Appropriateness in Health Care
This paper discusses the concept of appropriateness in health care and advances the following definition:
The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care.
Building on that definition it makes the following policy recommendations:
* Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care.
* Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes.
* Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care.
As health systems struggle with the issue of sustainability and evidence that the quality of care is often sub-optimal, increasing attention is focused on the concept of appropriateness. A World Health Organization study published in 2000 described appropriateness as "a complex, fuzzy issue"1. Yet if the term is to be applied with benefit to health care systems, it demands definitional clarity. This policy document presents the Canadian Medical Association definition of appropriateness which addresses both quality and value. The roots of the definition are anchored in the evolution of Canadian health care over the last two decades. The document then considers the many issues confronting the operationalization of the term. It concludes that appropriateness can play a central role in positive health system transformation.
At the Canadian Medical Association General Council in 2013 the following resolution was adopted:
The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care.
This definition has five key components:
* right care is based on evidence for effectiveness and efficacy in the clinical literature and covers not only use but failure to use;
* right provider is based on ensuring the provider's scope of practice adequately meets but does not far exceed the skills and knowledge to deliver the care;
* right patient acknowledges that care choices must be matched to individual patient characteristics and preferences and must recognize the potential challenge of reconciling patient and practitioner perceptions;
* right venue emphasizes that some settings are better suited in terms of safety and efficiency to delivering a specific type of care than others;
* right time indicates care is delivered in a timely manner consistent with agreed upon bench marks.
It is essential to appreciate that the "right cost" is a consequence of providing the right care, that it is an outcome rather than an input. In other words, if all five components above are present, high quality care will have been delivered with the appropriate use of resources, that is, at the right cost. Equally, however, it should be cautioned that right cost may not necessarily be the affordable cost. For example, a new drug or imaging technology may offer small but demonstrable advantages over older practices, but at an enormous increase in cost. Some might argue that right care includes the use of the newer drug or technology, while others would contend the excessive opportunity costs must be taken into consideration such that the older practices remain the right care.
An Evolving Canadian Perspective from 1996 to 2013
In a pioneering paper from 1996 Lavis and Anderson wrote:
...there are two distinct types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided. The differences between the two parallel the differences between two other concepts in health care: effectiveness and cost-containment...An appropriate service is one that is expected to do more good than harm for a patient with a given indication...The appropriateness of the setting in which care is provided is related to cost effectiveness2.
This very serviceable definition moved beyond a narrow clinical conception based solely on the therapeutic impact of an intervention on a patient, to broader contextual consideration focused on venue. Thus, for example, the care provided appropriately in a home-care setting might not be at all appropriate if given in a tertiary care hospital. Significantly, the authors added this important observation: "Setting is a proxy measure of the resources used to provide care"2. This sentence is an invitation to expand the original Lavis and Anderson definition to encompass other resources and inputs identified over the ensuing decades. Three elements are especially important.
Timeliness became an issue in Canadian health care just as the Lavis and Anderson paper appeared. In 1997 almost two-thirds of polled Canadians felt surgical wait times were excessive, up from just over half of respondents a year earlier3. By 2004 concern with wait times was sufficiently pervasive that when the federal government and the provinces concluded the First Ministers' Agreement, it included obligations to provide timely access to cancer care, cardiac care, diagnostic imaging, joint replacement and sight restoration4. These rapid developments indicate that timeliness was now considered an essential element in determining the appropriateness of care.
A second theme that became prominent in health care over the last two decades was the concept of patient-centredness. When the Canadian Medical Association released its widely endorsed Health Care Transformation in Canada in 2010, the first principle for reform was building a culture of patient-centred care. Succinctly put, this meant that "health care services are provided in a manner that works best for patients"5. To begin the process of operationalizing this concept CMA proposed a Charter for Patient-centred Care. Organized across seven domains, it included the importance of: allowing patients to participate fully in decisions about their care; respecting confidentiality of health records; and ensuring care provided is safe and appropriate. This sweeping vision underscores the fact that care which is not matched to the individual patient cannot be considered appropriate care.
A third significant development over the last two decades was heightened awareness of the importance of scopes of practice. This awareness arose in part from the emphasis placed on a team approach in newer models of primary care6, but also from the emergence of new professions such as physician assistants, and the expansion of scopes of practice for other professionals such as pharmacists7. As the same health care activity could increasingly be done by a wider range of health professionals, ensuring the best match between competence required and the service provided became an essential element to consider when defining appropriateness. Under-qualified practitioners could not deliver quality care, while overly-qualified providers were a poor use of scarce resources.
To summarize, as a recent scoping review suggested, for a complete conceptualization of appropriateness in 2013 it is necessary to add the right time, right patient and right provider to the previously articulated right care and right setting8.
Why Appropriateness Matters
The most frequent argument used to justify policy attention to appropriateness is health system cost. There is a wealth of evidence that inappropriate care - avoidable hospitalizations, for example, or alternative level of care patients in acute care beds - is wide spread in Canada9; eliminating this waste is critical to system sustainability. In Saskatchewan, for example, Regina and Saskatoon contracted in 2011 with private clinics to provide a list of 34 surgical procedures. Not only were wait times reduced, but costs were 26% lower in the surgical clinics than in hospitals for doing the same procedures10.
There is, however, an equally important issue pointing to the importance of ensuring appropriate care: sub-optimal health care quality. In the United States, for example, a study evaluated performance on 439 quality indicators for 30 acute and chronic conditions. Patients received 54.9% of recommended care, ranging from a high of 78.7% for senile cataracts to 10.5% for alcohol dependence11. A more recent Australian study used 522 quality indicators to assess care for 22 common conditions. Patients received clinically appropriate care in 57% of encounters, with a range from 90% for coronary artery disease to 13% for alcohol dependence12. While no comparable comprehensive data exist for Canada, it is unlikely the practices in our system depart significantly from peer nations. Focusing on appropriateness of care, then, is justified by both fiscal and quality concerns.
Methodology: the Challenge of Identifying Appropriateness
While there is a clear need to address appropriateness - in all its dimensions - the methods by which to assess the appropriateness of care are limited and, to date, have largely focused on the clinical aspect.
The most frequently used approach is the Rand/University of California Los Angeles (Rand) method. It provides panels of experts with relevant literature about a particular practice and facilitates iterative discussion and ranking of the possible indications for using the practice. Practices are labeled appropriate, equivocal or inappropriate13. A systematic review in 2012 found that for use on surgical procedures the method had good test-retest reliability, interpanel reliability and construct validity14. However, the method has been criticized for other short-comings: panels in different countries may reach different conclusions when reviewing the same evidence; validity can only be tested against instruments such as clinical practice guidelines that themselves may have a large expert opinion component2; Rand appropriateness ratings apply to an "average" patient, which cannot account for differences across individuals; and, finally, Rand ratings focus on appropriateness when a service is provided but does not encompass underuse, that is, failure to provide a service that would have been appropriate9.
The Rand method, while not perfect, is the most rigorous approach to determining clinical appropriateness yet devised. It has recently been suggested that a method based on extensive literature review can identify potentially ineffective or harmful practices; when applied to almost 6000 items in the Australian Medical Benefits Schedule, 156 were identified that may be inappropriate15. This method also presents challenges. For example, the authors of a study using Cochrane reviews to identify low-value practices note that the low-value label resulted mainly from a lack of randomized evidence for effectiveness16.
Assessing the appropriateness of care setting has focused almost exclusively on hospitals. Some diagnoses are known to be manageable in a community setting by primary care or specialty clinics. The rate of admissions for these ambulatory care sensitive conditions (ACSCs) - which fell from 459 per 100,000 population in 2001-02 to 320 per 100,00 in 2008-09 - is one way of gauging the appropriateness of the hospital as a care venue9. A second measure is the number of hospital patients who do not require either initial or prolonged treatment in an acute care setting. Proprietorial instruments such as the Appropriateness Evaluation Protocol (AEP)17or the InterQual Intensity of Service, Severity of Illness and Discharge Screen for Acute Care (ISD-AC)18 have been used to assess the appropriateness of hospital care for individual patients. While these instruments have been applied to Canadian hospital data19,20, there is a lack of consensus in the literature as to the reliability and utility of such tools21-23.
Benchmarks exist for appropriate wait times for some types of care in Canada through the work of the Wait Time Alliance4. These include: chronic pain, cancer care, cardiac care, digestive health care, emergency rooms, joint replacement, nuclear medicine, radiology, obstetrics and gynecology, pediatric surgery, plastic surgery, psychiatric illness, and sight restoration. The recommendations are based on evidence-informed expert opinion.
The other two domains of appropriateness - right patient, right provider - as yet have no objective tools by which to assess appropriateness.
Determining appropriateness demands a complex and time-consuming approach, and its operationalization faces a number of barriers.
The availability of some health care services may be subject to political influence which will over-ride appropriateness criteria. For example, recommendations to close smaller hospitals deemed to be redundant or inefficient may not be implemented for political reasons.
Patient expectations can challenge evidence-based appropriateness criteria. In a primary care setting, for instance, it may be difficult to persuade a patient with an ankle sprain that an x-ray is unlikely to be helpful. The insistence by the patient is compounded by an awareness of potential legal liability in the event that clinical judgment subsequently proves incorrect. Choosing Wisely Canada recommends physicians and patients become comfortable with evidence-informed conversations about potentially necessary care24.
Traditional clinical roles are difficult to revise in order to ensure that care is provided by the most appropriate health professional. This is especially true if existing funding silos are not realigned to reflect the desired change in practice patterns.
Finally, and perhaps most importantly, even if agreed upon appropriateness criteria are developed, holding practitioners accountable for their application in clinical practice is extremely difficult due to data issues25. Chart audits could be conducted to determine whether appropriateness criteria were met when specific practices were deployed, but this is not feasible on a large scale. Rates of use of some practices could be compared among peers from administrative data; however, variation in practice population might legitimately sustain practice variation. For diagnostic procedures it has been suggested that the percentage of negative results is an indicator of inappropriate use; however, most administrative claim databases would not include positive or negative test result data26. This data deficit must be addressed with health departments and regional health authorities.
There are several additional constraints on the use of the concept by health system managers.
First, the vast majority of practices have never been subject to the Rand or any other appropriateness assessment. Even for surgical procedures clinical appropriateness criteria exist for only 10 of the top 25 most common inpatient procedures and for 6 of the top 15 ambulatory procedures in the United States. Most studies are more than 5 years old27.
Second, while the notion is perhaps appealing to policy makers, it is incorrect to assume that high use of a practice equates with misuse: when high-use areas are compared to low use areas, the proportion of inappropriate use has consistently been shown to be no greater in the high-use regions28,29.
Finally, it is uncertain how large a saving can be realized from eliminating problematic clinical care. For example, a US study modeling the implementation of recommendations for primary care found that while a switch to preferentially prescribing generic drugs would save considerable resources, most of the other items on the list of questionable activities "are not major contributors to health care costs"30. What is important to emphasize is that even if dollars are not saved, by reducing inappropriate care better value will be realized for each dollar spent.
These methodological and other challenges31 notwithstanding, the Canadian Medical Association puts forward the following recommendations for operationalizing the concept of appropriateness and of clinical practice.
1. Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care.
Jurisdictions should develop a framework32 for identifying potentially inappropriate care, including under-use. This involves selecting criteria by which to identify and prioritize candidates for assessment; developing and applying a robust assessment methodology; and creating mechanisms to disseminate and apply the results. Frameworks must also include meaningful consideration of care venue, timeliness, patient preferences and provider scope of practice. International examples exist for some aspects of this exercise and should be adapted to jurisdictional circumstances. Necessarily, a framework will demand the collection of supporting data in a manner consistent with the following 2013 General Council resolution:
The Canadian Medical Association supports the development of data on health care delivery and patient outcomes to help the medical profession develop an appropriateness framework and associated accountability standards provided that patient and physician confidentiality is maintained.
2. Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes.
Both trainees and practicing physicians should have access to education and guidance on the topic of appropriateness and on practices that are misused, under-used, or over-used. Appropriately designed continuing education has been shown to alter physician practice. Point of care guidance via the electronic medical record offers a further opportunity to alert clinicians to practices that should or should not be done in the course of a patient encounter33.
An initiative co-led by the Canadian Medical Association that is designed to educate the profession about the inappropriate over use of diagnostic and therapeutic interventions is Choosing Wisely Canada. The goal is to enhance quality of care and only secondarily to reduce unnecessary expenditures. It is an initiative consistent with the intent of two resolutions from the 2013 General Council:
The Canadian Medical Association will form a collaborative working group to develop specialty-specific lists of clinical tests/interventions and procedures for which benefits have generally not been shown to exceed the risks.
The Canadian Medical Association believes that fiscal benefits and cost savings of exercises in accountability and appropriateness in clinical care are a by-product rather than the primary focus of these exercises.
3. Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care.
Practitioners should be provided with incentives to eliminate inappropriate care. These incentives may be financial - delisting marginal activities or providing bonuses for achieving utilization targets for appropriate but under-used care. Any notional savings could also be flagged for reinvestment in the health system, for example, to enhance access. Giving physicians the capacity to participate in audit and feedback on their use of marginal practices in comparison to peers generally creates a personal incentive to avoid outlier status. Public reporting by group or institution may also move practice towards the mean30. In any such undertakings to address quality or costs through changes in practice behaviour it is essential that the medical profession play a key role. This critical point was captured in a 2013 General Council resolution:
The Canadian Medical Association will advocate for adequate physician input in the selection of evidence used to address costs and quality related to clinical practice variation.
When appropriateness is defined solely in terms of assessing the clinical benefit of care activities it can provide a plausible rational for "disinvestment in" or "delisting of" individual diagnostic or therapeutic interventions. However, such a narrow conceptualization of appropriateness cannot ensure that high quality care is provided with the optimal use of resources. To be truly useful in promoting quality and value appropriateness must be understood to mean the right care, provided by the right provider, to the right patient, in the right venue, at the right time.
Achieving these five components of health care will not be without significant challenges, beginning with definitions and moving on to complex discussions on methods of measurement. Indeed, it may prove an aspirational goal rather than a completely attainable reality. But if every encounter in the health system - a hospitalization, a visit to a primary care provider, an admission to home care - attempted to meet or approximate each of the five criteria for appropriateness, a major step towards optimal care and value will have been achieved across the continuum. Viewed in this way, appropriateness has the capacity to become an extraordinarily useful organizing concept for positive health care transformation in Canada.
Approved by CMA Board on December 06, 2014
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2. Lavis JN, Anderson GM. Appropriateness in health care delivery: definitions, measurement and policy implications. CMAJ. 1996;154(3):321-8.
3. Sanmartin C, Shortt SE, Barer ML, Sheps S, Lewis S, McDonald PW. Waiting for medical services in Canada: lots of heat, but little light. CMAJ. 2000;162(9):1305-10.
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6. Canadian Medical Association. CMA Policy: Achieving Patient-centred Collaborative Care. Ottawa: Canadian Medical Association; 2008.
7. Maxwell-Alleyne A, Farber A. Pharmacists' expanded scope of practice: Professional obligations for physicians and pharmacists working collaboratively. Ont Med Rev. 2013;80(4):17-9.
8. Sanmartin C, Murphy K, Choptain N, et al. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care. 2008;24(3)342-9.
9. Canadian Institute for Health Information. Health Care in Canada 2010. Ottawa: CIHI; 2010.
10. MacKinnon J. Health Care Reform from the Cradle of Medicare. Ottawa: Macdonald-Laurier Institute; 2013.
11. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. NEJM. 2003;348(26):2635-45.
12. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100-5.
13. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care. 1986;2(1):53-63.
14. Lawson EH, Gibbons MM, Ko CY, Shekelle PG. The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012;65(11):1133-43.
15. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. Med J Aust. 2012;197(10):556-60.
16. Garner S, Docherty M, Somner J, et al. Reducing ineffective practice: challenges in identifying low-value health care using Cochrane systematic reviews. J Health Serv Res Policy. 2013;18(1):6-12.
17. Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981;19(8):855-71.
18. Mitus AJ. The birth of InterQual: evidence-based decision support criteria that helped change healthcare. Prof Case Manag. 2008;13(4):228-33.
19. DeCoster C, Roos NP, Carriere KC, Peterson S. Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review. CMAJ. 1997;157(7):889-96.
20. Flintoft VF, Williams JI, Williams RC, Basinski AS, Blackstien-Hirsch P, Naylor CD. The need for acute, subacute and nonacute care at 105 general hospital sites in Ontario. Joint Policy and Planning Committee Non-Acute Hospitalization Project Working Group. CMAJ . 1998;158(10):1289-96.
21. Kalant N, Berlinguet M, Diodati JG, Dragatakis L, Marcotte F. How valid are utilization review tools in assessing appropriate use of acute care beds? CMAJ. 2000;162(13):1809-13.
22. McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds. A systematic review of methods and results. Health policy. 2000;53(3):157-84.
23. Vetter N. Inappropriately delayed discharge from hospital: what do we know? BMJ. 2003;326(7395):927-8.
24. Choosing Wisely Canada. Recent News. Ottawa: Choosing Wisely Canada; 2015. Available: www.choosingwiselycanada.org. (accessed Dec 2014)
25. Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ. 2011;343:d4519.
26. Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC. Design and use of performance measures to decrease low-value services and achieve cost-conscious care. Ann Intern Med. 2013;158(1):55-9.
27. Lawson EH, Gibbons MM, Ingraham AM, Shekelle PG, Ko CY. Appropriateness criteria to assess variations in surgical procedure use in the United States. Arch Surg. 2011;146(12):1433-40.
28. Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987;258(18):2533-7.
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31. Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy. 2007;4:23.
32. Elshaug AG, Moss JR, Littlejohns P, Karnon J, Merlin TL, Hiller JE. Identifying existing health care services that do not provide value for money. Med J Aust. 2009;190(5):269-73.
33. Shortt S GM, Gorbet S. Making medical practice safer: the role of public policy. Int J Risk Saf Med. 2010;22(3):159-68.
When physicians believe their patients may require the expertise of another physician, effective, timely and informative communication between all physicians is essential to ensure appropriate use of specialty care services. The results of physician surveys indicate a lack of informative referral communication exists in Canada. Significant variation exists in referral request processes*. This is contributing to the poor access to specialty care that many patients are experiencing.
Some of this variation is necessary, however, which means that a single, standardized solution to improve the entire referral and consultation process is not feasible. Nonetheless, while communication processes and information requirements for referral requests vary considerably, the communication and information needs in consultant responses is essentially the same for all referring physicians. Unfortunately, provision of this information is often lacking. This problem can be addressed through standard communication protocols because all referring physicians benefit from receiving the same types of information in response to referral requests; for example, acknowledgement of referral receipt or patient consult reports.
Furthermore, when referrals are initiated, specific types of requests can benefit from standardization of communication methods and information requirements. Such activities are already underway in Canada in select areas. These successful initiatives, used together as complementary approaches to address the varying needs of referral requests, should be adopted throughout the country. Visit CMA's Referral and Consultation Process Toolbox1 for examples.
Recognition, in the form of appropriate compensation, must also be given to the time spent preparing and analyzing referral requests as well as conducting consultations. Support for the use of information technology infrastructure, where available, will also facilitate efforts to streamline referral and consultation processes.
It should be noted that, while the language of this policy statement has a focus on primary to specialty care referrals, the concepts and recommendations apply to referrals between all specialties.
* All stakeholders, especially physicians, but also, where appropriate, office assistants, nurses, other health care providers as well as patients, must be engaged in an early and meaningful way regarding any initiative that has a goal to improve referral or consultation processes.
* There is no single best way to access specialist expertise; as a result, a combination of complementary initiatives (e.g., formal consultation systems, standardized referral processes with central intake systems and/or physician directories) should be implemented to reduce variation in the approaches that are used and to facilitate more timely access to specialty care for patients.
* While acknowledging the referring physician's ability to interpret certain test results, the referral must be accompanied by appropriate information to allow the consulting specialist to fully assess the request, and the referring physician must be informed of what is "appropriate".
* The referring physician (and family physician if different), as well as the patient, should be kept informed, in a timely fashion, of the status of the referral request, using standardized procedures, minimum information requirements and timelines.
* Physician and/or physician practices should receive compensation and support in recognition of the time and effort undertaken to communicate appropriate information regarding referral requests as well as to conduct electronic or real-time consultations.
When a physician decides that a patient requires the expertise of another specialist, the most appropriate next step can range from the specialist answering a question to assessing the need for a particular procedure or treatment. No matter how simple or complex the specialist's involvement may be, successful communication between all physicians is critical. Unfortunately, this does not occur as often as it should. In October 2012, a survey of physicians on the topic of referrals found that while over half of both family physicians (52%) and other specialists (69%) agree that referral communication is effective, two-thirds of family physicians noted that some kind of communication problem was a main source of frustration for them; for example not being informed about: referral receipt, the patient's appointment, a treatment plan, or that the specialist does not do the service requested. A similar proportion of specialists noted a lack of basic or supporting information (e.g., reason for referral or lab test results) as a main frustration with referral requests.2
The most appropriate method of communication differs depending on the degree of specialist involvement that is required. There are no standards about which method of communication is the most appropriate or effective, or what information is required, for each situation. Referral request processes† vary significantly; not only across specialties but among specialists within a particular specialty and even within a geographic region. Examples of this variation include: some consulting specialists will accept referrals only if the referring physician has used their specific referral form; others accept referrals using only one particular communication method (e.g., by fax); and others accept referrals on just one day each month. Such variation creates inefficiencies because referring physicians must familiarize themselves with each request process that is required by each consulting specialist. The range and quality of information provided in a referral request also varies considerably; for example, too little information (i.e. no reason for referral provided), insufficient information (i.e. out-of-date or a lack of lab or imaging tests), or to too much information (i.e. non-contributory family history).
This lack of standardization is problematic. In this context, standardization means simplification rather than obligation. Standardized processes facilitate communications for referrals by removing ambiguities about which method is most appropriate for each situation. Communication methods and the types of information that are transferred between referring physicians and consulting specialists vary based on numerous factors, ranging from those beyond the control of physicians such as regulations and available technology, to those completely within their control such as their own individual preferences.
An effective way to facilitate appropriate and timely access to specialty care that is within the control of the health care profession is to explore the rationale behind these varying communication and information preferences and address these variations by developing, with meaningful participation and approval from physicians and their administrative staff, standard processes for requesting a specialist referral and for communicating back to the referring physician.
Some of the provincial Colleges of Physicians and Surgeons have guidelines or standards of practice specifically about referrals and consultations. The most comprehensive of these are the College of Physicians & Surgeons of Nova Scotia's (CPSNS) Guidelines for Physicians Regarding Referral and Consultation3 and the College of Physicians and Surgeons of Alberta's (CPSA) Standard for Practice on The Referral Consultation Process.4 In addition, the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (Royal College) developed collaboratively a guide to enhancing referrals and consultations between physicians.5 While these documents do not discuss which method of communication should be used for each referral request scenario, they do provide guidance in a number of areas, including:
* minimum requirements for information that should be provided with all referral requests
* information that should be conveyed to patients (e.g., why they are being referred, information about the specialist appointment, etc) as well as who should be providing this information
* processes that should be followed for patients requiring ongoing care from the consulting physician
While standardization of the minimum information requirements that should be included in communications between referring and consulting physicians is essential for finding efficiencies with referral processes, these efficiencies will not be fully realized without proper consideration of the information technology infrastructure that is used to convey this information. The way in which the information is provided should not require additional effort for either the sender or the receiver. Electronic referral systems, where all data necessary for an informative referral can be easily obtained by the appropriate physician from the patient's electronic health record, would be the best way to ensure that this occurs. However, until this becomes a reality, a suitable compromise can be found by allowing flexibility in the format in which the information is provided.
Communication from Primary Care to Specialty Care
When the extent of a specialist's involvement in patient care is simply providing a second opinion or advice about appropriate next steps, standardizing the process for this kind of communication is relatively straightforward. This is because the variation that exists in this situation is primarily due to the availability of the consulting specialist and the methods of communication that each referring physician can use to contact the specialist.
Certain regions of the country have established consultation services whereby specialists participating in the program must respond to consult requests within a specified time frame. Examples of effective consultation systems include the telephone advice line known as Rapid Access to Consultative Expertise (RACE)6 in BC or the secure electronic consultation system known as Building Access to Specialist Care through e-Consultation (BASE)7 in the Champlain Local Health Integration Network (LHIN) in Ontario. Such services have proven quite effective at reducing the number of unnecessary referrals8,9; thereby ensuring more appropriate use of specialty care and helping to reduce wait times for this care. Through both of these systems, specialists ensure that they are available to respond to the consult question in a timely manner and each system uses only one form of communication.
At the other end of the spectrum of specialist involvement in patient care, when the patient sees the specialist, there is a much greater degree of variation in what is required of the specialist - from one-time interventions such as surgical procedures, to chronic care. The best approach for streamlining the referral process in these more complex situations varies, depending on the type of specialist care that is required.
With central intake referral systems, the referring physician sends a referral request to one location. This central location can be organized in two ways; central triage or pooled referrals. With central triage, referrals are assigned to specialists based on their level of urgency. With pooled referrals, each referral is allocated to the next available specialist, who then does the triaging. The differences in where the triaging occurs exist due to a number of factors; including the type of care the specialty provides as well as the number of specialists in the geographic region. However, for both types of central intake systems, the referring physician follows a standard process regardless of the specialist who assumes care of the patient.
Regardless of the type of central intake method that is used, the option to choose a particular specialist must always be available. However, even with this option in place, a central intake system of any kind is not necessarily the most appropriate solution for all specialties. This is often the case when ongoing patient-specialist relationships are quite common. For example, a woman might prefer that the same obstetrician cares for her during all of her pregnancies, or patients with chronic conditions such as arthritis or diabetes and require continuous care throughout their lifetime. In these situations, coordinating a central intake program where a significant proportion of specialist appointments are repeat visits is difficult.
A physician directory might be a more useful referral tool in situations where specialties do not have sufficient numbers of specialists in one geographic region or for those that have a high degree of sub-specialization. Such directories provide, at a minimum, details of the services each specialist provides and does not provide. Those that provide information regarding wait times, especially those with information on the wait for the first specialist visit, are extremely useful for referring physicians as it allows them to select a specialist with the most appropriate wait time for their patient and, where relevant, it also allows the referring physician to develop an appropriate care plan based on the time the patient must wait for specialty care.
Despite the fact that the complexities with specialty referrals mean that there is no one solution that is appropriate for all types of specialties, the extreme variation in processes that currently exists is also unnecessary.
Standard referral information requirements for specialty groups with similar needs, such as most surgical specialties, have been effectively established in some areas of the country. For example, in Calgary, Alberta, a major initiative known as Medical Access to Service10, has, among other things, successfully developed a standard referral form and process for central intake for multiple specialties. While most of these specialties also request additional information, each specialty has agreed on a standard set of minimum requirements. These standards were developed collaboratively with physicians and could be expanded nationwide, while taking regulatory and technological differences into account.
When establishing the requirements for an informative referral, consulting specialists must acknowledge that the referring physician may not have the expertise necessary to appropriately interpret certain test results. In such cases it is the consulting specialists who should order these tests.
Communication from Specialty Care to Primary Care
What must not be overlooked is that referral communication is bilateral. Informative and timely communication from the consulting specialist to the referring physician is also critical for a successful referral. Such a referral can be defined as one where the patient receives appropriate and timely specialty care where all parties - patient, specialist(s), referring physician and family physician (when the referring physician is not the patient's family physician) - are aware of all of the patient's relevant interactions with the health care system as well as any follow-up care that may be required. To ensure this occurs, after the referral request is initiated, the referring physician (and family physician if different) should be informed, in a timely manner, of the status of the referral at all stages:
* referral receipt
* request for more information
* referral acceptance/rejection (with explanation and suggested alternatives)
* patient appointment has been scheduled
* patient consult notes (including recommended treatment plan and follow-up)
A definition of what is considered "timely" is required. Standards must be established based on what is considered to be an acceptable response time at each stage. The patient must also be promptly informed of the status of the referral request throughout the entire process.
Examples of the types of information that should be conveyed include (where appropriate):
* how the referral request will be processed; e.g., pooled referral or central triage
* expected wait time or when the appointment has been scheduled
* whether another specialist has been contacted
* whether a repeat visit is required
* whether the patient has been contacted about anything that is relevant to them; e.g., referred elsewhere, wait time, appointment(s) scheduled
The information and communication that the referring physician requires from the consulting specialist for all referrals is much more homogeneous. In addition, there are no regulatory or technological barriers preventing the provision of this information at the appropriate stages of the referral process. This is one area where communication between physicians is within their control. Therefore, improved communication for responses to referral requests through standardized processes can be much more easily established. Unfortunately this is not the case, causing considerable effort to be undertaken by referring physicians and/or their office staff to track the status of referrals.
Considerably less attention has been given to this part of the process; however, some activities described in the CMA's Referral and Consultation Process Toolbox1 do address problems regarding the referral response. Central Intake systems are an example. These often include standard response times for at least the first three stages noted above, as well as information about the specialist who has received the referral request.
The previously cited guidelines developed by the CPSNS 3, the standard of practice by the CPSA4 and the guide to enhancing referrals and consultations between physicians developed by the CFPC and the Royal College5 also have recommendations for consulting specialist responses to referral requests (including information requirements and timelines). These resources can be used as a starting point for establishing referral communication standards in both directions and with patients. As an important example, the guidelines for both provincial colleges specifically indicate that the consulting specialist is responsible for arranging appointments with the patient and notifying the referring physician of the date(s).
Compensation and Support
Another aspect of the referral process that is not given sufficient consideration is the time and effort that is involved in preparing and responding to a referral request. Both preparing an informative referral request and responding to one is time-consuming; very little recognition is given towards this work. In some areas of the country, physicians receive compensation for participating in electronic or telephone consultation programs. This form of recognition has successfully helped avoid unnecessary referrals and should be expanded nation-wide; however, much more should be done to acknowledge this effort, especially when a specialist visit is necessary.
The time referring physicians spend gathering the necessary data for a referral request, or the time consulting specialists spend analyzing this data, triaging the referrals accordingly and preparing patient consult notes, is almost never acknowledged as part of a physician compensation package. In most jurisdictions this work is considered to be just a component of a typical patient visit. Since many primary care group practices employ administrative staff who are "referral coordinators"; whose main role is to assist physicians in the data gathering and preparation that is required for an informative referral request, as well as following up on referral requests; the process of referring a patient to specialty care is much more than "just a component of a typical patient visit".
Support for widespread implementation of effective information technology infrastructure can facilitate the preparation of appropriate referral requests and responses and can also encourage timely and informative communication between referring physicians and consulting specialists.
The high degree of variability in both the methods of communication and the information transferred between physicians is a significant barrier to timely access to specialty care for patients. Significant effort by physicians and their office staff is expended unnecessarily in the referral process, not only in initiating or responding to the request, but also in tracking and follow-up.
While there is no single solution that will address all referral communication problems, several complementary solutions exist that can reduce this variability and wasted effort, thereby simplifying the process and facilitating appropriate, timely and informative communication between referring physicians and consulting specialists. Examples of such initiatives can be found in the CMA's Referral and Consultation Process Toolbox.1
* For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care.
† For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care.
1 Canadian Medical Association. Referral/Consultation Process. Available at: http://www.cma.ca/referrals. Accessed 29 Nov 2013.
2 Canadian Medical Association. Challenges with patient referrals - a survey of family physicians and other specialists; October 2012 (Unpublished).
3 College of Physicians and Surgeons of Nova Scotia. Guidelines for Physicians Regarding Referral and Consultation. Available at: http://www.cpsns.ns.ca/Portals/0/Guidelines-policies/guidelines-referral-consultation.pdf. Accessed 15 Nov 2013.
4 College of Physicians & Surgeons of Alberta. The Referral Consultation Process. Available at: http://www.cpsa.ab.ca/Libraries/standards-of-practice/the-referral-consultation-process.pdf?sfvrsn=0. Accessed 16 Sep 2014.
5 College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada. Guide to enhancing referrals and consultations between physicians. Available at: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=3448. Accessed 27 Nov 2013.
6 Rapid Access to Specialist Expertise. Available at: www.raceconnect.ca. Accessed 27 Nov 2013.
7 Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consultation. Open Med. 2013 Jan 8;7(1):e1-8. Available at: http://www.openmedicine.ca/article/view/551/492. Accessed 27 Nov 2013.
8 Wilson M. Rapid Access to Consultative Expertise: An innovative model for shared care. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/RACE-Overview-March-2014.pdf. Accessed 16 Sep 2014.
9Afkham A. Champlain BASE project: Building Access to Specialists Through e-Consultation. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Champlain-BASE-Dec2013-e.pdf. Accessed 16 Sep 2014.
10 Alberta Health Services, University of Calgary Department of Medicine. Medical Access to Service (MAS). Available at: http://www.departmentofmedicine.com/MAS/ Accessed 15 Nov 2013.