiatry, and hospitalists). Medicare CT payments to NRPs peaked in 2008 at $284.1 million and declined to $94.7 million in 2016 (-67% from peak). Cardiologists, primary care physicians, internal medicine specialists, urologists, and medical oncologists accounted for the most payments made to NRPs. Dollars paid to radiologists for private office MRI and CT dropped substantially since they peaked in 2006.Conclusions: NRP private offices (and radiology offices also) experienced massive decreases in Medicare payments for MRI and CT since peaking in 2006 and 2008, respectively. These trends suggest the financial viability of private office practice may be in jeopardy. However, certain recent policy changes could promote a resurgence. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to analyze the utilization of elective stress nuclear myocardial perfusion imaging (MPI) in the Medicare population.Methods: Nationwide Medicare Part B fee-for-service databases for 2004 to 2016 were reviewed. Current Procedural Terminology codes for stress MPI were selected: standard planar and single-photon emission computed tomography (STD) and PET. Utilization rates per 1,000 Medicare beneficiaries were calculated. Elective examinations were identified using place-of-service codes for private offices and hospital outpatient departments (HOPDs). Medicare physician specialty codes identified the performing physician. Because Medicare Part B databases are complete population counts, sample statistics were not required.Results: Elective STD MPI utilization peaked in 2006 at 74 studies/1,000 and had declined by 36% by 2016. Cardiologists' share of STD MPI grew from 79% to 87% between 2004 and 2016. Cardiologists perform STD MPI primarily in private offices, where utilization peaked in 2008 and then demonstrated an absolute decline of 28 studies/1,000 by 2016. During this same time period, cardiologists' use of STD MPI in HOPDs demonstrated an absolute increase of 8.1 studies/1,000. From 2004 to 2016, STD MPI use by radiologists declined by 58%. Elective PET MPI maintained an upward trend, reflecting increasing use by cardiologists in private offices.Conclusions: Elective STD MPI use is declining, but cardiologists are performing an increasing share in outpatient settings. The drop in private office STD MPI among cardiologists was far greater than the corresponding increase in its use in HOPDs, suggesting that many studies previously performed in private offices were unindicated. Self-referred PET MPI utilization has rapidly grown in cardiology private offices. [ABSTRACT FROM AUTHOR]

Background: Evidence of the oncological benefit of scheduled follow‐up in head and neck squamous cell carcinoma is weak; symptom‐oriented self‐referral may be an alternative. Patients' preferences regarding follow‐up remain poorly investigated. Methods: We conducted a cross‐sectional survey among patients undergoing follow‐up at a tertiary outpatient clinic, focusing on their preferences, correlating factors, fear of recurrence, and willingness for participation in a randomized trial on follow‐up. Results: Of 101 patients, 89.1% preferred scheduled follow‐up to self‐referral, 57% favored fewer visits than the current standard, and 85.1% endorsed regular imaging. Recurrence or second primary was associated with preference of intensive follow‐up schedules (P = 0.02). There were trends for women and patients with high fear of recurrence score to favor intensive follow‐up. Two‐third of the participants declared willingness to participate in a randomized controlled trial. Conclusions: Patients' preferences only partially correspond to current follow‐up guidelines. Recruitment for randomized controlled studies evaluating the value of follow‐up seems feasible. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: 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.Methods: 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.Results: 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.Conclusions: Results support the feasibility of a school-based, self-referral intervention with older adolescents in a definitive future full-scale trial (Trial no. ISRCTN88636606). [ABSTRACT FROM AUTHOR]

Background: There is increasing interest in self-referral and direct access as alternatives pathways to care to improve patient access to specialist services. The impact of these pathways on health inequalities is unknown., Objectives: The purpose of this systematic review is to explore the impact of self-referral and direct access pathways on inequalities in health care use., Design: Three databases (Ovid Medline, Embase, Web of Science) and grey literature were systematically searched for articles from January 2000 to February 2023, reporting on self-referral and direct access pathways to care. Title and abstracts were screened against eligibility criteria to identify studies that evaluated the impact on health inequalities. Data were extracted from eligible studies after full text review and a quality assessment was performed using the ROBINS-I tool., Results: The search strategy identified 2948 articles. Nineteen records were included, covering seven countries and six healthcare services. The impact of self-referral and direct access on inequalities was mixed, suggesting that the relationship is dependent on patient and system factors. Typically self-referral pathways and direct access pathways tend to widen health inequalities. White, younger, educated women from less deprived backgrounds are more likely to self-refer, exacerbating existing health inequalities., Conclusions: Self-referral pathways risk widening health inequalities. Further research is required to understand the context-dependent mechanisms by which this can occur, explore ways to mitigate this and even narrow health inequalities, as well as understand the impact on the wider healthcare system., Competing Interests: Declarations of Competing Interest None., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

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.

Patient self-referral is a condition when patients refer themselves to higher level health facilities without having to see anyone else first. Despite the expansion in the number of health facilities, it has been seen when patients routinely accessed referral hospitals without a formal referral. The study aims to evaluate cost of treatment among self-referred outpatients at referral hospitals compared to primary health care facilities. Comparative cross-sectional study design was used and the required sample size for the study was determined by using formula of double populations mean comparison cost of treatment for diseases leading to outpatient visits. A total of 794 participants (397 from referral hospital and 397 from primary health facilities) were included in the study. Data was collected using face-to-face interview from December 1 to 30, 2017. Data entry and analysis were made using SPSS version 20. Descriptive statistics and independent samples t-test were performed. A total of 783 outpatients responded to the interview of the study and 391 of them were from referral hospital and 392 from primary health facilities. The mean of outpatient visit cost per visit for the treatment of diseases leading to outpatient visits was significantly higher at referral hospitals compared to primary health facilities [95% CI=6.13 (5.07-7.18)] USD. The mean cost of outpatient visits for the treatment of all type of diseases leading to outpatient visits was significantly higher at referral hospitals and at least two times of primary level health facilities. Health care providers should create awareness in the community about referral linkages to inform patients and their families the additional costs they incur when they bypass the proximal primary health facilities. [ABSTRACT FROM AUTHOR]