Factors influencing referral of patients with voice disorders from primary care to otolaryngology

Abstract

Objective To evaluate the frequency, timing, and factors that influence referral of patients with laryngeal/voice disorders to otolaryngology following initial evaluation by a primary care physician (PCP). Study Design Retrospective analysis of a large, national administrative U.S. claims database. Methods Patients with a laryngeal disorder based on ICD-9-CM codes from January 1, 2004 to December 31, 2008, seen by a PCP as an outpatient (with or without otolaryngology involvement), and continuously enrolled for 12 months were included. Patient age, gender, geographic region, last PCP laryngeal diagnosis, comorbid conditions, time from first PCP visit to first otolaryngology visit, number of PCP outpatient visits, and number of PCP laryngeal diagnoses were collected. Cox and generalized linear regressions were performed. Results 149,653 unique patients saw a PCP as an outpatient for a laryngeal/voice disorder with 136,152 (90.9%) only seeing a PCP, 6013 (4.0%) referred by PCP to an otolaryngologist, and 3820 (2.6%) self-referred to an otolaryngologist. Acute laryngitis had a lower hazard ratio (HR) for otolaryngology referral than chronic laryngitis, non-specific dysphonia, and laryngeal cancer. Multiple comorbid conditions had a greater HR for otolaryngology referral than having no comorbidities. Patient age, gender, and geographic region also affected otolaryngology referral. The time to otolaryngology evaluation ranged from < 1 month to > 3 months. PCP referred patients had less time to the otolaryngology evaluation than self-referred patients. Conclusions Multiple factors affected otolaryngology referral for patients with laryngeal/voice disorders. Further education of PCPs regarding appropriate otolaryngology referral for laryngeal/voice disorders is needed.

What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis

“…233 There were also 29 studies which consisted of an analysis of patient records, documents, case notes, admissions data and referral forms. 138,166,167,173,197,219,223,235,241,243,254,256,263,[265][266][267] Most of these studies (n = 23) were retrospective designs, but four employed a prospective cohort design. 173,223,254,266 In addition, one study employed Delphi methods 196 and one final study used a group-based assessment of referral appropriateness.…”

“…210,[263][264][265][266][267][268]270 A further two lower-risk studies showed no association between these factors. 138,269 Overall, the strength of evidence was graded as weaker.…”

“…Twenty-five studies showed an association between age and referral rate, of which 14 studies reported higher rates of referral for older patients 164,166,181,188,212,263,264,267,268,275,281,[283][284][285] and six studies reporting higher rates of referral for younger patients. 234,278,[286][287][288]295 Chan et al 275 also reported that children were referred more often than adults and Vinker et al 269 reported more urgent referral for younger patients.…”

Derivaciones en los centros de salud de Andalucía según el sexo de profesionales y pacientes: un análisis de género

“…En el análisis multinivel para la TDxV, además del incremento de las derivaciones asociado a la edad del paciente, coherente con hallazgos previos 2,11,26,30 , observamos que las mujeres tienen menor probabilidad de ser derivadas que los hombres, concretamente del 88% y del 87% para médicos y médicas respectivamente. Numerosos estud i o s c o n c u e r d a n c o n e s t e r e s u l t ado 10,14,19,22,30 y, como ocurre en nuestro estudio, solo en las investigaciones que analizan las derivaciones por paciente -TDxC-se observan mayores tasas en las mujeres 2,11,13,26 .…”

“…Numerosos estud i o s c o n c u e r d a n c o n e s t e r e s u l t ado 10,14,19,22,30 y, como ocurre en nuestro estudio, solo en las investigaciones que analizan las derivaciones por paciente -TDxC-se observan mayores tasas en las mujeres 2,11,13,26 . También en Finlandia se observó que aunque se derivaban más mujeres la TDxV fue superior en los hombres, apoyando la idea de que el juicio médico es que los hombres consultan menos pero por motivos más serios 22 .Un estudio con derivaciones a otorrinolaringología mostró que ajustando por diagnóstico y comorbilidad las mujeres fueron menos derivadas a pesar de que consultaron más, concluyendo los autores que los/las MF pueden sesgar su práctica por considerar más graves los problemas que presentan los hombres 30 . En el seguimiento de casi 130.000 pacientes para evaluar desigualdades sociales analizó las derivaciones por dolor de cadera, dispepsia y sangrado posmenopáusico 14 , los resultados mostraron desigualdades por edad, estatus económico y género, ya que las mujeres fueron menos derivadas por dolor de cadera, lo que podría deberse, por un lado, a su mayor reticencia a operarse (por vivir con más frecuencia solas y/o ser responsables del cuidado familiar) y, por otro, a la existencia de sesgos en el sis-…”