General practitioners’ referrals to specialist health services. Exploring elements and factors in the referral process having an impact om patients’ access to specialty care

Background: The referral process between first and second line health care is complex and multidimensional, with medical, interpersonal, logistical, legal, as well as indeterminate aspects. There is a great need to explore the various elements and factors having an impact on the referral process. Main objectives: The objective of this thesis has been to study general practitioners´ and hospital consultants´ role in the referral process, from the moment the GP decides to refer a patient to hospital, until the hospital consultant assesses the referral and prioritizes the patient for further investigation or treatment in specialist health care. The specific aims for the three sub-studies were to identify and describe 1) general practitioners’ reflections on and attitudes to the referral process and their cooperation with hospital consultants, 2) hospital consultants’ reflections on and attitudes to the referral process and their cooperation with general practitioners, and 3) potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. Design and methods: The first two parts were qualitative studies. General practitioners and hospital consultants were interviewed and a systematic text condensation method was used for analysis. The third part was a quantitative cross-sectional study of GPs’ impressions and feelings about referring and a registration of a selection of data on the work done by referring to hospital during one month, analysed by using a principal component analysis and abduction. Results: The GPs expressed a dual responsibility towards patients and the national health system. Many experienced pressure from patients to be referred; the younger doctors especially specified this as a frequent reason for a referral. All the participants expressed a willingness to change according to guidelines, as long as such guidelines were the result of a consensus between hospital specialists and general practitioners. The hospital consultants experienced a considerable workload assessing referrals and prioritizing patients for further investigation and treatment. They emphasized the importance of precise referrals as essential for a reasonable and fair prioritization process. All focused on the importance of good communication and cooperation with the referring GPs. Good referrals were considered to make the prioritization process easier. As for the typologies, younger male GPs experienced more heavy work-load and patient pressure when they referred to hospital. The experienced female GPs referred in a more patient-centred way, completing the referrals during the consultation with the patient present. Conclusions and implications: Many factors have an impact on the referral process and the individual referral rates. Good communication and cooperation by phone or electronically between hospital consultants and GPs are important factors to make the referral process more balanced, and the participants more like partners. More use of electronic decision support systems for the referring physicians can make this process more standardized and predictable for both partners. Educating and training GPs in professional competence and personal confidence as well as a more patient-centred way of referring, making priority decisions and completing the referrals during the consultation may be timesaving for the actors and can be associated with less work-load

Buoyancy of Atlantic cod larvae in relation to developmental stage and maternal influences

17 pages, 5 figures, 7 tables.In this experimental study on Atlantic cod, Gadus morhua, buoyancy was found to vary significantly with season, developmental stage, egg size and maternal condition. Before the start of the experiments, wild fish were caught in the Barents Sea and acclimatized to laboratory conditions. Pairs (n = 8), one female (recruit spawner) and one male, spawned naturally in large, indoor compartments of a circular tank and every third egg batch (out of up to 19 batches collected per female) was incubated in aquaria. Following sedation (50 mg l-1metomidate hydrochloride, 30 min), individual larval specific gravity was precisely reported (30 min) using a density-graduated column. Larval specific gravity (meant) increased steadily during the first early stages of development (0–25 day-degrees), remained nearly constant during the following stages (25–35 day-degrees), but then decreased gradually (35–55 day-degrees). In general, late-season larvae were significantly less buoyant, i.e. showed higher meant, than early-season larvae. Meantwas negatively correlated with female condition and egg size and dry weight. Possible implications of these findings for drift and survival are discussed.This study was supported by the Training and Mobility of Researchers Programme, EU Contract No ERBFMBICT960772 (F.S.-R.). The writing-up of this paper was also supported by EU Contract No FAIRCT- 98-4122, STEREO (O.S.K. and A.T.).Peer reviewe

Typologies in GPs’ referral practice

Background: GPs’ individual decisions to refer and the various ways of working when they refer are important determinants of secondary care use. The objective of this study was to explore and describe potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. Methods: Observational cross-sectional study using data from 128 Norwegian GPs who filled in a questionnaire with statements on how they regarded the referral process, and who were invited to collect data when they actually referred to hospital during one month. Only elective referrals were recorded. The 57 participants (44,5 %) recorded data from 691 referrals. The variables were included in a principal component analysis. A multiple linear regression analysis was conducted to identify typologies with GP’s age, gender, specialty in family medicine and location as independent variables. Results: Eight principal components describe the different ways GPs think and work when they refer. Two typologies summarize these components: confidence characterizing specialists in family medicine, mainly female, who reported a more patient-centred practice making priority decisions when they refer, who confer easily with hospital consultants and who complete the referrals during the consultation; uncertainty characterizing young, mainly male non-specialists in family medicine, experiencing patients’ pressure to be referred, heavy workload, having reluctance to cooperate with the patient and reporting sparse contact with hospital colleagues. Conclusions: Training specialists in family medicine in patient-centred method, easy conference with hospital consultant and cooperation with patients while making the referral may foster both self-reflections on own competences and increased levels of confidence.publishedVersio

Half a century of high-latitude fisheries oceanography research on the "recruitment problem" in Northeast Arctic cod (Gadus morhua)

Predicting recruitment in a reliable fashion is a great challenge within operational fisheries advice. Here, we consulted the unique but undercommunicated IMR Cod Larva Project (1975–1990), its spin-offs, placed in an international era of advancements over the last 50 years to glance into the future. Few initiatives of this kind have applied such extensive research approaches, spanning from laboratory, mesocosm, tank, and field studies to process modelling. The “critical period” concept appeared misleading, covering months rather than days of the early life history stages (ELHS) of Northeast Arctic cod. Larval feeding success was strongly modified by improved encounter rates from wind-induced turbulence. In addition, the following maternal effect studies evidenced that the dynamics of stock demography prior to spawning should be upheld to promote recruitment success. Although we now have lower-trophic level models as well as ELHS individual-based models, such models are still insufficiently reflecting the needed spatiotemporal resolution. The same problem applies to climate/circulation models. Nevertheless, this long-lasting research has significantly improved the mechanistic understanding of ELHS dynamics but also of the more predictable adult reproductive parameters. Based on a “to-list list,” we suggest research avenues that should be pursued to further improve our ability predicting recruitment strength in marine fish stocks.publishedVersio

Advances in methods for determining fecundity: application of the new methods to some marine fishes

Estimation of individual egg production (realized fecundity) is a key step either to understand the stock and recruit relationship or to carry out fisheries-independent assessment of spawning stock biomass using egg production methods. Many fish are highly fecund and their ovaries may weigh over a kilogram; therefore the work time can be consuming and require large quantities of toxic fixative. Recently it has been shown for Atlantic cod (Gadus morhua) that image analysis can automate fecundity determination using a power equation that links follicles per gram ovary to the mean vitellogenic follicular diameter (the autodiametric method). In this article we demonstrate the precision of the autodiametric method applied to a range of species with different spawning strategies during maturation and spawning. A new method using a solid displacement pipette to remove quantitative fecundity samples (25, 50, 100, and 200 milligram [mg]) is evaluated, as are the underlying assumptions to effectively fix and subsample the ovary. Finally, we demonstrate the interpretation of dispersed formaldehyde-fixed ovarian samples (whole mounts) to assess the presence of atretic and postovulatory follicles to replace labor intensive histology. These results can be used to estimate down regulation (production of atretic follicles) of fecundity during maturation

Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study

Background: In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients. Methods: Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.Results: The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter. Conclusion: Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes

The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage

Background Patients referred to specialised mental health care are usually triaged based on referral information provided by general practitioners. However, knowledge about this system’s ability to ensure timely access to and equity in specialised mental health care is limited. We aimed to investigate to the degree to which patient triage, based on referral letter information, corresponds to triage based on a hospital specialist’s consultation with the patient, and whether the degree of correspondence is affected by the quality of the referral letter. Methods We gathered information from three specialised mental health centres in Norway regarding patients that were referred and offered health care (N = 264). Data consisted of triage decisions for each patient (i.e., the hospital specialist’s assessment of maximum acceptable waiting time), which were determined on the basis of a) referral information and b) meeting the patient. Referral letter quality was evaluated using the Quality of Referral information-Mental Health checklist. The reliability of priority setting and the impact of referral letter quality on this measure were investigated using descriptive analyses, binary logistic regression and Nadaraya-Watson kernel regression. Results In 143 (54%) cases, the triage decision based on referral information corresponded with the decision based on patient consultation. In 70 (27%) cases, the urgency of need for treatment was underestimated when based on referral information compared with that based on information from patient consultation. Referral letter quality could not explain the differences between the two triage decisions. However, when a cut-off value of 7 on the Quality of Referral information-Mental Health scale was used, low-quality letters were found more frequently among patients whose urgency of need was underestimated, compared with those whose need was overestimated. Conclusions Deciding the urgency of patient need for specialised mental health care based on referral information is a reliable system in many situations. However, the possibility of under- and overestimation is present, implying risks to patient safety and inappropriate use of resources. Improving the content of referral letters does not appear to reduce this risk when the letters are of acceptable quality.publishedVersio

Care pathways and factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe traumatic brain injury: a population-based study from the Norwegian trauma registry

Background Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals. Methods A population-based cohort study from the national Norwegian Trauma Registry (2015–2020) of adult patients (≥16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head≥3, AIS Body<3 and maximum 1 AIS Body=2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability. Results The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P<0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P<0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤13: 55% vs. 27, P<0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients<77 years, and increasing NISSs until the effect was inverted at higher scores. Decreased transfer probability was significantly associated with increasing age and comorbidity, and distance between the acute care trauma hospital and the nearest neurotrauma center, except for extreme NISSs. Conclusions Acute care trauma hospitals managed a substantial burden of isolated moderate-to-severe TBI patients primarily and definitively, highlighting the importance of high-quality neurotrauma care in non-neurosurgical hospitals. The transfer probability declined with increasing age and comorbidity, suggesting that older patients were carefully selected for transfer to specialized care

Systematic bias in estimates of reproductive potential of cod stocks: implications for stock/recruit theory and management

Stock/recruit relationships, describing the relationship between the parental population and the number of offspring produced, are a central tool in population ecology. For fish populations the stock/recruit relationship uses spawning stock biomass (SSB) to represent reproductive potential of the parental population. This assumes that the proportion of SSB comprised of females and the relative fecundity (number of eggs produced per unit mass) are both constant over time. To test these two constancy assumptions female-only spawner biomass (FSB) and total egg production (TEP) were estimated for the Northeast Arctic cod stock over a 56-year time period (1946-2001). During that time period the proportion of females (FSB/SSB) varied between 24 and 68% and the variation was systematic with length such that SSB became more female-biased as the mean length of spawners increased and more male-biased as mean length decreased. Over the same time period, relative fecundity of the stock (TEP/SSB) varied between 115 and 355 eggs g-1 and, like FSB/SSB, was significantly, positively correlated mean length of spawners. Because both FSB/SSB and TEP/SSB covaried with length composition, SSB is systematically biased estimate of reproductive potential. FSB and TEP were evaluated as possible replacements for SSB in stock/recruit relationship. Both indices gave a different interpretation of the recruitment response to reductions in stock size (over-compensatory) compared to that obtained using SSB (either compensatory or depensatory). The threshold level of stock size below which recruitment becomes impaired was estimated for each of the different stock/recruit relationships using piecewise linear regression. There was no difference between SSB and FSB in the assessment of stock status, however, in recent years (1980-2001) TEP fell below the threshold level more frequently than SSB fell below. This suggests that using SSB as a measure of stock reproductive potential may lead to overly optimistic assessments of stock status

First thorough assessment of de novo oocyte recruitment in a teleost serial spawner, the Northeast Atlantic mackerel (Scomber scombrus) case

The understanding of teleost fecundity type (determinate or indeterminate) is essential when deciding which egg production method should be applied to ultimately estimate spawning stock biomass. The fecundity type is, however, unknown or controversial for several commercial stocks, including the Northeast Atlantic mackerel (Scomber scombrus). Aiming at solving this problem, we applied state-of-the-art laboratory methods to document the mackerel fecundity type, including any de novo oocyte recruitment during spawning. Initially, active mackerel spawning females were precisely classified according to their spawning status. The number and size of all phasei-specific oocytes (12 phases), with a special attention to previtellogenic oocytes phases (PVO [PVO2 to PVO4a–c]), were also thoroughly investigated. Examinations of relative fecundity (RFi) clarified that the latest phase of PVOs (PVO4c) are de novo recruited to the cortical alveoli–vitellogenic pool during the spawning period, resulting in a dome-shaped seasonal pattern in RFi. Hence, we unequivocally classify mackerel as a true indeterminate spawner. As PVO4c oocytes were currently identified around 230 µm, mackerel fecundity counts should rather use this diameter as the lower threshold instead of historically 185 µm. Any use of a too low threshold value in this context will inevitably lead to an overestimation of RFi and thereby underestimated spawning stock biomass.publishedVersio