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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 360-366

Current situation of the referral system in family practice in Shebein El-Koum District, Menoufia Governorate, Egypt


Department of Family Medicine, Faculty of Medicine, Menoufia University, Menufia, Egypt

Date of Submission17-Mar-2013
Date of Acceptance22-Dec-2013
Date of Web Publication31-Aug-2015

Correspondence Address:
Marwa Aldemerdash
Banha Family Health Center, Ebrahim Mossa Street, Banha City, Qalubiya Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.163885

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  Abstract 

Objectives
The main aim of this study was to improve the referral system. The specific aims were to determine the referral rate, to study its current status as well as to identify the obstacles at family health facilities in Shebein El-Koum District, Menoufia Governorate, Egypt.
Background
The referral system is a process that ensures accessibility to higher levels of medical care for patients attending the primary healthcare facility. Referral is usually sought to obtain expert professional advice, undergo a diagnostic technique, seek a therapeutic intervention, or receive inpatient care when these are not available at the referring site. The referral system aims to provide efficient, effective, affordable, and equitable community-based healthcare services. For a successful referral, there must be first and foremost geographical access to referral care facilities, referral staff must be trained to provide high-quality care, services must be affordable, and essential drugs, supplies, and equipment must be available.
Participants and methods
A cross-sectional study was carried out from 1st of March 2011 to the end of April 2013 in all rural and urban family health units/centers (No. 23 and 4, respectively) of Shebein El-Koum District, which was selected randomly to represent Menoufia Governorate, Egypt. All the managers (No. 25), family physicians (No. 125), and nurses (No. 186) at the site of the study were subjected to a predesigned questionnaire for complete assessment of the current status of the referral system.
Results
The referral rate was significantly higher in urban versus rural areas (16.2 and 11.2%, respectively). The usage of referral letter is the main means of referral; the highest referral rate was among adults and the lowest was among adolescents. There was no significant difference in the referral rate in terms of sex in either urban or rural facilities. Training of the physicians is considered an important factor for quality assurance of the referral system.
Conclusion
We found that the highest referral rate was found among adults; however, the lowest referral rate was found among adolescents. The rate was high for ENT and Ophthalmology Clinics. Lack of training and availability of means of transportation and absence of feedback were the most common obstacles for the referral process.

Keywords: family health center, family practice, referral system


How to cite this article:
Farahat T, Al-Kot M, Aldemerdash M. Current situation of the referral system in family practice in Shebein El-Koum District, Menoufia Governorate, Egypt. Menoufia Med J 2015;28:360-6

How to cite this URL:
Farahat T, Al-Kot M, Aldemerdash M. Current situation of the referral system in family practice in Shebein El-Koum District, Menoufia Governorate, Egypt. Menoufia Med J [serial online] 2015 [cited 2020 Feb 27];28:360-6. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/360/163885


  Introduction Top


The referral system is one of the cornerstones of basic healthcare systems. It is a complete and sustainable system with two directions to connect the primary healthcare units/centers and hospitals. It is one of the basic healthcare systems [1] . It leads to continuous improvement of comprehensive health care for all patients by assigning priorities to those who need it [2] .

A good referral system should maintain an efficient record system; as it depends on the use of referral letters, it must be simple, uniform all over the country, and include an original and a copy [3] , which is kept in the office of the referred specialty [4] . In terms of the reasons for referral, the most frequent ones are for a second opinion for diagnosis and management, lack of required facilities or skills, and need for admission [5] .

For successful referral, there must be first and foremost geographical access to referral care facilities. Provided that referral services are accessible, referral staff must be trained to provide high-quality care, and services must be affordable. Essential drugs, supplies, and equipment must be available for good referral practice [6] . The most complex aspect of referral care is often the caretaker's acceptance of and compliance with referral recommendations [7] .

Referral hospital is an institution to which patients with a complex medical condition can be sent for diagnosis, treatment, and care and that can also act as a resource center for the healthcare provider of the peripheral health institutions [8] .


  Aim of the work Top


The main aim of this study was to improve the quality of the referral system and the specific aims were to study the current status of the referral system, study its rate and types, and to determine the obstacles and difficulties in Shebein El-Koum District, Menoufia Governorate, Egypt.


  Participants and methods Top


Type and site of the study

This study was a cross-section comparative analytic study carried out from the 1st of March 2011 to the end of April 2013. The study was carried out in all rural family health units (No. 23) and urban family health centers (No. 4) of Shebein El-Koum District, Menoufia Governorate, Egypt.

Population of the study

All healthcare providers in the primary healthcare units and centers in Shebein El-Koum District [primary healthcare managers (No. 25), family physicians (No. 125), and nurses (No. 186)] were included in the study after they provided consent.

Materials of the study

All family health folders, referral letters, and feedback reports of referred patients attending the selected primary healthcare sites during the period of the study (420 folders in rural family health units and 322 folders in urban family health centers) were subjected to comprehensive auditing to fill personal and clinical data, the reason for and type of referral, matching with clinical guidelines, etc.

Procedure of the study

All the managers, family physicians, and nurses in the sites of the study were subjected to an interview to make them aware of the aims of the study; policy and procedures were explained and written consents were obtained. All managers, physicians, and nurses were invited to fill out pre-designed specific questionnaires to study the current status of the referral system.

All records (family health records, referral letters, and feedbacks as well as the prescription sheets) for all patients attending the selected site of the study during 3 months were subjected to a complete comprehensive audit in terms of the following: presence of personal and clinical data, provisional or final diagnosis, referral practice (referral letter, reason for and type of referral, site of referral, registration, transportation, feedback, given treatment, adherence to national clinical guidelines, and prescription sheets).

The referral rate was calculated as the number of referred cases against the total number of cases visited the health center during the period of study. Also, the feedback rate was calculated as the number of cases who received a feedback from a hospital against the total number of cases referred to this hospital during the period of the study.


  Results Top


The main results in this study were that the referral rate was higher (16.2%) in urban versus rural family health facilities (11.2%), the usage of a referral letter was the main means of referral, 10.2 versus 8.7% in urban and rural areas, respectively, and the highest referral rate was among adults (20.4%) and the lowest was among adolescents (7.7%). There was no significant difference in the referral rate in terms of sex in urban or rural sites. Training of the physicians is considered an important factor for the quality of the referral system. Referral rate was significantly much higher among physicians with a postgraduate degree (25.9 vs. 11.9% in graduated vs. nongraduated physicians). The referral rate was much higher in winter (15.2%) and autumn (14.7%) than other seasons because of the increase in the incidence of chest infections during these seasons. Lack of training and specialist adherence, unavailability of means of transportation, and absence of feedback were the most common obstacles for the referral process. The study showed that 88% of FHCs/units had a defined referral site, only 5% had means of transportation, and 78% used the referral letter. However, only 28% had a referral register and 21% maintained communication with the secondary healthcare providers. Seventy-two percent of the physicians provided the recommended first-aid services, 81% documented the data in the family folders, and 77% were interested in clarifying the reason for referral; 58% of the studied files showed that the management provided was in compliance with the national clinical guideline. The type of refer (urgent vs. elective) was clarified in only 51% of the files studied and only 13% provided feedback. Only 5% of the secondary care physicians initiated any communication with the physicians at the primary care sites. Most of the feedbacks (72%) were provided to the patients. Only 56% of the files had complete personal data and only 51% clarified the treatment provided. We found that ophthalmology and ENT were the most common fields of referral [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] [Figure 6] and [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9].
Figure 1: Qualification of the referral registers in the FHCs and units studied

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Figure 2: Referral performance at the primary care level

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Figure 3: Clinical performance and dealing with the referred patients at the secondary care

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Figure 4: Methods of delivering feedback to the primary healthcare level

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Figure 5: Characteristics of the referral form studied

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Figure 6: Patient respect in the referral system at the primary healthcare sites studied

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Table 1 Referral rate in urban versus rural family health centers/units

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Table 2 Utilization of a referral letter in the referral process in urban versus rural family health centers/units

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Table 3 Referral rate in terms of human life cycle — stages in the family health centers/units studied

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Table 4 Rate of referral versus diagnosis in urban and rural centers

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Table 5 Referral rate versus sex in urban and rural family health centers/units

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Table 6 Rate of referral versus training of physicians on the referral system in urban and rural family health centers

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Table 7 Rate of referral versus degree of postgraduate study of the physicians

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Table 8 Rate of referral versus seasonal variations in the urban and rural family health centers

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Table 9 Obstacles to referral from the physician's point of view

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  Discussion Top


In the present study, the referral rate was higher in urban than rural family health facilities (16.2 vs. 11.2%, respectively). Many authors reported results that were in agreement with these interstudy variations [9] . Also, although the referral rate was 40% in Great Britain, it is as high as 65% in other primary care sites. These intercountry differences can be attributed to environmental factors, geographical location, and socioeconomic variations, yielding new clues about the referral system [7] . The study showed that utilization of the referral letter was significantly higher in urban than rural family health facilities (8.7 vs. 10.2%, respectively); these results were more or less in agreement with the results of Kieman et al. [10] . They were also in agreement with a study by the WHO (2008) that showed that the referral letter is the main cornerstone for the referral process and it is the only means of communication between general practitioners and specialists. This is inconsistent with the findings of Zefkomani et al. (2007), who found that, during 1 month of a study in an emergency center, only 150 of 400 attending patients (37.5%) were referred with referral letters. These variations in results were because of differences in knowledge, attitudes, and practices as well as working in a site having good referral system. In the present study, adults had the highest referral rate and the lowest rate was among adolescents. The correlation between age and the referral rate has been reported in some previous works [11] . This study was not in agreement with Kieman et al. [10] , who found no significant relationships between referral rate and age. These variations in results in different studies are mainly because of the timing of referral system implementation as well as adherence and knowledge of its importance. There was no significant difference in the referral rate in sex in urban or rural family health facilities; this finding is in agreement with Jani et al. [7] , who found that there was no impact of sex on the referral rate. However, it was in disagreement with Abd-Elwahid et al. [12] , who reported that women made up the highest percentage of referred patients, and this difference was attributed to good referral systems that aid family planning, reproductive health clinics, and other clinics that offer clients the right care at the right place. Linking services with delivery sites offers clients access to appropriate care at every level of the health care system from community facilities for basic care to district, regional, or higher-level facilities for specialized one. The referral rate is more or less the same irrespective of training or education of the physician as it affects the quality rather than the rate of referral. In this study, the referral rate was much higher in winter and autumn than other seasons, with a peak in winter (15.2 vs. 14.7%); these variations were attributed to differences in weather, with more respiratory diseases in winter and endemic diseases during the summer vacation, which mainly require lab investigations. These findings are in agreement with those of Zielinski et al. [13] , who found seasonal variations, with a peak in winter. These results are also not in agreement with those of Jani et al. [7] , who reported that the referral rate was higher in autumn, and also not in agreement with the findings of Piterman and Koritsas [14] , who did not report any seasonal variations. Lack of training and availability of means of transportation and absence of feedback were the most common obstacles for the referral process; however, it was observed that hospital consultants rarely recorded any advice provided to the patient or his/her relatives about the patient's illness. This is not in agreement with the findings of Van et al. (2004), who reported that 86% of the hospital consultants and 91% of the family physicians recorded instructions and/or recommendations to the patient or to the family in their referral letters. The reason for such a low rate of feedback reports, compared with higher rates in some studies, could be because of the lack of awareness of the importance of communications with PHC physicians in maintaining the continuity of care and establishment of patient satisfaction. Nonetheless, there was marked variability in the feedback rate among different hospital departments, in agreement with the findings of several studies of Anderze et al. (2008), who reported that the feedback from hospital has low quality and also some obstacles where these results agree with the Ministry of Health [4] . However, this study is not in agreement with that of Komani et al. [15] , who reported that the team has a program for training on the referral system and there are several means of transportation to facilitate the referral process. In this study, 82% of referral registers were nurses; however, the remaining were physicians. This was in agreement with the findings of Gilson and McIntyre [16] , who found that most of the referral registers (80%) were nurses. Also, the study showed that 72% provided the recommended first-aid healthcare services, 81% documented the data in the family folders, 77% were interested in clarifying the reason for referral, and the management provided was in accordance with the guidelines in 58% of the studied files. Only 51% of primary care physicians clarified the type of referral (urgent vs. elective). These findings are in agreement with those of Jani and colleagues [7],[17] , who found that 70% provided the recommended first aid services. However, the study is not in agreement with Abd Elwahid et al. [12] , who showed that 55% provided the recommended first-aid services, 40% documented the data in the family folders, and 67% were interested in clarifying the reason for referral; the management provided was in accordance with the guidelines in 80% of the files studied. However, 51% clarified the type of referral (urgent vs. elective) and these variations were attributed to the differences in knowledge and criteria of implementation of the referral system. The study showed that only 13% of referred patients returned back with feedback reports, and only 5% of the secondary care physicians initiated any kind of communication with the physicians at the primary care sites. These results are in considerable agreement with the results of Kieman et al. [10] , who found that only 12% returned with feedback. Also, these results are not in agreement with the findings of Zefkomani et al. (2007), who found that only 30% received feedback reports. These variations in results were because of differences in the knowledge, attitude, practice, training programs, and implementation of a good referral system. In terms of the methods of delivering the feedback to the primary healthcare level, most of the feedbacks were provided to the patients (72%). This result is in agreement with a study by most of the feedbacks were provided to the patients. This is not in agreement with the findings of Zielinski et al. [13] , who reported that mail was the most common means for providing feedback. It was found that only 56% had complete personal data and 51% clarified the treatment provided, in agreement with the results of Cervantes et al. [11] . However, this study was in agreement with Kieman et al. [10] , who found no relationship between completion and clarification. The study showed that only 51% of patients were informed about the risk of refusing the referee and only 27% of physicians respected the patient's compliance with the referral process. These findings are in agreement with those of Zielinske et al. [13] , who found that these variations are reported by 52.5% of the studied cases. This is also not in agreement with the findings of Piterman et al. [14] , who reported that there is no relation between variation and referral rate. We found that ophthalmology and ENT were the most common fields of referral, ENT 11.9% and ophthalmology 17.8%, because of more diseases encountered by the GP that also required a second opinion, and also because of their limited knowledge of this specially. This was in agreement with the findings of Zofkoman et al. (2010), who reported that that the most common reason for referral is management to best control the diseases.

However, this result is comparable with that of other studies that reported the highest referral rates, for example, Kim et al. (2003), who reported that dermatology was the most common specialty for referral by the GP, 30%, and this difference is because of different exposure to skin affections in different situations. Another factor could be limited knowledge of the GP.


  Conclusion Top


The referral rate was found to be 27.4% in Menoufia Governorate Shebein El-Koum District. It is more to the outpatients versus inpatient's health services. The highest referral rate was found among adults and the lowest was found among adolescents. Sex has no impact on the referral rate. The rate was more in winter and autumn than in other seasons. Lack of feedback was the main obstacle of the referral system.[19]

Recommendations

When establishing a well-functioning and effective healthcare referral system, some key factors should be considered: identification of types of services to be provided through each level of institution, which will enable identification of the level of care available at each institution, development of referral protocols and referral cards, streamlining of the referral procedures, creating awareness among the health staff and the communities about the referral mechanism, establishment of proper communication mechanisms between PHCs and other higher level referral centers, and identification of suitable means of transport to transfer the patients who need referral.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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Abstract
Introduction
Aim of the work
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Results
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