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Examining the appropriateness of new referrals to the urology outpatient clinic of a tertiary care pediatric hospital
Martha Pokarowski, MPH1, Joana Dos Santos, MD1, Amre Kesavan, Medical Student2, Walid A. Farhat, MD1, Darius J. Bagli, MDCM1, Abby Varghese, NP1, Mandy Rickard, NP1, Mohammed Beaiti, MD1, Fadi Zu'bi, MD1, Anne-Sophie Blais, MD1, Nicolas Fernandes, MD1, Martin A. Koyle, MD1.
1The Hospital for Sick Children, Toronto, ON, Canada, 2School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.

BACKGROUND: Approximately 12,000 patients are seen in our pediatric urology outpatient clinic each year, amongst 5 full time faculty. Up to 3,500 of these patients are new referrals. Anecdotally, it has been our impression that a large proportion of new referrals were "inappropriate", in that they could have been managed more efficiently by alternative means rather than "in-person". In an era of value-based medicine, efforts to improve the triage of patients for maximum patient and provider benefit are imperative. We proposed to assess the clinical appropriateness of referrals to our institution's pediatric urology outpatient clinic.
METHODS: Following approval from our institutional Quality Improvement Committee, we administered a survey to non-sequential patients/families newly referred to our clinic to collect demographic information, details regarding the patient's diagnosis, and overall impressions with the clinic visit. A second concurrent survey assessing the appropriateness of each new referral and overall visit satisfaction was administered to physicians and nurse practitioners (NPs) at the same clinic visit. Details regarding the referring physician were obtained from our electronic referral management system (ARMs).
RESULTS: A total of 100 patients/families were recruited over 3 months. Although indicated as new referrals on ARMs, 20% of families reported visiting our outpatient clinic once and 15% reported visiting 2 or more times. Families were more satisfied with their visit than physicians and NPs (p<0.001). 39% of referrals were deemed as somewhat or totally inappropriate. The majority of these were referred by family physicians when compared with pediatricians or other referring professionals (p=0.015). Premature referrals (15%), spontaneously resolved conditions (10%), and more efficient management at the primary care level (36%) were the most common reasons provided for somewhat or totally inappropriate referrals. Physicians and NPs reported an increase in visit satisfaction with an increase in referral appropriateness (p<0.001).
CONCLUSIONS: A substantial number of referrals were reported as somewhat or totally inappropriate, where a significantly larger number of these were referred by family physicians. Referral inappropriateness impacts provider satisfaction and potentially affects burnout. Improved understanding of referral appropriateness can help guide interventions that will increase service efficiency without compromising quality of patient care.


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