PubMed · 15318672
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Marie-Thérèse Lussier, Claude Richard. 2004. Getting started.. https://pubmed.ncbi.nlm.nih.gov/15318672/
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BACKGROUND: The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES: To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY: We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Three studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices and requiring a second 'in-house' opinion prior to referral), all of which were effective. Five studies (six comparisons) evaluated financial interventions. Two studies evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS: There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
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BACKGROUND: In this article we describe differences in workload for male and female physicians according to the gender of their patients. MATERIAL AND METHODS: Data from the National Insurance Service for the autumn of 2001 (1637 general practitioners) and from a comprehensive questionnaire survey among general practitioners in the autumn of 2002 (2306). RESULTS: 62 % of the patients of female physicians are women, compared to 47 % of the patients of male physicians. Female physicians have a mean of 200 fewer patients on their lists than have their male colleagues. Female physicians also have a high proportion of women on their list irrespective of the length of their list. Of those with a long patient list (>1800 patients), almost 50 % of the female physicians wanted a shorter list, compared to only 26 % of their male colleagues. INTERPRETATION: The total workload in terms of length of patient list and gender distribution of patients on the list is not necessarily different for male and female physicians. Female physicians may have chosen to have a shorter patient list in order to compensate for the fact that their patients on average have more consultations and receive more services. On the other hand, male physicians may allow themselves to have a longer patient list because they have patients who on average require less treatment.