In the paper a referral system to assist the medical experts in the screening/referral of diabetic retinopathy is suggested. The system has been developed by a sequential use of different existing mathematical techniq...In the paper a referral system to assist the medical experts in the screening/referral of diabetic retinopathy is suggested. The system has been developed by a sequential use of different existing mathematical techniques. These techniques involve speeded up robust features（SURF）, K-means clustering and visual dictionaries（VD）. Three databases are mixed to test the working of the system when the sources are dissimilar. When experiments were performed an area under the curve（AUC） of 0.9343 was attained. The results acquired from the system are promising.展开更多
AIM: To assess the current knowledge and practices in diabetic eye care and referral system regarding diabetic retinopathy(DR) in health centers of Islamabad and RawalPindi. METHODS: A cross-sectional study was carrie...AIM: To assess the current knowledge and practices in diabetic eye care and referral system regarding diabetic retinopathy(DR) in health centers of Islamabad and RawalPindi. METHODS: A cross-sectional study was carried out in 4 government and private health centers in RawalpindiIslamabad from May 2018 to Oct. 2018. A total of 38 Primary Care Physicians(general practitioners, family physicians, and internists) were recruited out of which data for 2 were either not returned, or were missing partially. Data were collected through a 27-item consented & validated, multiple-choice questionnaire based on physician characteristics, knowledge and practice of diabetic eye care and challenges faced due current DR referral system. Descriptive analyses for all variables were performed including, mean and standard deviation. Analytical analyses were also conducted to study association between different study variables. RESULTS: Mean scores of knowledge for general practitioners, family physicians, and internists were 41.7%, 42.0% and 46.6% respectively. A lack of knowledge, and suboptimal practices were observed regarding signs, symptoms, screening, testing, evaluation and referral of DR regardless of physicians’ specialty, or years in practice. Lack of expertise regarding direct ophthalmoscopy, interpretation of findings, and referral to an ophthalmologist were noted. Physicians who performed consultation and counselling according to patients’ needs referred more patients to an ophthalmologist than those who restricted their consultationto a fixed amount of time and had more patients per unit time(P=0.01). Physicians who had taken care of less than 5 number of patients with DR marked less incorrect answers with no significantly greater number or correct answers compared to physicians who had taken care of more than 5 number of patients with DR(P=0.044). An association of more than 5 patients with DR taken care of with more need based patient consultation and counselling was also noted(P=0.017). An evaluation of the current referral system for DR revealed major loopholes in the health care infrastructure, proper guidelines, properly functioning equipment, check and balances, and lack of guidance to physicians regarding acquiring and updating knowledge regarding DR. CONCLUSION: Lack of updated and adequate knowledge, practices among primary care physicians, and suboptimal diabetic eye care and referral system have contributed to late presentation of DR. Interventions are needed to improve current diabetic eye care, and knowledge and practices of primary care physicians.展开更多
With the increasing prevalence of mental disorders,regional mental health service systems face challenges including uneven resource distribution,inefficient referral pathways,and fragmented information.To address thes...With the increasing prevalence of mental disorders,regional mental health service systems face challenges including uneven resource distribution,inefficient referral pathways,and fragmented information.To address these issues,a platform-based bidirectional referral model centered on a municipal psychiatric specialty hospital was developed and implemented,linking community hospitals and county-level psychiatric departments.A unified regional mental health information platform was used to integrate patient data.Community hospitals conducted preliminary screening,county-level psychiatric departments performed referral assessment,and the municipal psychiatric specialty hospital made centralized evaluation and admission decisions.The implementation results demonstrated standardized screening processes,clearer referral pathways,reduced unnecessary hospitalizations,improved accuracy of patient admission,and enhanced mental health service capacity at the primary care level.This model contributes to optimizing mental health resource allocation and improving the efficiency of tiered mental health services.展开更多
Referral systems are widely used to coordinate heterogeneous healthcare providers(e.g.,general hospitals(GHs)and community healthcare centers(CHCs))for improved efficiency.This paper investigates referral coordination...Referral systems are widely used to coordinate heterogeneous healthcare providers(e.g.,general hospitals(GHs)and community healthcare centers(CHCs))for improved efficiency.This paper investigates referral coordination within a typical two-tiered system centered around a general hospital(GH)and a community healthcare center(CHC).Specifically,we compare the coordination value of two prevalent mechanisms:one-way referral and two-way referral.We develop a queueing-theoretic model to derive optimal capacity and pricing decisions for the GH and the CHC under each mechanism and then evaluate their relative effectiveness,with key metrics including total system profit,healthcare service prices,and patient waiting times.Our base model yields two key findings.First,counterintuitively,under certain conditions,the one-way referral mechanism can outperform both the two-way mechanism and a non-coordinated baseline.Second,within the one-way framework,full cooperation between the GH and CHCs can lead to a Pareto improvement,benefiting all stakeholders(i.e.,the GH,the CHCs,and the patients).This finding is based on an analysis extended to a system of one GH and multiple CHCs,where we show how a profit allocation scheme can be designed to foster such cooperation.Further analysis of a congested system with referral-dependent arrival rates reveals that the two-way mechanism becomes unequivocally superior.Finally,numerical studies confirm that optimal profits across all scenarios increase with the arrival rates of both severe patients in the GH and common patients in the CHCs.展开更多
BACKGROUND Systemic lupus erythematosus(SLE)can affect multiple organs or systems.The involvement of the central nervous system can result in the manifestation of epilepsy,an acute confusional state,and other rare neu...BACKGROUND Systemic lupus erythematosus(SLE)can affect multiple organs or systems.The involvement of the central nervous system can result in the manifestation of epilepsy,an acute confusional state,and other rare neuropsychiatric presentations,such as catatonia.CASE SUMMARY We present a case of an adolescent male patient with first-onset SLE who presented with neuropsychiatric symptoms including epilepsy and delirium.The initial utilization of olanzapine to alleviate symptoms of agitation precipitated the emergence of catatonia,which was mitigated by discontinuing olanzapine and supplementing with lorazepam.In this case,whether the catatonia was secondary to the utilization of antipsychotics or to an organic disease is a question that warrants differential diagnosis.CONCLUSION Multidisciplinary collaborative management is the cornerstone for the successful management of severe cases of SLE.展开更多
BACKGROUND Dysphagia requires prompt evaluation but data regarding referral-to-assessment intervals and its association with outcomes in tertiary care are scarce,especially in Saudi Arabia.AIM To investigate the asses...BACKGROUND Dysphagia requires prompt evaluation but data regarding referral-to-assessment intervals and its association with outcomes in tertiary care are scarce,especially in Saudi Arabia.AIM To investigate the assessment and outcome of consecutive dysphagia referrals to a tertiary gastroenterology practice.METHODS This retrospective single-center study analyzed 207 consecutive dysphagia referrals to King Saud Medical City(2022-2023).Data collection included referral timelines,diagnostic investigations,etiologies and outcomes.Statistical Package for the Social Sciences version 28.0,employing χ^(2) tests and analysis of variance,with P<0.05 considered statistically significant.RESULTS Total 168 patients included in this study(mean age 45.7±17.7 years,50% male),referral delays>2 weeks occurred in 44%for clinical assessment and 50%for endoscopy.Gastroesophageal reflux disease was most common(45.2%),followed by eosinophilic esophagitis(14.8%)and malignancy(6.5%).Patients receiving endoscopy within 2 weeks showed an 84.6%improvement,compared to 76.0%with delayed referral(P=0.012).All malignant cases were referred within 2 weeks,compared to 52.7% of non-malignant cases(P=0.013).However,67%of the malignant cases worsened,and 33%died.CONCLUSION Early endoscopy within 2 weeks provides significant benefit.Optimised management of dysphagia should consist of more direct referral pathways.展开更多
Objective To examine general practitioners’(GPs)referral patterns to allied health services for people with dementia compared with those without dementia across two large Australian Primary Health Networks(PHNs).Desi...Objective To examine general practitioners’(GPs)referral patterns to allied health services for people with dementia compared with those without dementia across two large Australian Primary Health Networks(PHNs).Design A retrospective cohort study using routinely collected general practice data.Logistic regression was used to compare odds of allied health referrals,adjusting for age,sex and socioeconomic status.Setting De-identified patient and episode activity data from 537 GP practices across two PHNs in Australia between 2018 and 2023.Participants Data from 1153304 patients and 28667517 GP episodes of care were analysed.After merging records,693328 unique patients were identified,including 16610 patients with dementia.Subcohorts included patients with dementia,stroke,Parkinson’s disease and combinations of these conditions.Results The dementia cohort(n=16610)had a similar overall allied health referral rate(36.1%)to the control cohort(n=48977)(35.4%).Patients with dementia only were significantly less likely to receive any allied health referral compared with those with stroke(adjusted OR(aOR)0.76,95%CI 0.72 to 0.80;p<0.001)or Parkinson’s disease(aOR 0.72,95%CI 0.66 to 0.78;p<0.001).Those with dementia and stroke were also less likely to receive referrals than those with stroke only(aOR 0.71,95%CI 0.61 to 0.82;p<0.001).No significant difference was found between dementia with Parkinson’s and Parkinson’s only groups(p=0.48).Patients with dementia were consistently less likely to be referred to key allied health services(p<0.05).Conclusion Despite strong evidence supporting allied health interventions for dementia,referral rates remain comparatively low.Enhancing GP referral resources and education,integrating dementia-specific care pathways and implementing supportive policy changes are needed to improve access and equity in dementia care.展开更多
BACKGROUND Not all neuropsychiatric(NP)manifestations in patients with systemic lupus erythematosus(SLE)are secondary to lupus.The clarification of the cause of NP symptoms influences therapeutic strategies for SLE.AI...BACKGROUND Not all neuropsychiatric(NP)manifestations in patients with systemic lupus erythematosus(SLE)are secondary to lupus.The clarification of the cause of NP symptoms influences therapeutic strategies for SLE.AIM To understand the attribution of psychiatric manifestations in a cohort of Chinese patients with SLE.METHODS This retrospective single-center study analyzed 160 inpatient medical records.Clinical diagnosis,which is considered the gold standard,was used to divide the subjects into a psychiatric SLE(PSLE)group(G1)and a secondary psychiatric symptoms group(G2).Clinical features were compared between these two groups.The sensitivity and specificity of the Italian attribution model were explored.RESULTS A total of 171 psychiatric syndromes were recorded in 138 patients,including 87 cases of acute confusional state,40 cases of cognitive dysfunction,18 cases of psychosis,and 13 cases each of depressive disorder and mania or hypomania.A total of 141(82.5%)syndromes were attributed to SLE.In contrast to G2 patients,G1 patients had higher SLE Disease Activity Index-2000 scores(21 vs 12,P=0.001),a lower prevalence of anti-beta-2-glycoprotein 1 antibodies(8.6%vs 25.9%,P=0.036),and a higher prevalence of anti-ribosomal ribonucleoprotein particle(rRNP)antibodies(39.0%vs 22.2%,P=0.045).The Italian attribution model exhibited a sensitivity of 95.0%and a specificity of 70.0%when the threshold value was set at 7.CONCLUSION Patients with PSLE exhibited increased disease activity.There is a correlation between PSLE and anti-rRNP antibodies.The Italian model effectively assesses multiple psychiatric manifestations in Chinese SLE patients who present with NP symptoms.展开更多
Alcohol use has contributed to large disease burdens,and alcohol-related problems are prevalent among patients in general hospitals and primary care settings.This review aims to deepen the understanding of screening,i...Alcohol use has contributed to large disease burdens,and alcohol-related problems are prevalent among patients in general hospitals and primary care settings.This review aims to deepen the understanding of screening,intervention,and treatment referral for alcohol-related problems in these settings.We searched the literature published in English from PubMed,ScienceDirect,and the World Health Organization website.We found that while a series of screening tools can be used,screening rates were low.The awareness of screening should be strengthened.Brief interventions and pharmacotherapy are the two main methods used in general hospitals and primary care settings,with complementary and alternative medicine considered under the framework of integrative medicine.Individuals with severe alcohol-related problems or alcohol use disorders should be referred to specialty treatment for alcohol abuse,but referral is sometimes ignored.A gap exists between general hospitals/primary care facilities and specialized alcohol-related treatment providers.In conclusion,screening,intervention,and referral to treatment comprise a continuum for patients with alcohol-related problems.Opportunities to prevent and manage these problems in general hospitals and primary care settings are abundant,and taking action will promote the addressing of this public health issue.展开更多
The study evaluated the impact of digital health tools, task sharing, capacity building, and maternal health financing on Maternal, Newborn, and Child Health (MNCH) systems in Kisii, Kajiado, and Migori counties in Ke...The study evaluated the impact of digital health tools, task sharing, capacity building, and maternal health financing on Maternal, Newborn, and Child Health (MNCH) systems in Kisii, Kajiado, and Migori counties in Kenya, under the Tekeleza project1. It aimed to assess how these interventions influenced MNCH service uptake, outcomes, and referral systems, using a mixed-methods approach with data from healthcare providers, community health promoters, and mothers. Findings showed that digital tools like the LUCY App improved coordination and maternal care but highlighted the need for better app features and wider access. Task sharing in areas like sonography enhanced service delivery but required stronger stakeholder engagement. Capacity-building through training was crucial for skill development, though additional training on emerging health issues was needed. Financial interventions, such as the Linda Mama program, boosted service uptake, but reimbursement processes needed improvement. Strengthening referral systems between lower- and higher-level facilities was identified as essential for timely access to care. The study concludes that integrating digital tools, expanding task sharing, enhancing training, and reinforcing health financing and referral systems are critical for strengthening MNCH services in rural Kenya, with broader implications for similar low-resource settings.展开更多
AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of pa...AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.展开更多
Our study was to investigate the epidemiological characteristics of M.tuberculosis from a national tuberculosis referral center in China. All strains isolated from TB patients, were genotyped by the RD105 deletion, 8 ...Our study was to investigate the epidemiological characteristics of M.tuberculosis from a national tuberculosis referral center in China. All strains isolated from TB patients, were genotyped by the RD105 deletion, 8 and 51 SNP loci and VNTR. The high differentiation SNPs of modern Beijing strains were analyzed for protein function and structure. 413 M. tuberculosis were included. Of 379 Beijing lineage M. tuberculosis, ＇modern＇ and ＇ancient＇ strains respectively represented 85.5% （324/379） and 14.5% （55/379）. Rv2494 （V48A） and Rv0245 （Sl03F） were confirmed as high differentiation SNPs associated with modern strains. In a word, Modern Beijing lineage M.tuberculosis was dominant and the structural models suggested that modern sub-lineage may more easily survive in ＇extreme＇ host condition.展开更多
To describe and analyze the factors affecting the referral of presumptive tuberculosis patients between health-care facilities that are not affiliated with the National TB Control Program （NTP） and NTP-designated me...To describe and analyze the factors affecting the referral of presumptive tuberculosis patients between health-care facilities that are not affiliated with the National TB Control Program （NTP） and NTP-designated medical facilities in China, we carried out a retrospective study based on data collected in the Tuberculosis Information Management System in 2015. Out of 324,221 presumptive pulmonary tuberculosis （PTB） cases reported by non-NTP health-care facilities, 302,006 （93.1%） reported cases successfully arrived at designated medical facilities and 22,215 cases （6.9%） were lost to follow-up. The arrival rate of presumptive cases among male patients （92.9%） was slightly lower than that among female ones （93.7%）, and this difference is statistically significant. The majority （73.3%） of reported cases were local permanent residents. Migrants have a higher risk of being lost to follow-up compared with local residents （adjusted odds ratios 4.126 and 5.003, respectively）. Compared with farmers and herdsmen, pre-school children, unemployed laborers, retirees, and people with other occupations （adjusted odds ratios 2.361, 1.274, 1.068, and 1.993, respectively） had higher rates of loss to follow-up during the referral and tracing processes. In conclusion, this study demonstrates that the high referral rate of presumptive TB cases from non-NTP health-care facilities to designated medical facilities in China is due to implementation of effective active case identification strategies. In addition, migrant populations, pre-school children, unemployed laborers, and retirees were identified as high-risk groups that contribute to the loss to follow-up.展开更多
Outcomes associated with magnetic sphincter augmentation(MSA)in patients with gastroesophageal reflux disease(GERD)have been reported,however the optimal population for MSA and the related patient care pathways have n...Outcomes associated with magnetic sphincter augmentation(MSA)in patients with gastroesophageal reflux disease(GERD)have been reported,however the optimal population for MSA and the related patient care pathways have not been summarized.This Minireview presents evidence that describes the optimal patient population for MSA,delineates diagnostics to identify these patients,and outlines opportunities for improving GERD patient care pathways.Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018.Clinical experts contextualized the evidence based on clinical experience.The optimal MSA population may be the 2.2-2.4%of GERD patients who,despite optimal medical management,continue experiencing symptoms of heartburn and/or uncontrolled regurgitation,have abnormal pH,and have intact esophageal function as determined by high resolution manometry.Diagnostic work-ups include ambulatory pH monitoring,high-resolution manometry,barium swallow,and esophagogastroduodenoscopy.GERD patients may present with a range of typical or atypical symptoms.In addition to primary care providers(PCPs)and gastroenterologists(GIs),other specialties involved may include otolaryngologists,allergists,pulmonologists,among others.Objective diagnostic testing is required to ascertain surgical necessity for GERD.Current referral pathways for GERD management are suboptimal.Opportunities exist for enabling patients,PCPs,GIs,and surgeons to act as a team in developing evidence-based optimal care plans.展开更多
Background: Hypertensive disease in pregnancy is an important cause of morbidity, long-term disability, and maternal and neonatal mortality. The aim is to determine the socio-demographic characteristics and maternal p...Background: Hypertensive disease in pregnancy is an important cause of morbidity, long-term disability, and maternal and neonatal mortality. The aim is to determine the socio-demographic characteristics and maternal prognosis of these women with Hypertension during pregnancy. Material and Method: We conducted a cross-sectional study, we interview patients and after discussion we transcripts in a database in Excel software before analysis with SPSS version 20.0 and Stata 14.0 The qualitative variables have been summarised by the Percentage and the quantitative variables will be summarised by Means and Standard Deviation. The associations of the variables were calculated by Pearson’s chi-square test with a significance level set at a p-value Result: The average age of the patients was 30.33 ± 7.020 years, 92.1% were married, 79.8% lived in urban areas, most of the patients were overweight (43%), 92.1% of them had monofetal pregnancies, 36% were multiparous, 34.2% had a previous history of preeclampsia in pregnancy and 14% were known to have hypertension. Pre-eclampsia was the most frequent form of hypertension in pregnancy with 73.68% of cases and represents 84.8% of severe forms of hypertension in pregnancy, 53.4% of the patients delivered vaginally. Eclampsia was the most frequent complication in our patients with 31.7% frequency and among the socio-demographic parameters, age and body mass index were significantly associated with maternal complications. Conclusion: Maternal age and body mass index are important socio-demographic factors associated with the occurrence of maternal complications in women with hypertensive disorders in pregnancy.展开更多
Introduction: Our objective was to compare the epidemiologic profile of maternal mortality in two structures serving as referral levels of care in Cameroon. Methodology: This cross-sectional, comparative study took pl...Introduction: Our objective was to compare the epidemiologic profile of maternal mortality in two structures serving as referral levels of care in Cameroon. Methodology: This cross-sectional, comparative study took place at the maternities of the Yaoundé Central Hospital (YCH) and the Bamenda Regional Hospital (BRH) from December 1st 2014 to May 31st 2015, a 6 months’ period. The medical records of deceased women over 5 years, from January 2010 to December 2014, were collected. We calculated the MMR (Maternal mortality rate) and studied the causes and risk factors associated with maternal death. The Epi info software 3.5.4 was used to analyze data with a significance level of P < 0.05. Results: The maternal mortality ratio (MMR) was 964 and 247 per 100,000 live births for YCH and BRH, respectively. More deaths occurred within the aged group range 20 to 34 years, 76.8% at YCH and 64.7% at BRH. At YCH, 70.7% of these patients were referrals versus 32.4% at BRH. Complication from abortion was often implicated at BRH (P = 0.007;OR = 0.31;CI = 0.13 - 0.74). Others causes were hemorrhage (YCH = 43.4%;BRH = 35.5%), hypertensive diseases (YCH = 17.2%;BRH = 14.7%) and infections (YCH = 8.1%;BRH = 17.6%). At YCH time elapsed from admission to death was <3 h (P = 0.005;OR = 6.63;CI = 1.49 - 29.5). Conclusion: Both hospitals have similar causes of maternal deaths, differing only in the context within which the deaths occurred. Improving access to good quality health care, satisfying unmet needs for family planning, availability of blood products and the establishment of health insurance could decrease the maternal mortality rate.展开更多
AIM:To determine whether a communication instru-ment provided to patients prior to their primary carephysician(PCP)visit initiates a conversation with theirPCP about colorectal cancer screening(CRC-S),impact-ing scree...AIM:To determine whether a communication instru-ment provided to patients prior to their primary carephysician(PCP)visit initiates a conversation with theirPCP about colorectal cancer screening(CRC-S),impact-ing screening referral rates in fully insured and underin-sured patients.METHODS:A prospective randomized control studywas performed at a single academic center outpatient internal medicine(IRMC,underinsured)and fam-ily medicine(FMRC,insured)resident clinics prior to scheduled visits.In the intervention group,a pamphlet about the benefit of CRC-S and a reminder card were given to patients before the scheduled visit for prompt-ing of CRC-S referral by their PCP.The main outcome measured was frequency of CRC-S referral in each clinic after intervention.RESULTS:In the IRMC,148 patients participated,a control group of 72 patients(40F and 32M)and 76 patients(48F and 28M)in the intervention group.Re-ferrals for CRC-S occurred in 45/72(63%)of control vs 70/76(92%)in the intervention group(P≤0.001).In the FMRC,126 patients participated,66(39F:27M)con-trol and 60(33F:27M)in the intervention group.CRC-S referrals occurred in 47/66(71%)of controls vs 56/60(98%)in the intervention group(P≤0.001).CONCLUSION:Patient initiated physician prompting produced a significant referral increase for CRC-S in un-derinsured and insured patient populations.Additional investigation aimed at increasing CRC-S acceptance is warranted.展开更多
A nested Stackelberg game among a provider of a product,a sender(existing customer),and a receiver(new customer)is developed to explore the optimal referral reward programs(RRPs)for innovative offerings.The results in...A nested Stackelberg game among a provider of a product,a sender(existing customer),and a receiver(new customer)is developed to explore the optimal referral reward programs(RRPs)for innovative offerings.The results indicate that the provider should forsake RRPs and purely rely on customers'organic word-of-mouth communication under certain conditions.In particular,when the innovativeness of the referred product is extremely high,the provider should forsake RRPs completely,even though few customers will make organic referrals for the product.When the innovativeness is on other levels,the provider should make optimal RRPs decision depending on both the sender's persuasion effectiveness and the tie-strength between the two customers.Moreover,the optimal rewards increase with the innovativeness of the referred product when the provider opts to use RRPs.These results seem contrary to the existing empirical finding to some extent,and it is due to the high referral cost for making a successful referral for the high innovative offerings.展开更多
AIM:To describe the referral patterns of children with primary childhood glaucoma(PCG)or secondary childhood glaucoma(SCG)and their presenting symptoms in Northern Tanzania.METHODS:A retrospective observational study ...AIM:To describe the referral patterns of children with primary childhood glaucoma(PCG)or secondary childhood glaucoma(SCG)and their presenting symptoms in Northern Tanzania.METHODS:A retrospective observational study of children<17 y with PCG or SCG who were referred to Kilimanjaro Christian Medical Centre(KCMC)Eye Department between 2000 and 2013 was conducted.Presenting symptoms,age at presentation,place of origin,distance to hospital,type of glaucoma,visual acuity,optic disc appearance(vertical cupto-disc ratio)and type of referral were described.RESULTS:Seventy patients with PCG and 27 patients with SCG were included in the study.Median age at first presentation was 1 y in the PCG group(range 0-16 y)and 9 y in the SCG group(range 1-15 y).In both groups around 87%of the children presented already with low vision(logM AR>0.48,better eye).Most of the children(60%)and their caretakers presented on their own initiative,while 24%were sent by different general health cadres and 16%by eye care professionals.Buphthalmos was the main symptom mentioned as a trigger for presentation.CONCLUSION:The study shows that most of the children presented late resulting in advanced stages of glaucoma at the time of initiation of treatment.The majority attended the referral eye department on their own initiative with buphthalmos being the most commonly 452described symptom.Awareness creation among caretakers of children,general health and eye care providers,ideally embedded in general child health promotion activities,is needed to increase and accelerate referrals.展开更多
Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is e...Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is essential. This study aims to assess the effect and cost effectiveness of different referral strategies for inflammatory arthritis in primary care patients. Methods: This study follows a cluster randomized controlled trial design. General practitioners from primary care centers in Southwest-The Netherlands are randomly assigned to either one of the two strategic interventions for referring adult patients who are in the opinion of the general practitioner suspected of inflammatory arthritis: 1) Standardized digital referral algorithm based on existing referral models PEST, CaFaSpA and CARE;2) Triage by a rheumatologist in the local primary care center. These interventions will be compared to a control group, e.g. usual care. The primary outcome is the percentage of patients diagnosed with inflammatory arthritis by the rheumatologist. Secondary outcomes are quality of life as a patient reported outcome, work participation and healthcare costs. These data, including demographic and clinical parameters, are prospectively collected at baseline, three, six, and twelve months. Discussion: If this study can demonstrate improvements in appropriate referrals to the rheumatologist, thereby improving cost-effectiveness, there is sufficient supporting evidence to implement one of the referral strategies as a standard of care. Finally, with these optimization strategies a higher quality of care can be achieved, that might be of value for all patients with arthralgia. Trial Registration: NCT03454438, date of registration: March 5, 2018. Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03454438?term=NCT03454438&draw=1&rank=1.展开更多
文摘In the paper a referral system to assist the medical experts in the screening/referral of diabetic retinopathy is suggested. The system has been developed by a sequential use of different existing mathematical techniques. These techniques involve speeded up robust features（SURF）, K-means clustering and visual dictionaries（VD）. Three databases are mixed to test the working of the system when the sources are dissimilar. When experiments were performed an area under the curve（AUC） of 0.9343 was attained. The results acquired from the system are promising.
文摘AIM: To assess the current knowledge and practices in diabetic eye care and referral system regarding diabetic retinopathy(DR) in health centers of Islamabad and RawalPindi. METHODS: A cross-sectional study was carried out in 4 government and private health centers in RawalpindiIslamabad from May 2018 to Oct. 2018. A total of 38 Primary Care Physicians(general practitioners, family physicians, and internists) were recruited out of which data for 2 were either not returned, or were missing partially. Data were collected through a 27-item consented & validated, multiple-choice questionnaire based on physician characteristics, knowledge and practice of diabetic eye care and challenges faced due current DR referral system. Descriptive analyses for all variables were performed including, mean and standard deviation. Analytical analyses were also conducted to study association between different study variables. RESULTS: Mean scores of knowledge for general practitioners, family physicians, and internists were 41.7%, 42.0% and 46.6% respectively. A lack of knowledge, and suboptimal practices were observed regarding signs, symptoms, screening, testing, evaluation and referral of DR regardless of physicians’ specialty, or years in practice. Lack of expertise regarding direct ophthalmoscopy, interpretation of findings, and referral to an ophthalmologist were noted. Physicians who performed consultation and counselling according to patients’ needs referred more patients to an ophthalmologist than those who restricted their consultationto a fixed amount of time and had more patients per unit time(P=0.01). Physicians who had taken care of less than 5 number of patients with DR marked less incorrect answers with no significantly greater number or correct answers compared to physicians who had taken care of more than 5 number of patients with DR(P=0.044). An association of more than 5 patients with DR taken care of with more need based patient consultation and counselling was also noted(P=0.017). An evaluation of the current referral system for DR revealed major loopholes in the health care infrastructure, proper guidelines, properly functioning equipment, check and balances, and lack of guidance to physicians regarding acquiring and updating knowledge regarding DR. CONCLUSION: Lack of updated and adequate knowledge, practices among primary care physicians, and suboptimal diabetic eye care and referral system have contributed to late presentation of DR. Interventions are needed to improve current diabetic eye care, and knowledge and practices of primary care physicians.
文摘With the increasing prevalence of mental disorders,regional mental health service systems face challenges including uneven resource distribution,inefficient referral pathways,and fragmented information.To address these issues,a platform-based bidirectional referral model centered on a municipal psychiatric specialty hospital was developed and implemented,linking community hospitals and county-level psychiatric departments.A unified regional mental health information platform was used to integrate patient data.Community hospitals conducted preliminary screening,county-level psychiatric departments performed referral assessment,and the municipal psychiatric specialty hospital made centralized evaluation and admission decisions.The implementation results demonstrated standardized screening processes,clearer referral pathways,reduced unnecessary hospitalizations,improved accuracy of patient admission,and enhanced mental health service capacity at the primary care level.This model contributes to optimizing mental health resource allocation and improving the efficiency of tiered mental health services.
基金supported by the National Natural Science Foundation of China(72222015,72171215,72101243)Key Funds for Youth Innovation of University of Science and Technology of China(YD2040002018).
文摘Referral systems are widely used to coordinate heterogeneous healthcare providers(e.g.,general hospitals(GHs)and community healthcare centers(CHCs))for improved efficiency.This paper investigates referral coordination within a typical two-tiered system centered around a general hospital(GH)and a community healthcare center(CHC).Specifically,we compare the coordination value of two prevalent mechanisms:one-way referral and two-way referral.We develop a queueing-theoretic model to derive optimal capacity and pricing decisions for the GH and the CHC under each mechanism and then evaluate their relative effectiveness,with key metrics including total system profit,healthcare service prices,and patient waiting times.Our base model yields two key findings.First,counterintuitively,under certain conditions,the one-way referral mechanism can outperform both the two-way mechanism and a non-coordinated baseline.Second,within the one-way framework,full cooperation between the GH and CHCs can lead to a Pareto improvement,benefiting all stakeholders(i.e.,the GH,the CHCs,and the patients).This finding is based on an analysis extended to a system of one GH and multiple CHCs,where we show how a profit allocation scheme can be designed to foster such cooperation.Further analysis of a congested system with referral-dependent arrival rates reveals that the two-way mechanism becomes unequivocally superior.Finally,numerical studies confirm that optimal profits across all scenarios increase with the arrival rates of both severe patients in the GH and common patients in the CHCs.
基金Supported by STI2030-Major Projects,No.2021ZD0202001Capital Funds for Health Improvement and Research,No.CFH 2022-2-4012.
文摘BACKGROUND Systemic lupus erythematosus(SLE)can affect multiple organs or systems.The involvement of the central nervous system can result in the manifestation of epilepsy,an acute confusional state,and other rare neuropsychiatric presentations,such as catatonia.CASE SUMMARY We present a case of an adolescent male patient with first-onset SLE who presented with neuropsychiatric symptoms including epilepsy and delirium.The initial utilization of olanzapine to alleviate symptoms of agitation precipitated the emergence of catatonia,which was mitigated by discontinuing olanzapine and supplementing with lorazepam.In this case,whether the catatonia was secondary to the utilization of antipsychotics or to an organic disease is a question that warrants differential diagnosis.CONCLUSION Multidisciplinary collaborative management is the cornerstone for the successful management of severe cases of SLE.
文摘BACKGROUND Dysphagia requires prompt evaluation but data regarding referral-to-assessment intervals and its association with outcomes in tertiary care are scarce,especially in Saudi Arabia.AIM To investigate the assessment and outcome of consecutive dysphagia referrals to a tertiary gastroenterology practice.METHODS This retrospective single-center study analyzed 207 consecutive dysphagia referrals to King Saud Medical City(2022-2023).Data collection included referral timelines,diagnostic investigations,etiologies and outcomes.Statistical Package for the Social Sciences version 28.0,employing χ^(2) tests and analysis of variance,with P<0.05 considered statistically significant.RESULTS Total 168 patients included in this study(mean age 45.7±17.7 years,50% male),referral delays>2 weeks occurred in 44%for clinical assessment and 50%for endoscopy.Gastroesophageal reflux disease was most common(45.2%),followed by eosinophilic esophagitis(14.8%)and malignancy(6.5%).Patients receiving endoscopy within 2 weeks showed an 84.6%improvement,compared to 76.0%with delayed referral(P=0.012).All malignant cases were referred within 2 weeks,compared to 52.7% of non-malignant cases(P=0.013).However,67%of the malignant cases worsened,and 33%died.CONCLUSION Early endoscopy within 2 weeks provides significant benefit.Optimised management of dysphagia should consist of more direct referral pathways.
基金funded by the Australian Government Medical Research Future Fund(MRFF),Grant number 2015947.
文摘Objective To examine general practitioners’(GPs)referral patterns to allied health services for people with dementia compared with those without dementia across two large Australian Primary Health Networks(PHNs).Design A retrospective cohort study using routinely collected general practice data.Logistic regression was used to compare odds of allied health referrals,adjusting for age,sex and socioeconomic status.Setting De-identified patient and episode activity data from 537 GP practices across two PHNs in Australia between 2018 and 2023.Participants Data from 1153304 patients and 28667517 GP episodes of care were analysed.After merging records,693328 unique patients were identified,including 16610 patients with dementia.Subcohorts included patients with dementia,stroke,Parkinson’s disease and combinations of these conditions.Results The dementia cohort(n=16610)had a similar overall allied health referral rate(36.1%)to the control cohort(n=48977)(35.4%).Patients with dementia only were significantly less likely to receive any allied health referral compared with those with stroke(adjusted OR(aOR)0.76,95%CI 0.72 to 0.80;p<0.001)or Parkinson’s disease(aOR 0.72,95%CI 0.66 to 0.78;p<0.001).Those with dementia and stroke were also less likely to receive referrals than those with stroke only(aOR 0.71,95%CI 0.61 to 0.82;p<0.001).No significant difference was found between dementia with Parkinson’s and Parkinson’s only groups(p=0.48).Patients with dementia were consistently less likely to be referred to key allied health services(p<0.05).Conclusion Despite strong evidence supporting allied health interventions for dementia,referral rates remain comparatively low.Enhancing GP referral resources and education,integrating dementia-specific care pathways and implementing supportive policy changes are needed to improve access and equity in dementia care.
基金Supported by STI2030-Major Projects,No.2021ZD0202001National Natural Science Foundation of China,No.T2341003Capital Funds for Health Improvement and Research,No.CFH 2022-2-4012.
文摘BACKGROUND Not all neuropsychiatric(NP)manifestations in patients with systemic lupus erythematosus(SLE)are secondary to lupus.The clarification of the cause of NP symptoms influences therapeutic strategies for SLE.AIM To understand the attribution of psychiatric manifestations in a cohort of Chinese patients with SLE.METHODS This retrospective single-center study analyzed 160 inpatient medical records.Clinical diagnosis,which is considered the gold standard,was used to divide the subjects into a psychiatric SLE(PSLE)group(G1)and a secondary psychiatric symptoms group(G2).Clinical features were compared between these two groups.The sensitivity and specificity of the Italian attribution model were explored.RESULTS A total of 171 psychiatric syndromes were recorded in 138 patients,including 87 cases of acute confusional state,40 cases of cognitive dysfunction,18 cases of psychosis,and 13 cases each of depressive disorder and mania or hypomania.A total of 141(82.5%)syndromes were attributed to SLE.In contrast to G2 patients,G1 patients had higher SLE Disease Activity Index-2000 scores(21 vs 12,P=0.001),a lower prevalence of anti-beta-2-glycoprotein 1 antibodies(8.6%vs 25.9%,P=0.036),and a higher prevalence of anti-ribosomal ribonucleoprotein particle(rRNP)antibodies(39.0%vs 22.2%,P=0.045).The Italian attribution model exhibited a sensitivity of 95.0%and a specificity of 70.0%when the threshold value was set at 7.CONCLUSION Patients with PSLE exhibited increased disease activity.There is a correlation between PSLE and anti-rRNP antibodies.The Italian model effectively assesses multiple psychiatric manifestations in Chinese SLE patients who present with NP symptoms.
基金Supported by Shandong Province Medical and Health Technology Development Plan Project,No.202203090753.
文摘Alcohol use has contributed to large disease burdens,and alcohol-related problems are prevalent among patients in general hospitals and primary care settings.This review aims to deepen the understanding of screening,intervention,and treatment referral for alcohol-related problems in these settings.We searched the literature published in English from PubMed,ScienceDirect,and the World Health Organization website.We found that while a series of screening tools can be used,screening rates were low.The awareness of screening should be strengthened.Brief interventions and pharmacotherapy are the two main methods used in general hospitals and primary care settings,with complementary and alternative medicine considered under the framework of integrative medicine.Individuals with severe alcohol-related problems or alcohol use disorders should be referred to specialty treatment for alcohol abuse,but referral is sometimes ignored.A gap exists between general hospitals/primary care facilities and specialized alcohol-related treatment providers.In conclusion,screening,intervention,and referral to treatment comprise a continuum for patients with alcohol-related problems.Opportunities to prevent and manage these problems in general hospitals and primary care settings are abundant,and taking action will promote the addressing of this public health issue.
文摘The study evaluated the impact of digital health tools, task sharing, capacity building, and maternal health financing on Maternal, Newborn, and Child Health (MNCH) systems in Kisii, Kajiado, and Migori counties in Kenya, under the Tekeleza project1. It aimed to assess how these interventions influenced MNCH service uptake, outcomes, and referral systems, using a mixed-methods approach with data from healthcare providers, community health promoters, and mothers. Findings showed that digital tools like the LUCY App improved coordination and maternal care but highlighted the need for better app features and wider access. Task sharing in areas like sonography enhanced service delivery but required stronger stakeholder engagement. Capacity-building through training was crucial for skill development, though additional training on emerging health issues was needed. Financial interventions, such as the Linda Mama program, boosted service uptake, but reimbursement processes needed improvement. Strengthening referral systems between lower- and higher-level facilities was identified as essential for timely access to care. The study concludes that integrating digital tools, expanding task sharing, enhancing training, and reinforcing health financing and referral systems are critical for strengthening MNCH services in rural Kenya, with broader implications for similar low-resource settings.
文摘AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.
基金supported by the National Natural Science Foundation of China(No.81273144)Beijing Natural Science Foundation Program and Scientific Research Key Program of Beijing Municipal Commission of Education(KZ201510025024)Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support(ZYLX201304)
文摘Our study was to investigate the epidemiological characteristics of M.tuberculosis from a national tuberculosis referral center in China. All strains isolated from TB patients, were genotyped by the RD105 deletion, 8 and 51 SNP loci and VNTR. The high differentiation SNPs of modern Beijing strains were analyzed for protein function and structure. 413 M. tuberculosis were included. Of 379 Beijing lineage M. tuberculosis, ＇modern＇ and ＇ancient＇ strains respectively represented 85.5% （324/379） and 14.5% （55/379）. Rv2494 （V48A） and Rv0245 （Sl03F） were confirmed as high differentiation SNPs associated with modern strains. In a word, Modern Beijing lineage M.tuberculosis was dominant and the structural models suggested that modern sub-lineage may more easily survive in ＇extreme＇ host condition.
基金supported by the World Health Organization Western Pacific TB Operational Research Grant(WPDCC1408653)
文摘To describe and analyze the factors affecting the referral of presumptive tuberculosis patients between health-care facilities that are not affiliated with the National TB Control Program （NTP） and NTP-designated medical facilities in China, we carried out a retrospective study based on data collected in the Tuberculosis Information Management System in 2015. Out of 324,221 presumptive pulmonary tuberculosis （PTB） cases reported by non-NTP health-care facilities, 302,006 （93.1%） reported cases successfully arrived at designated medical facilities and 22,215 cases （6.9%） were lost to follow-up. The arrival rate of presumptive cases among male patients （92.9%） was slightly lower than that among female ones （93.7%）, and this difference is statistically significant. The majority （73.3%） of reported cases were local permanent residents. Migrants have a higher risk of being lost to follow-up compared with local residents （adjusted odds ratios 4.126 and 5.003, respectively）. Compared with farmers and herdsmen, pre-school children, unemployed laborers, retirees, and people with other occupations （adjusted odds ratios 2.361, 1.274, 1.068, and 1.993, respectively） had higher rates of loss to follow-up during the referral and tracing processes. In conclusion, this study demonstrates that the high referral rate of presumptive TB cases from non-NTP health-care facilities to designated medical facilities in China is due to implementation of effective active case identification strategies. In addition, migrant populations, pre-school children, unemployed laborers, and retirees were identified as high-risk groups that contribute to the loss to follow-up.
文摘Outcomes associated with magnetic sphincter augmentation(MSA)in patients with gastroesophageal reflux disease(GERD)have been reported,however the optimal population for MSA and the related patient care pathways have not been summarized.This Minireview presents evidence that describes the optimal patient population for MSA,delineates diagnostics to identify these patients,and outlines opportunities for improving GERD patient care pathways.Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018.Clinical experts contextualized the evidence based on clinical experience.The optimal MSA population may be the 2.2-2.4%of GERD patients who,despite optimal medical management,continue experiencing symptoms of heartburn and/or uncontrolled regurgitation,have abnormal pH,and have intact esophageal function as determined by high resolution manometry.Diagnostic work-ups include ambulatory pH monitoring,high-resolution manometry,barium swallow,and esophagogastroduodenoscopy.GERD patients may present with a range of typical or atypical symptoms.In addition to primary care providers(PCPs)and gastroenterologists(GIs),other specialties involved may include otolaryngologists,allergists,pulmonologists,among others.Objective diagnostic testing is required to ascertain surgical necessity for GERD.Current referral pathways for GERD management are suboptimal.Opportunities exist for enabling patients,PCPs,GIs,and surgeons to act as a team in developing evidence-based optimal care plans.
文摘Background: Hypertensive disease in pregnancy is an important cause of morbidity, long-term disability, and maternal and neonatal mortality. The aim is to determine the socio-demographic characteristics and maternal prognosis of these women with Hypertension during pregnancy. Material and Method: We conducted a cross-sectional study, we interview patients and after discussion we transcripts in a database in Excel software before analysis with SPSS version 20.0 and Stata 14.0 The qualitative variables have been summarised by the Percentage and the quantitative variables will be summarised by Means and Standard Deviation. The associations of the variables were calculated by Pearson’s chi-square test with a significance level set at a p-value Result: The average age of the patients was 30.33 ± 7.020 years, 92.1% were married, 79.8% lived in urban areas, most of the patients were overweight (43%), 92.1% of them had monofetal pregnancies, 36% were multiparous, 34.2% had a previous history of preeclampsia in pregnancy and 14% were known to have hypertension. Pre-eclampsia was the most frequent form of hypertension in pregnancy with 73.68% of cases and represents 84.8% of severe forms of hypertension in pregnancy, 53.4% of the patients delivered vaginally. Eclampsia was the most frequent complication in our patients with 31.7% frequency and among the socio-demographic parameters, age and body mass index were significantly associated with maternal complications. Conclusion: Maternal age and body mass index are important socio-demographic factors associated with the occurrence of maternal complications in women with hypertensive disorders in pregnancy.
文摘Introduction: Our objective was to compare the epidemiologic profile of maternal mortality in two structures serving as referral levels of care in Cameroon. Methodology: This cross-sectional, comparative study took place at the maternities of the Yaoundé Central Hospital (YCH) and the Bamenda Regional Hospital (BRH) from December 1st 2014 to May 31st 2015, a 6 months’ period. The medical records of deceased women over 5 years, from January 2010 to December 2014, were collected. We calculated the MMR (Maternal mortality rate) and studied the causes and risk factors associated with maternal death. The Epi info software 3.5.4 was used to analyze data with a significance level of P < 0.05. Results: The maternal mortality ratio (MMR) was 964 and 247 per 100,000 live births for YCH and BRH, respectively. More deaths occurred within the aged group range 20 to 34 years, 76.8% at YCH and 64.7% at BRH. At YCH, 70.7% of these patients were referrals versus 32.4% at BRH. Complication from abortion was often implicated at BRH (P = 0.007;OR = 0.31;CI = 0.13 - 0.74). Others causes were hemorrhage (YCH = 43.4%;BRH = 35.5%), hypertensive diseases (YCH = 17.2%;BRH = 14.7%) and infections (YCH = 8.1%;BRH = 17.6%). At YCH time elapsed from admission to death was <3 h (P = 0.005;OR = 6.63;CI = 1.49 - 29.5). Conclusion: Both hospitals have similar causes of maternal deaths, differing only in the context within which the deaths occurred. Improving access to good quality health care, satisfying unmet needs for family planning, availability of blood products and the establishment of health insurance could decrease the maternal mortality rate.
文摘AIM:To determine whether a communication instru-ment provided to patients prior to their primary carephysician(PCP)visit initiates a conversation with theirPCP about colorectal cancer screening(CRC-S),impact-ing screening referral rates in fully insured and underin-sured patients.METHODS:A prospective randomized control studywas performed at a single academic center outpatient internal medicine(IRMC,underinsured)and fam-ily medicine(FMRC,insured)resident clinics prior to scheduled visits.In the intervention group,a pamphlet about the benefit of CRC-S and a reminder card were given to patients before the scheduled visit for prompt-ing of CRC-S referral by their PCP.The main outcome measured was frequency of CRC-S referral in each clinic after intervention.RESULTS:In the IRMC,148 patients participated,a control group of 72 patients(40F and 32M)and 76 patients(48F and 28M)in the intervention group.Re-ferrals for CRC-S occurred in 45/72(63%)of control vs 70/76(92%)in the intervention group(P≤0.001).In the FMRC,126 patients participated,66(39F:27M)con-trol and 60(33F:27M)in the intervention group.CRC-S referrals occurred in 47/66(71%)of controls vs 56/60(98%)in the intervention group(P≤0.001).CONCLUSION:Patient initiated physician prompting produced a significant referral increase for CRC-S in un-derinsured and insured patient populations.Additional investigation aimed at increasing CRC-S acceptance is warranted.
基金The National Social Science Foundation of China(No.17BGL196)。
文摘A nested Stackelberg game among a provider of a product,a sender(existing customer),and a receiver(new customer)is developed to explore the optimal referral reward programs(RRPs)for innovative offerings.The results indicate that the provider should forsake RRPs and purely rely on customers'organic word-of-mouth communication under certain conditions.In particular,when the innovativeness of the referred product is extremely high,the provider should forsake RRPs completely,even though few customers will make organic referrals for the product.When the innovativeness is on other levels,the provider should make optimal RRPs decision depending on both the sender's persuasion effectiveness and the tie-strength between the two customers.Moreover,the optimal rewards increase with the innovativeness of the referred product when the provider opts to use RRPs.These results seem contrary to the existing empirical finding to some extent,and it is due to the high referral cost for making a successful referral for the high innovative offerings.
文摘AIM:To describe the referral patterns of children with primary childhood glaucoma(PCG)or secondary childhood glaucoma(SCG)and their presenting symptoms in Northern Tanzania.METHODS:A retrospective observational study of children<17 y with PCG or SCG who were referred to Kilimanjaro Christian Medical Centre(KCMC)Eye Department between 2000 and 2013 was conducted.Presenting symptoms,age at presentation,place of origin,distance to hospital,type of glaucoma,visual acuity,optic disc appearance(vertical cupto-disc ratio)and type of referral were described.RESULTS:Seventy patients with PCG and 27 patients with SCG were included in the study.Median age at first presentation was 1 y in the PCG group(range 0-16 y)and 9 y in the SCG group(range 1-15 y).In both groups around 87%of the children presented already with low vision(logM AR>0.48,better eye).Most of the children(60%)and their caretakers presented on their own initiative,while 24%were sent by different general health cadres and 16%by eye care professionals.Buphthalmos was the main symptom mentioned as a trigger for presentation.CONCLUSION:The study shows that most of the children presented late resulting in advanced stages of glaucoma at the time of initiation of treatment.The majority attended the referral eye department on their own initiative with buphthalmos being the most commonly 452described symptom.Awareness creation among caretakers of children,general health and eye care providers,ideally embedded in general child health promotion activities,is needed to increase and accelerate referrals.
文摘Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is essential. This study aims to assess the effect and cost effectiveness of different referral strategies for inflammatory arthritis in primary care patients. Methods: This study follows a cluster randomized controlled trial design. General practitioners from primary care centers in Southwest-The Netherlands are randomly assigned to either one of the two strategic interventions for referring adult patients who are in the opinion of the general practitioner suspected of inflammatory arthritis: 1) Standardized digital referral algorithm based on existing referral models PEST, CaFaSpA and CARE;2) Triage by a rheumatologist in the local primary care center. These interventions will be compared to a control group, e.g. usual care. The primary outcome is the percentage of patients diagnosed with inflammatory arthritis by the rheumatologist. Secondary outcomes are quality of life as a patient reported outcome, work participation and healthcare costs. These data, including demographic and clinical parameters, are prospectively collected at baseline, three, six, and twelve months. Discussion: If this study can demonstrate improvements in appropriate referrals to the rheumatologist, thereby improving cost-effectiveness, there is sufficient supporting evidence to implement one of the referral strategies as a standard of care. Finally, with these optimization strategies a higher quality of care can be achieved, that might be of value for all patients with arthralgia. Trial Registration: NCT03454438, date of registration: March 5, 2018. Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03454438?term=NCT03454438&draw=1&rank=1.
