Surgical referral systems in low- and middle-income countries: A review of the evidence

Abstract

BackgroundReferral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions.MethodsMEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach.ResultsMultiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities.DiscussionThe field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.

Designing, Implementing, and Managing a National Emergency Medical Service in Sierra Leone

“…Comparing to the few other existing prehospital referral systems in Africa, NEMS' strengths lie in the presence of extensive SOPs, well-established communication flow, structured data collection system, and continuing education programs. 24,25 In this manuscript, the design and implementation phases of NEMS are described, a process that was not exempt from challenges, including lack of experience of local staff, paucity of information related to existing health care facilities, and poor condition of available vehicles. Moreover, problems had to be tackled related to the development of a brand new EMS from scratch, that needed to be properly integrated in the current National Health System and widely accepted by a population that experienced the stigma and fear associated with ambulances during the ravaging Ebola epidemic.…”

The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

“…The quality and efficiency in referral systems in Lower and Middle Income Countries (LMIC) are often undermined due to system-related inefficiencies such as poor infrastructure, relevant materials/equipment and insufficient skilled human resource [ 9 ]. Despite having established superior services, the inefficiencies in referral methods of health systems in high–income countries are more pronounced [ 10 ] and the problem of long waiting times for elective surgeries more explicit in developed health systems. Delays in patients receiving specialised care due to inefficiencies in referral methods are purely a systems issue and could be resolved with streamlining the care pathways [ 11 ].…”

“…A more recent systematic review of guidelines for elective referrals of adult patients to surgical specialists concluded that these improve the appropriateness of care [ 28 ]. However, a more up-to-date review is needed to help healthcare systems develop comprehensive protocols to establish effective and efficient referral systems in surgical care pathways [ 10 ]. To bridge the evidence gap in existing literature, this comprehensive systematic review will synthesise global evidence on policy strategies with a unique insight to effective primary care referral methods.…”

The Effectiveness of Different Patient Referral Methods on Waiting Times for Adults Needing Elective Surgery - Systematic Review

“…A more recent systematic review of guidelines for elective referrals of adult patients to surgical specialists concluded that these improve the appropriateness of care (25). However, a more up-to-date review is needed to help healthcare systems develop comprehensive protocols to establish effective and e cient referral systems in surgical care pathways (26). The objective of this paper, therefore, is to review and summarise recent research evidence relevant to primary care referral methods as part of the surgical care pathways that aimed to shorten waiting time for elective surgeries in adult patients.…”