Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.
Nijmegen International Centre for Health Systems Research and Education, Radboud University, Nijmegen, The Netherlands.
Trop Med Int Health. 2020 Jul;25(7):824-833. doi: 10.1111/tmi.13406. Epub 2020 May 14.
Reliable referral systems are essential to the functionality and efficiency of the wider health care system in low- and middle-income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under-researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned.
We conducted a prospective analysis of all inter-hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014-2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process.
1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely.
Our findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present.
可靠的转诊系统对于中低收入国家（LMICs）更广泛的医疗体系的功能和效率至关重要，特别是在手术领域，因为疾病负担不断增加，而资源仍然有限且分布不均。然而，这是一个研究严重不足的领域。本研究旨在全面评估马拉维这一中低收入国家的外科转诊系统，以期揭示公共卫生的这一重要方面，并分享经验教训。
我们对 2014 年至 2015 年期间伊丽莎白女王中央医院（QECH）接收的所有医院间转诊进行了前瞻性分析。对 255 例转诊进行了三位独立外科专家的评估，以确定转诊过程中是否存在效率低下的情况。
在研究期间，有 1317 名患者被转诊到 QECH（平均每月 53 例），其中 80%由政府地区医院转诊。三分之一的转诊是不必要的，其中许多可以在当地得到管理。82%的转诊病例在转诊前与 QECH 没有沟通，41%的转诊医生的诊断不正确/不完整，39%的转诊不及时。
我们的研究结果提供了马拉维外科转诊系统现状的第一个证据，并为构建必要的知识体系以促进系统改进做出了贡献。应对措施应包括减少对专科治疗的不适当使用，并确保为外科患者提供更好的治疗途径，特别是在目前无法获得专科专业知识的农村地区。
