Implementation of referral guidelines at the interface between pediatric primary and subspecialty care

Cornell, Erin; Chandhok, Laura; Rubin, Karen

doi:10.1016/j.hjdsi.2015.02.003

Cited by 17 publications

(20 citation statements)

References 12 publications

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“…Pediatricians’ referral rates to subspecialists have varied widely [12, 13], suggesting a lack of uniformity in the referral criteria. Locale-specific referral guidelines might improve the appropriateness of referrals [14, 15]. Because <60% of referred patients in the present study were judged by pediatric endocrinologists to require treatment of hypothyroidism, we sought to develop evidence-based guidelines that could help primary care practitioners decide when to refer patients for further treatment.…”

Section: Discussionmentioning

confidence: 99%

Referrals for Elevated Thyroid Stimulating Hormone to Pediatric Endocrinologists

Gammons

Presley

White

2019

Journal of the Endocrine Society

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Objective We aimed to determine the reproducibility of TSH testing in pediatric patients referred to pediatric endocrinologists and to identify the threshold TSH levels that would predict the presence of antithyroid autoantibodies and inform decisions by pediatric endocrinologists to initiate or continue treatment with levothyroxine. Study Design We analyzed a retrospective case series of 325 children aged 1 to 18 years referred for hypothyroidism to the endocrinology clinic at a tertiary care children’s hospital. The receiver operating characteristic area under curve (AUC) determined the ability of the initial TSH level to predict pediatric endocrinologists’ treatment decisions, presence of thyroid autoantibodies, and reproducibility of elevated TSH on repeat testing. Results Of 325 patients, 191 were treated. The treated patients were more likely to have had a higher referral TSH, positive autoantibodies, and abnormal thyroid gland examination findings. An initial TSH of 5 had a specificity of only 14% for a repeat TSH of ≥5. An initial TSH level of 11 had a specificity of 90% for a repeat TSH of ≥11, with sensitivity of 90%. TSH was a relatively poor predictor (AUC, 0.711) of the presence of autoantibodies with optimal classification at TSH >8.8 mIU/L. It was better (AUC, 0.878) at predicting whether endocrinologists started or continued treatment with levothyroxine, with optimal classification at 8.2 mIU/L. TSH levels combined with antibody status and thyroid examination findings had the best ability to predict treatment (AUC, 0.930). Conclusions TSH levels slightly above the reference range should not prompt referral to pediatric endocrinologists unless another basis for clinical concern is present.

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Section: Discussionmentioning

confidence: 99%

Referrals for Elevated Thyroid Stimulating Hormone to Pediatric Endocrinologists

Gammons

Presley

White

2019

Journal of the Endocrine Society

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“…10 The report, along with others, highlighted the sequential steps required to complete referrals and provided guidance on interventions to improve specific steps in the process. 2,10,11 Some emerging interventions aim to aid in primary care referral decisions, including referral guidelines 12 and electronic consultations. [13][14][15] Other interventions, such as electronic referrals, aim to bypass barriers in the scheduling process, thereby improving appointment scheduling rates.…”

mentioning

confidence: 99%

Unscheduled Referrals and Unattended Appointments After Pediatric Subspecialty Referral

Bohnhoff

Taormina²,

Ferrante³

et al. 2019

Pediatrics

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OBJECTIVES: Incomplete subspecialty referrals, whether unscheduled or unattended, represent unmet patient needs and an opportunity to improve patient safety and experiences. Our objectives were to describe the rates of appointment scheduling and visit attendance after pediatric subspecialty referral and to examine patient and systems factors associated with scheduled referrals and attended appointments. METHODS: We conducted a retrospective review of referrals within a network of 52 primary and urgent care sites from November 2016 to October 2017. We included referrals for children #17 years old referred to medical or surgical subspecialists. We examined patient and health systems factors associated with (1) appointment scheduling and (2) visit attendance. RESULTS: Of 20 466 referrals, 13 261 (65%) resulted in an appointment scheduled within 90 days and 10 514 (51%) resulted in a visit attended within 90 days. In adjusted analyses, referral to surgical subspecialists was associated with an increased likelihood of appointment scheduling but a decreased likelihood of visit attendance. Compared with appointments scheduled within 7 days, appointments with intervals from referral to scheduled appointment exceeding 7 days were associated with decreasing likelihood of visit attendance (adjusted odds ratio 8-14 days 0.48; 95% confidence interval 0.37-0.61). Patient factors associated with decreased likelihood of both appointment scheduling and visit attendance included African American race, public insurance, and lower zip code median income. CONCLUSIONS: Patient and system factors were associated with variation in appointment scheduling and visit attendance. Decreased interval to appointment was significantly associated with visit attendance. These factors represent targets for interventions to improve referral completion. WHAT'S KNOWN ON THIS SUBJECT: Incomplete subspecialty referrals represent an opportunity to improve patient safety and experiences. Data on factors associated with variation in appointment scheduling and visit attendance after pediatric subspecialty referral are limited. WHAT THIS STUDY ADDS: Two-thirds of pediatric subspecialty referrals resulted in scheduled appointments, and half resulted in attended visits. Both patient and system factors were associated with variation in appointment scheduling and visit attendance, and time to appointment was strongly associated with attendance.

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“…A similar initiative has been implemented at our institution for outpatient referrals in an effort to reduce unnecessary and costly specialist care. Such interventions have had published success in pediatric subspecialty care, but require considerable time and resources . With referrals and orders performed in an electronic health record, hospital systems can further collect information on practice patterns of providers to assess for adherence and reward for quality care.…”

Section: Discussionmentioning

confidence: 99%

Clinician adherence to the clinical practice guideline: Acute otitis externa

et al. 2019

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Objectives/Hypothesis: Over 10 years have passed since the Clinical Practice Guideline: Acute Otitis Externa (CPG-AOE) was first published, and it has been several years since its update. We sought to assess clinicians' adherence as well as referral patterns.Study Design: Survey. Methods: A 23-question survey was distributed to regional primary care clinicians evaluating demographic data, perception of the clinical practice guideline (CPG), adherence, and details of specialist referral. Statistical analysis was performed to compare adherence and referral patterns using the Fisher exact test or the χ 2 test.Results: One hundred seventeen clinicians completed the survey. Fifteen respondents (12.8%) had reviewed the CPG. The recommendations with the least reported adherence were pain management (39.1%) and accounting for prior radiotherapy as a modifying factor (43.0%). The recommendations of prescribing ototopical therapy and avoiding systemic antimicrobials in uncomplicated acute otitis externa had adherence of 94.0% and 83.8%, respectively. When analyzed by provider type (e.g., resident, nurse practitioner/physician assistant), there were no significant differences in adherence. No significant differences in adherence were observed based on previous review of the CPG. When reporting frequency of specialist referral, the majority of respondents selected rarely (53.9%). The most favored reason for referral was symptoms >4 weeks (86.3%).Conclusions: Of the providers who responded, very few had reviewed the CPG-AOE. Despite the added emphasis on pain management in the CPG update, this recommendation had the lowest adherence. Rates of adherence were similar across provider types and did not differ significantly if the CPG was reviewed. Efforts at improved provider education should be considered to increase adherence to the CPG.

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Implementation of referral guidelines at the interface between pediatric primary and subspecialty care

Cited by 17 publications

References 12 publications

Referrals for Elevated Thyroid Stimulating Hormone to Pediatric Endocrinologists

Referrals for Elevated Thyroid Stimulating Hormone to Pediatric Endocrinologists

Unscheduled Referrals and Unattended Appointments After Pediatric Subspecialty Referral

Clinician adherence to the clinical practice guideline: Acute otitis externa

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