The online version of this article (doi:10.1186/1471-2296-15-75) contains supplementary material, which is available to authorized users.
The authors declare that they have no competing interests.
XB drafted the manuscript, coordinated the study, participated in the conception and design of the study, acquisition of data and statistical analysis, OE participated in the acquisition of data and statistical analysis. DN participated in the acquisition of data. EC participated in the acquisition of data and statistical analysis. SF participated in the acquisition of data. AC helped to draft the manuscript. ALS participated in the conception and design of the study and helped to draft the manuscript. All authors participated in the analysis and interpretation of data, revised the manuscript for intellectual content and read and approved the final manuscript.
In Spain, primary healthcare (PHC) referrals for diagnostic procedures are subject to long waiting-times, and physicians and patients often use the emergency department (ED) as a shortcut. We aimed to determine whether patients evaluated at a hospital outpatient quick diagnosis unit (QDU) who were referred to ED from 12 PHC centers could have been directly referred to QDU, thus avoiding ED visits. As a secondary objective, we determined the proportion of QDU patients who might have been evaluated in a less rapid, non-QDU setting.
We carried out a cross-sectional retrospective cohort study of patients with potentially serious conditions attended by the QDU from December 2007 to December 2012. We established 2 groups of patients: 1) patients referred from PHC to QDU (PHC-QDU group) and 2) patients referred from PHC to ED, then to QDU (PHC-ED-QDU group). Two observers assessed the appropriateness/inappropriateness of each referral using a scoring system. The interobserver agreement was assessed by calculating the kappa index. Multivariate logistic regression analysis was performed to identify the factors associated with the dependent variable ‘ED referral’.
We evaluated 1186 PHC-QDU and 1004 PHC-ED-QDU patients and estimated that 93.1% of PHC-ED-QDU patients might have been directly referred to QDU. In contrast, 96% of PHC-QDU patients were found to be appropriately referred to QDU first. The agreement for PHC-QDU referrals (PHC-QDU group) was rated as excellent (ϰ = 0.81), while it was rated as good for PHC-ED referrals (PHC-ED-QDU group) (ϰ = 0.75). The mean waiting-time for the first QDU visit was longer in PHC-QDU (4.8 days) than in PHC-ED-QDU (2.6 days) patients (P = .001). On multivariate analysis, anemia (OR 2.87, 95% CI 1.49–4.55, P < .001), rectorrhagia (OR 2.18, 95% CI 1.10–3.77, P = .01) and febrile syndrome (OR 2.53, 95% CI 1.33-4.12, P = .002) were independent factors associated with ED referral. Nearly one-fifth of all QDU patients were found who might have been evaluated in a less rapid, non-QDU setting.
Most PHC-ED-QDU patients might have been directly referred to QDU from PHC, avoiding the inconvenience of the ED visit. A stricter definition of QDU evaluation criteria may be needed to improve and hasten PHC referrals.
Additional file 1: Table S1: Main characteristics and differences of the two groups of patients according to the eight main reasons for consultation. Data expressed as mean (SD) and median [25th-75th percentiles] or number (percentage). PHC denotes primary care; QDU, quick diagnosis unit; ED, emergency department; Charlson com in., Charlson comorbidity index; GI, gastrointestinal; NS, nonsignificant; IBS, irritable bowel syndrome; CLD, chronic liver disease. (DOCX 23 KB)
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