Gelinne Aaron, Thakrar Raj, Tranmer Bruce I, Durham Susan R, Jewell Ryan P, Penar Paul L, Lollis S Scott
Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA.
Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA.
World Neurosurg. 2019 Jun;126:e564-e569. doi: 10.1016/j.wneu.2019.02.095. Epub 2019 Mar 1.
Rising cost and limited resources remain major challenges to U.S. health care and neurosurgery in particular. To ensure an efficient and cost-effective health care system, it is important that referrals to neurosurgery clinics are appropriate, and that referred patients have a reasonably high probability of requiring surgical intervention or, at a minimum, ongoing neurosurgical follow-up. This retrospective study tests the null hypothesis that the probability of a referred patient requiring surgery is independent of referring provider credentials and referring service specialty.
A database of all patients referred to the neurosurgery clinic from 2015 through 2018 (n = 5677) was reviewed; the database included referring provider, referring provider specialty, number of subsequent clinic visits, and outcome of surgery or no surgery. Associations between categorical variables were tested using a χ analysis with post hoc relative risk (RR) calculations and binary logistical regression.
Compared with patients referred by allopathic physicians, patients referred by osteopathic physicians (RR, 0.63; 95% confidence interval [CI], 0.48-0.84) and those referred by nurse practitioners (RR, 0.66; 95% CI, 0.51-0.86) were significantly less likely to require surgery. Probability of surgical intervention also varied by referrer specialty. Patients referred by neurologists required surgery 35% of the time, whereas patients referred by family practitioners required surgery 19% of the time, and patients referred by pediatricians required surgery only 7% of the time (P < 0.01). Binary logistic regression revealed that referrals from nurse practitioners and osteopathic physicians were independently associated with a decreased probability of surgical intervention.
Our data strengthen the concept of having interdisciplinary teams led by physicians at the primary care level to ensure appropriate referrals. Training and adherence to guidelines must continually be reinforced to ensure proper referrals.
成本上升和资源有限仍然是美国医疗保健尤其是神经外科面临的主要挑战。为确保建立一个高效且具有成本效益的医疗保健系统，神经外科诊所的转诊恰当且被转诊患者有合理的高概率需要手术干预或至少持续接受神经外科随访，这一点很重要。这项回顾性研究检验了零假设，即被转诊患者需要手术的概率与转诊医生资质和转诊服务专科无关。
回顾了2015年至2018年转诊至神经外科诊所的所有患者的数据库（n = 5677）；该数据库包括转诊医生、转诊医生专科、后续门诊就诊次数以及手术或未手术的结果。分类变量之间的关联通过χ分析以及事后相对风险（RR）计算和二元逻辑回归进行检验。
与接受全科医生转诊的患者相比，接受整骨疗法医生转诊的患者（RR，0.63；95%置信区间[CI]，0.48 - 0.84）和接受执业护士转诊的患者（RR，0.66；95%CI，0.51 - 0.86）需要手术的可能性显著更低。手术干预的概率也因转诊医生专科而异。由神经科医生转诊的患者35%的时间需要手术，而由家庭医生转诊的患者19%的时间需要手术，由儿科医生转诊的患者仅7%的时间需要手术（P < 0.01）。二元逻辑回归显示，执业护士和整骨疗法医生的转诊与手术干预概率降低独立相关。
我们的数据强化了在初级保健层面由医生领导跨学科团队以确保恰当转诊的理念。必须持续加强培训并遵守指南以确保恰当转诊。
