Central Referral Triage System Improves Access to Rheumatology Care

Rheumatology referrals for patients improve after the implementation of centralized intake and triage systems, according to research published in Arthritis Care and Research.

Glen S. Hazlewood, MD, PhD, FRCPC, of the Cumming School of Medicine at the University of Calgary and the University of Toronto, and colleagues, set out to evaluate the short- and long-term impact of the Central Referral and Triage in Rheumatology (CReATe Rheum) system on wait times, efficiency, quality of referrals, and triage accuracy in a cohort of 2 million rheumatology patients.

CReATe Rheum was implemented in 2006. Upon implementation, all new patient referrals to rheumatologists in the Calgary area were received via a single fax number at a central office location which served as a service hub.

A standardized referral form provided guidance for referring physicians, and a nurse clinician with <15 years of rheumatology experience was hired to triage referrals. Additionally, the nurse clinician was tasked with formulating a working diagnosis and determining the urgency of each referral as eitheremergent, urgent, moderate, or routine.

Prior to implementation of CReATe Rheum, the researchers performed an audit of each participating practice and conducted pre-implementation satisfaction surveys of referring physicians. These data were used to guide the development of CReATe Rheum.

The impact of CReATe Rheum was prospectively evaluated over a 2-year period (January 1, 2007 to December 31, 2008). Long-term evaluation—beyond the 2 year period—included continued tracking of total number of received referrals, accepted referrals, and wait times over a 7-year period, concluding on December 31, 2013.

Through the pre-implementation practice audit, the researchers found significant inefficiencies in the referral process. Overall wait time was 155±88 days for routine referrals, 110±57 days for moderate referrals, and 29±46 days for urgent referrals; mean wait time for routine referrals varied between 43±25 days and 335±56 days among 13 individual rheumatologists. 

Similar variability was observed for both moderate and urgent referrals (39±24 days to 2015±65 days and 8±11.5 days to 59±85 days, respectively).

Eight percent of patients were found to be no-shows, and 6% of referrals were duplicate consultations. Additional data collected through the satisfaction survey showed a lack of communication between referring physicians and rheumatologists and indicated that poor-quality referrals resulted in triage difficulty.

Over 9000 referrals were received by CReATe Rheum during the 2-year study period. Ninety two percent of these referrals were accepted. Seventy-nine percent of the referrals were considered routine; 16% were moderate and 5% were urgent. Duplicate referrals were eliminated after the implementation of CReATe Rheum, and patient no-shows decreased from 8% to 6% but were not statistically significant (P =.46).

Mean wait times were similar for routine referrals (149±65 days, P =.11) but improved for moderate and urgent referrals (78±56 days, P <.001 and 18±23 days, P =.01, respectively). Referral quality was rated as moderate in 72% of cases, and 90% of the referrals fell into an “appropriate” triage category.

During the 7-year long-term follow-up period, 42,023 referrals were received via CReATe Rheum; 86% of those referrals were accepted. Patient no-shows decreased to less than 2% in 2012-2013, and wait times for both moderate and urgent referrals met the wait time targets of 1 to 4 weeks and 1 to 4 months, respectively.

Summary and Clinical Applicability

The innovative triage and referral system introduced by CReATe Rheum successfully facilitated timely access to care for rheumatology patients. Further long-term follow-up demonstrated that, despite an increasing number of referrals, CReATe Rheum can accurately cope with increased demand.

“Although our centralized referral system may not be feasible in all health care systems, it serves as a model for improving access to care,” the authors noted. “The system is based on a collegial approach to patient care by the rheumatologists in our group. It has the advantage of allowing us to prioritize patients and also to stream patients into specialty clinics where opportunities for quality assessment…are available.” 

Limitations and Disclosures

• The evaluation of the CReATe Rheum system was limited by the pre-/post-study design, and the authors noted that other changes in the health care system may have also been responsible for observed differences
• The researchers did not have access to a comparator population

Dr Lopatina receives support from the Arthur J.E. Child Chair in Rheumatology Outcomes research.

Dr Marshall receives support from the Canadian Institutes of health Research Canada Research Chair in Health Services and Systems Research, and from the Arthur J.E. Child Chair in Rheumatology Outcomes Research.