Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary–secondary care interface

Abstract

ObjectivesVariation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services.MethodsA scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour.ResultsThe 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness.ConclusionsThere are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’ skills through education or joint consultations with complex patients.

Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial

“…Integrated care is at the forefront of healthcare reform internationally, in part driven by growing numbers of people living with chronic disease, and the understanding that better integrated care with close cooperation between specialists and primary care providers is fundamental to future-ready healthcare systems [1,2]. This transformation in healthcare delivery appears vitally important for diabetes care.…”

Does an in-house internist at a GP practice result in reduced referrals to hospital-based specialist care?

“…To avoid this threat they are in favor of independent PC+ centers, where medical specialists work in a neutral environment [ 16 ]. Another review of interventions at the primary–secondary care interface found little evidence of a beneficial effect of specialist services in primary care on referral rates to secondary care [ 26 ]. A study about the effects of joint consultations described substantial educational benefits for GPs where a specialist visited the general practice [ 27 ].…”

Reorganising dermatology care: predictors of the substitution of secondary care with primary care

“…Since the literature shows that these systems lead to lower use of health services [9], more appropriate and more effective healthcare use [10] and lower expenditures [11], it is beneficial to further strengthen the position of primary care. Therefore, there have been many attempts to improve the effectiveness and efficiency of primary care and the referral process to outpatient hospital care to strengthen healthcare sustainability [12,13].…”

“…The aim of PC+ is to achieve substitution by stimulating integrated care through the facilitating of consultations with medical specialists in the primary care setting. Internationally, comparable models of care are implemented, as for example specialist outreach services and shifted outpatient clinics [12,13,19,20].…”