Bolton Saghdaoui Layla, Lampridou Smaragda, Tavares Sara, Lear Rachael, Davies Alun Huw, Wells Mary, Onida Sarah
Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, Fulham Palace Rd, 4th Floor (North), Vascular Outpatients, Room 4N22C, London, W6 8RF, UK.
Hanwell Health Centre, School of Public Health, Imperial College London, London, W7 1DR, UK.
Syst Rev. 2025 May 9;14(1):103. doi: 10.1186/s13643-025-02841-z.
Prior systematic reviews highlight that accessing specialist healthcare to treat chronic conditions can be obstructed by variations in referral rates, inappropriate referrals, and poor communication. Structured referral proformas, peer feedback, and educational interventions involving specialists have been identified as successful strategies for improving referral rates and appropriateness. However, the success of such interventions is often dependent on specific clinical contexts, and little is known about the practicalities of implementation. Additionally, with advancements in healthcare delivery, such as e-referral systems, there is a need to explore new interventions and how they address barriers to referral.
This systematic review evaluated the updated evidence exploring interventions aiming to improve rates and/or appropriateness of referral from primary care to specialist services in patients with chronic conditions.Five academic databases were searched (CINAHL, MEDLINE, Embase, British Nursing Index, and Public Health Database), and studies published in English between 2013 and 2023 were included. The Joanna Briggs Institute's appraisal tool was used to assess the quality of studies, and a narrative synthesis was conducted using the TiDiER framework (template for intervention description and replication).
Eighteen full-text publications and five abstracts were included. A behavioral theory or framework for intervention development was used in seven studies. All interventions were based on primary care, and thirteen studies evaluated a multi-component intervention. Process and system changes were most commonly used to improve referral, including electronic health systems, referral algorithms, collaborative working, and patient direct access. Interventions targeted at patients were the least common. Staff education was often used in addition to process and system changes. When used alone, referral algorithms and staff education were less effective at improving referral rates or appropriateness. Implementation barriers included time constraints, logistical issues, and patients/staff preconceived perceptions of referral necessity.
Unsurprisingly, the success of interventions aimed at improving referral practices is based on contextual circumstances, and as with previous reviews, there is no one-size-fits-all approach.Given the challenges highlighted in this review, multi-component interventions addressing referral barriers in both primary and secondary care appear to be a successful way to improve referral practices.
PROSPERO CRD42023480493.
先前的系统评价强调，转诊率的差异、不适当的转诊以及沟通不畅可能会阻碍患者获得专科医疗服务来治疗慢性病。结构化转诊表格、同行反馈以及涉及专科医生的教育干预措施已被确定为提高转诊率和转诊合理性的成功策略。然而，此类干预措施的成功往往取决于特定的临床环境，对于其实施的实际情况知之甚少。此外，随着医疗服务的发展，如电子转诊系统，有必要探索新的干预措施以及它们如何解决转诊障碍。
本系统评价评估了探索旨在提高慢性病患者从初级保健转诊至专科服务的比率和/或合理性的干预措施的最新证据。检索了五个学术数据库（CINAHL、MEDLINE、Embase、英国护理索引和公共卫生数据库），纳入了2013年至2023年间以英文发表的研究。使用乔安娜·布里格斯研究所的评估工具来评估研究质量，并使用TiDiER框架（干预描述和复制模板）进行叙述性综合分析。
纳入了18篇全文出版物和5篇摘要。七项研究使用了行为理论或干预开发框架。所有干预措施均基于初级保健，13项研究评估了多成分干预措施。流程和系统变革最常用于改善转诊，包括电子健康系统、转诊算法、协作工作和患者直接就诊。针对患者的干预措施最为少见。除了流程和系统变革外，通常还会进行员工教育。单独使用时，转诊算法和员工教育在提高转诊率或转诊合理性方面效果较差。实施障碍包括时间限制、后勤问题以及患者/员工对转诊必要性的先入为主的观念。
不出所料，旨在改善转诊实践的干预措施的成功取决于具体情况，与之前的评价一样，没有一种适用于所有情况的方法。鉴于本评价中突出的挑战，解决初级和二级保健中转诊障碍的多成分干预措施似乎是改善转诊实践的成功途径。
PROSPERO CRD42023480493
