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The growth of physician vertical integration raises concerns about distorted referral patterns, higher spending, and market foreclosure. Using 100% Medicare data, we combine reduced-form analysis with a discrete choice model to estimate the effects of physician vertical integration on patients' provider choices and welfare for two common "downstream" surgical procedures. Physician-hospital integration results in an approximately 10% increase in referrals to higher-priced facilities instead of lower-priced providers. Our counterfactual analysis implies that if all primary care physicians become integrated, total Medicare spending will increase by $315 million.

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Background and aim Primary care is an important element for every healthcare system around the world. Providing and optimizing the connection between the primary care centers and advanced clinical centers is a key concept for a well-functioning healthcare system. Our aim in this study was to analyze and review the referral data of primary care centers located in Ankara, Türkiye. Materials and methods We collected the entire referral data from the primary care centers, totaling 8,746 patients between January 1, 2019 and December 31, 2023 by using emergency medical services (EMS) transfer in Ankara. Demographic data, call reasons, transfer centers and transfer-related characteristics of the patients were recorded retrospectively, grouped by year, using EMS data. Results Our findings have shown that most of the referrals were made for Turkish citizens with 8,360 (95.6%) (p<0.001). Healthcare centers located in inner city had the most referrals made with 7,087 (81.0%) (p<0.001). Majority of the referrals were made by physicians in family healthcare centers with 6,583 (75.3%) (p<0.001) with chest pain being the most common diagnosis for referral initiation with 1,429 (16.3%) (p<0.001). This was followed by trauma, with 1,172 (13.4%) (p<0.001). Most common cause for trauma was falls with 613 (52.3%) (p<0.001). Conclusion Our data revealed important elements of local referral patterns. According to our data, majority of the referrals were made by inner city healthcare facilities. Family healthcare centers formed most of the referral requests. For this reason, strengthening these centers is important to prevent unnecessary resource use and delays.

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Purpose: To report demographic and clinical characteristics of patients who were more likely to receive proton beam therapy (PBT) than photon therapy from facilities with access to proton centers. Materials and Methods: We utilized the national cancer database to identify the facilities with access to PBT between 2004 and 2015 and compared the relative usage of photons and PBT for demographic and clinical scenarios in breast, prostate, and nonsmall cell cancer. Results: In total, 231 facilities with access to proton centers accounted for 168 323 breast, 39 975 lung, and 77 297 prostate cancer patients treated definitively. Proton beam therapy was used in 0.5%, 1.5%, and 8.9% of breast, lung, and prostate cases. Proton beam therapy was correlated with a farther distance traveled and longer start time from diagnosis for each site (P < .05).For breast, demographic correlates of PBT were treatment in the west coast (odds ratio [OR] = 4.81), age <60 (OR = 1.25), white race (OR = 1.94), and metropolitan area (OR = 1.58). Left-sided cancers (OR = 1.28), N2 (OR = 1.71), non-ER+/PR+/Her2Neu- cancers (OR = 1.24), accelerated partial breast irradiation (OR = 1.98), and hypofractionation (OR = 2.35) were predictors of PBT.For nonsmall cell cancer, demographic correlates of PBT were treatment in the south (OR = 2.6), metropolitan area (OR = 1.72), and Medicare insurance (OR = 1.64). Higher comorbid score (OR = 1.36), later year treated (OR = 3.16), and hypofractionation (not SBRT) (OR = 3.7) were predictors of PBT.For prostate, correlates of PBT were treatment in the west coast (OR = 2.48), age <70 (OR = 1.19), white race (OR = 1.41), metropolitan area (OR = 1.25), higher income/education (OR = 1.25), and treatment at an academic center (OR = 33.94). Lower comorbidity score (OR = 1.42), later year treated (OR = 1.37), low-risk disease (OR = 1.45), definitive compared to postoperative (OR = 6.10), and conventional fractionation (OR = 1.64) were predictors of PBT. Conclusion: Even for facilities with established referrals to proton centers, PBT utilization was low; socioeconomic status was potentially a factor. Proton beam therapy was more often used with left-sided breast and low-risk prostate cancers, without a clear clinical pattern in lung cancer.

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Sarcomas, rare and with lower survival rates than common tumors, offer insights into healthcare efficiency via the analysis of the total interval of the diagnostic pathway, combining the patient interval (time between the first symptom and visit with a physician) and diagnostic interval (time between first physician visit and histological diagnosis). Switzerland's healthcare system, Europe's costliest, lacks research on treating rare conditions, like mesenchymal tumors. This study examines the total interval of the diagnostic pathway for optimization strategies. Analyzing a dataset of 1028 patients presented from 2018 to 2021 to the Swiss Sarcoma Board (MDT/SB-SSN), this retrospective analysis delves into bone sarcoma (BS), soft-tissue sarcoma (STS), and their benign counterparts. Demographic and treatment data were extracted from medical records. The patient interval accounted for the largest proportion of the total interval and secondary care interval for the largest proportion of the diagnostic interval. Age, grade, and localization could be elicited as influencing factors of the length of different components of the total interval. An increasing age and tumor size, as well as the axial localization, could be elicited as factors increasing the probability of sarcoma. The patient and secondary care interval (SCI) offer the greatest potential for optimization, with SCI being the bottleneck of the diagnostic interval. New organizational structures for care work-ups are needed, such as integrated practice units (IPU) as integral part of value-based healthcare (VBHC).

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PURPOSE: The growing demand for implants has led to their implementation by general dental practitioners (GDPs) in clinical practice. The present study assessed referral patterns of GDPs for the surgical phase of implant dental treatment. MATERIALS AND METHODS: One hundred fifty GDPs were asked to fill out a structured questionnaire containing their demographic data and answer six questions characterising their referral patterns for implant dentistry. RESULTS: Forty-one (41%) percent performed the surgical phase, and 87% provided implant restoration. Gender was the only influencing factor for the surgical phase, as 51.4% of male GDPs and 6.5% of female GDPs performed implant surgery themselves. Experience and practice set-up did not influence the referring decision. Fifty-four percent of the practitioners referred 0 to 5 patients per month, and the chosen specialists were: 80% oral and maxillofacial surgeon, 11% periodontist, and 9% selected a specialist depending on the individual case. The major reasons influencing the referral pattern were the complexity of the surgical procedure, followed by systemic medical compromise of the patient. CONCLUSIONS: Most implant surgeries in Israel are still performed by specialists.

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PURPOSE: Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. METHODS: Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. RESULTS: Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. CONCLUSIONS: Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.

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BACKGROUND AND OBJECTIVES: Primary resection and debulking of liver metastases have been associated with improved survival in pancreatic neuroendocrine tumors (PNETs). The treatment patterns and outcomes differences between low-volume (LV) institutions and high-volume (HV) institutions remains unstudied. METHODS: A statewide cancer registry was queried for patients with nonfunctional PNET from 1997 to 2018. LV institutions were defined as treating <5 newly diagnosed patients with PNET per year, while HV institutions treated ≥5. RESULTS: We identified 647 patients: 393 with locoregional (n = 236 HV care, n = 157 LV care) and 254 with metastatic disease (n = 116 HV care, n = 138 LV care). Patients with HV care had improved disease-specific survival (DSS) compared to patients with LV care for both locoregional (median 63 vs. 32 months, p < 0.001) and metastatic disease (median 25 vs. 12 months, p < 0.001). In patients with metastatic disease, primary resection (hazard ratio [HR]: 0.55, p = 0.003) and HV institution (HR: 0.63, p = 0.002) were independently associated with improved DSS. Furthermore, diagnosis at a HV center was independently associated with higher odds of receiving primary site surgery (odds ratio [OR]: 2.59, p = 0.01) and metastasectomy (OR: 2.51, p = 0.03). CONCLUSIONS: Care at HV centers is associated with improved DSS in PNET. We recommend referral of all patients with PNETs to HV centers.

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Objective: To analyze the use of services regarding fertility preservation (FP) in cancer patients at a single institution. Design: A retrospective cohort study. Setting: Academic medical center. Patients: A total of 208 FP referrals. Interventions: None. Main Outcome Measures: Method of FP; time from referral to FP intervention. Results: A total of 553 patients were referred to a reproductive specialist for FP in the setting of a medical diagnosis from 2011 to 2016. Of these, 208 patients satisfied the inclusion criteria and met with a reproductive specialist. Ninety patients underwent FP services. The average age at referral was 30.9 ± 7.9 years. Breast cancer (n=94, 45%) and leukemia/lymphoma (n=62, 30%) were the most prevalent cancer diagnoses. A 68.9% of patients underwent oocyte cryopreservation (n=62), 26.7% underwent embryo cryopreservation (n=24) and 4.4% underwent ovarian tissue preservation (n=4). The time interval from the referral to the FP intervention ranged from 1 to 810 days, with a median of 17 days. Conclusions: In the setting of a cancer diagnosis, most patients undergoing FP intervention underwent oocyte cryopreservation, were <35 years old, and underwent FP intervention in <30 days from referral. Whereas FP should ideally be initiated at the time of cancer diagnosis, all patients with a cancer diagnosis should be referred to a reproductive specialist and counseled on options for FP to preserve the optionality for the reproductive future they desire.

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BACKGROUND AND AIMS: Fatty liver disease is a global health concern, but in the absence of specific guidelines, current referral patterns differ according to the preferences of the general practitioners. Outpatient Gastroenterology clinics spend futile resources on liver-healthy patients while diagnosing decompensated patients delayed. We aimed to describe referral patterns to a regional outpatient Gastroenterology clinic. METHODS: We reviewed 9684 referrals from primary care for suspected liver disease in the years 2016-2017, during two years. Data were extracted from the patients' hospital records to assess the clinical workup and patient outcomes until a mean of 43 months after the time of referral. Referrals were categorized as unnecessary (no signs of liver disease), timely (significant fibrosis/compensated cirrhosis), or delayed (decompensated cirrhosis). RESULTS: We included 375 patient referrals from primary care. The main reason for referral was elevated transaminases. More than half (54%) of patients had no signs of liver disease, being unnecessarily referred for evaluation, while 17% had decompensated liver disease and were thus referred too late. CONCLUSIONS: Only one-third of patients referred on suspicion of liver disease were referred on time, either before presenting with decompensated liver cirrhosis or with some evidence of significant liver disease, e.g., liver fibrosis. There is a huge unmet need for clinical referral pathways in primary care. Strengths and Limitations of this StudyA strength of this study is the complete mapping of all potential referrals to the outpatient clinic in the two-year period. Instead of retrieving the historic data by ICD-10 diagnosis codes, and reflecting only those patients where the GP clearly suspects liver disease, we have a strong reliance on our methods. We screened all potentially relevant referrals, e.g., referrals due to weight loss or fatigue, which may reflect symptoms of cirrhosis. Thereby we are confident that we have not missed any patients that originally were referred with unspecific symptoms, but after evaluation are diagnosed with liver disease.Another strength of our study is the long follow-up period, which allows us to fully evaluate the course for the individual patient, and the potential later coming diagnoses.Finally, it is a strength of the study that we were not exclusive to one liver disease etiology, both ALD and NAFLD etiology were included in the study.A limitation of this study is the use of historic data, and the fact that it is a single-center study, showing only the referral patterns in one outpatient Gastroenterology clinic.

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BACKGROUND: General dental practitioners often perceive root canal treatments as complex, and specialist referrals are commonplace in general dental practice. Therefore, the aim of this study was to better understand the knowledge of Australian general dentists and their attitudes regarding endodontics in general, and specifically (RCT), to highlight barriers and facilitating factors in the provision of endodontic care. METHODS: A combined paper-based and online survey was sent to general dental practitioners. The questionnaire consisted of 27 items, presented as checkboxes and in Likert scale format. Responses were tabled and statistically contrasted using Chi-square tests and linear regression analysis. RESULTS: A significant proportion of surveyed dentists were not confident in their ability to provide endodontic care, specifically root canal treatments (RCT). Confidence depended on factors, such as time in practice, participation in continuing professional development as well as fear of litigation and type of treatment. Other factors such as the availability of appropriate instruments and referral options, had comparatively little impact on practitioner confidence. DISCUSSION: While almost all general dental practitioners (GDPs) surveyed in this study believe RCT is important for improving the long-term retention of a tooth, just over half of the GDPs say they feel confident in their knowledge and provision of root canal treatment procedures.

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BACKGROUND: Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk. METHODS: We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0). RESULTS: We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949. CONCLUSIONS: This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension. TRIAL REGISTRATION: Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018.

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INTRODUCTION: Bariatric surgery (BS) has been shown to effectively treat morbid obesity and improve obesity-related comorbidities. Nonetheless, BS remains underutilized among qualified patients. MATERIALS AND METHODS: PubMed, SCOPUS, and OVID databases were searched to identify published comparative studies examining BS referral patterns. Data on barriers to BS referrals were examined and summarized. RESULTS: Barriers to referrals stemmed largely from a lack of familiarity with safety, efficacy, and postoperative care amongst providers. Providers with previous referrals were more likely to report higher knowledge, comfort in referring patients, and ability to provide postoperative care. Provider initiated discussion of BS was positively associated with referrals. Female and younger patients were more likely to receive referrals. Furthermore, access to appropriate peri-operative resources, local bariatric programs, and insurance eligibility were associated with referral rates. Encouragingly, providers across specialties report eagerness to gain exposure and training in BS. CONCLUSIONS: Lack of provider familiarity with BS efficacy, safety and postoperative care likely contributes to low utilization rates of BS. Further potential barriers in access to BS are logistic factors such as insurance coverage, limited local perioperative resources, and clinic time constraints for patient counseling. Promotion of BS amongst providers and both surgical and non-surgical trainees will likely have a significant impact on referral rates and access to this life-saving procedure. Future studies should further investigate the barriers to BS and delineate the effect size of each barrier on referral rates to efficiently increase access.

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INTRODUCTION: Cryptorchidism, or undescended testis (UDT), is identified in 1% of boys by one year of age and carries long term risks of infertility and testicular neoplasia. In 2014, the American Urological Association (AUA) released a guideline statement stating that patients with UDT should be referred to a urologist by 6 months of age in order to facilitate timely surgical correction. This study is the follow-up to a 2010 study assessing referral patterns to our university center from primary care providers. OBJECTIVE: In this new study, we aim to identify changes in referral patterns in response to the establishment of the 2014 AUA guidelines and to understand how our referring physicians stay abreast of current knowledge regarding UDT. STUDY DESIGN: A 9 question anonymous survey regarding UDT referral patterns was sent to providers who had previously referred a patient to our pediatric urology practice. The results were categorized by specialty and were compared to the similar survey from 2010. RESULTS: Surveys were sent to 500 physicians with 138 (27.6%) responses received. Less than half of respondents reported that they would refer a boy with unilateral or bilateral palpable UDT by 6 months of age (37.0% and 38.4% respectively). This was not significantly different than the 2010 survey (p = 0.68 and 0.27 respectively). Two-thirds of physicians would refer a patient with unilateral nonpalpable UDT within the recommended time frame (68.8%); this was also unchanged from 2010 (p = 0.87). There was an improvement in respondents who would refer immediately for bilateral nonpalpable testes from 49.8% in 2010 to 53.6% in 2017 (p = 0.01). Residency training was most commonly cited as the primary source of knowledge regarding UDT although 89.3% of respondents citing this were >5 years removed from residency training. DISCUSSION: Delayed referral patterns were reported by the majority of providers for palpable UDT and by greater than one-third of providers for nonpalpable UDT. There was minimal change in referral patterns between 2010 and 2017 despite the release of the AUA cryptorchidism guidelines in 2014. In both 2010 and 2017, residency training was identified as the primary source of knowledge regarding management of UDT. CONCLUSION: These findings suggest an unmet need for education regarding contemporary management of UDT for the primary care physicians in our community.

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OBJECTIVE: Despite evidence of volume-outcome relationships for cancer surgery, treatment at low-volume hospitals remains common. Our objective was to evaluate whether individuals actively involved in selecting their cancer surgeon were more likely to go to hospitals recognized for quality cancer care. METHODS: Individuals diagnosed with breast, prostate and colorectal cancer in 2015 completed online surveys in 2017-2018. Participants were categorized as "directed" to a surgeon (relied on referral) or "active" (sought additional information), and hospitals were categorized by NCI-designation, CoC accreditation, and academic affiliation. RESULTS: Of 299 participants, 42% were active. Individuals with breast cancer were more active (aOR = 2.46,95%CI:1.32-4.59). Active participants had nonsignificantly higher odds of surgery at NCI-designated facilities (aOR = 2.04,95%CI:0.95-4.38), or academic centers (aOR = 1.51,95%CI:0.86-2.64). CONCLUSIONS: While most participants were directed to their cancer surgeon, active participants tended to select NCI-designated/academic hospitals. Although centralization of cancer care would require altering referral patterns, decision-support resources may help patients make informed choices.

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AIM: The aim was to determine how nurse practitioner (NP) roles are translated into clinical practice across Victoria, Australia. This paper reports details about NP work patterns and scopes of practice across multiple clinical settings and geographic locations. DESIGN: A quantitative survey design was used. A data abstraction tool, based on previous work, was adapted for this study. METHODS: All NPs in one state of Australia were eligible to participate in the study and invited to complete an online survey about their NP practice. A previously developed data collection tool, capturing practice patterns of NPs, was adapted for online use in REDCAP. The data were exported, and descriptive statistics were analysed using SPSS. RESULTS: Participants were mostly female, with males accounting for 25%. Findings indicate several NPs working in outpatient settings, community settings and forensic care. Patterns of practice-prescribing and ordering diagnostics-are associated with clinical context and model of care of the NP work.

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BACKGROUND: Patients with rectal cancer treated at specialized or high-volume hospitals have better outcomes, but a minority of these patients are treated there. Physician recommendations are important considerations for patients with rectal cancer when making treatment decisions, yet little is known about the factors that affect these physician referral patterns. METHODS: Semistructured telephone interviews were conducted in 2018-2019 with Iowa gastroenterologists (GIs) and general surgeons (GSs) who performed colonoscopies in a community setting. A thematic approach was used to analyze and code qualitative data. RESULTS: We interviewed 10 GIs and 6 GSs with self-reported averages of 15.5 y in practice, 1100 endoscopic procedures annually, and 6 rectal cancer diagnoses annually. Physicians believed surgeon experience and colorectal specialization were directly related to positive outcomes in rectal cancer resections. Most GSs performed resections on patients they diagnosed and typically only referred patients to colorectal surgeons (CRS) in complex cases. Conversely, GIs generally referred to CRS in all cases. Adhering to existing referral patterns due to the pressure of health care networks was a salient theme for both GIs and GSs. CONCLUSIONS: While respondents believe that high volume/specialization is related to improved surgical outcomes, referral recommendations are heavily influenced by existing referral networks. Referral practices also differ by diagnosing specialty and suggest rural patients may be less likely to be referred to a CRS because more GSs perform colonoscopies in rural areas and tend to keep patients for resection. System-level interventions that target referral networks may improve rectal cancer outcomes at the population level.

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Palliative care (PC) serves a valuable role throughout the disease trajectory for adolescents and young adults (AYAs) living with cancer. A 3-year retrospective chart review was performed to characterize AYA PC referral patterns in patients aged 18-39 years to identify strategies for improving PC access. Despite known benefits, AYA referrals to PC during oncologic treatment occurred only for a small percentage of eligible patients (8.4%), largely occurred in the inpatient setting (73%), and were more likely in specific cancer types with high symptom burden and/or poor survival, with the greatest penetrance noted in lung cancer (51%).

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BACKGROUND: Placenta accreta spectrum (PAS) is a spectrum of conditions in which the placenta is abnormally adherent and invades the uterine wall. This invasion can cause life-threatening hemorrhage and lead to significant adverse maternal outcomes. Numerous studies have shown an association between treatment of PAS at high volume, specialized centers and improved maternal outcomes; however, little is known about how these data have influenced practice. OBJECTIVE: The objective of the study was to examine the patterns of care for women with placenta accreta spectrum over time. STUDY DESIGN: Data from New York Statewide Planning and Research Cooperative System (SPARCS) from 2000 to 2017 was used for this analysis. The study cohort comprised of women aged 15-54 years with PAS who underwent a hysterectomy during their delivery hospitalization. Study outcomes included severe maternal morbidity as defined by the Centers for Disease Control and Prevention, surgical complications, and transfusion. Hospitals were stratified into tertiles based on the volume of PAS hysterectomy cases. Patient demographic and clinical characteristics were compared across volume tertiles. Random intercept log-linear regression models with Poisson distributions and log link functions were fit to examine the association between hospital PAS volume and the outcomes of interest. RESULTS: A total of 1958 women with PAS who underwent hysterectomy at 123 hospitals were identified. The number of hospitals providing care ranged from 46 centers in 2000 to 52 hospitals in 2016. The median hospital-level case volume of PAS was 1 (interquartile range [IQR], 1-2) in 2000 and rose slightly to 2 (IQR, 1-4) by 2016. The PAS volume cut-point for the top decile of hospitals was three cases in 2000 and increased to six cases in 2016. There was no significant change in the median travel distance for women with PAS over time. The rate of severe maternal morbidity increased significantly from 14.1% (95% CI: 7.8-24.0%) in 2000 to 19.0% (95% CI: 13.6-25.8%) in 2016. Transfusion occurred in 66.2% (95% CI: 54.6-76.1%) of cases in 2000 compared to 60.1% (95% CI: 52.3-67.4%) in 2016. Surgical complications occurred in 16.9% (95% CI: 9.9-27.3%) of cases in 2000 to 24.7% (95% CI: 18.6-32.0) in 2016. There was no difference in the adjusted rates of transfusion or surgical complications based on hospital volume. Compared to low-volume centers, the risk of severe maternal morbidity was reduced by 33% (aRR = 0.67; 95% CI: 0.50-0.90) at the intermediate volume centers. CONCLUSION: There has been little change in the patterns of care for women with PAS in New York State. While the volume of patients with PAS has increased at the highest volume centers, a large number of relatively low-volume centers still provide care for a significant number of women with PAS.

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INTRODUCTION: Limited data exist on US referral/management patterns for moderate-to-severe thyroid eye disease (TED), a disabling condition. METHODS: US ophthalmologists and endocrinologists experienced in treating TED provided medical record data of moderate-to-severe TED patients and information on referral/treatment practices. Data on signs/symptoms, medical/surgical treatments, treatment response, and referral history were collected. Moderate and severe cases were stratified to interrogate treatment/practice differences. RESULTS: A total of 181 physicians provided data on 714 patients (49.4 ±â€…13.6 years old, 65% women, 14% severe disease). Reporting physicians diagnosed 55% of patients themselves and solely managed 37% of cases, with similar referral/comanagement patterns between moderate and severe cases. Topical therapies included lubricating (79%) and glucocorticoid (39%) eye drops. Systemic therapies included oral glucocorticoids (36%), IV glucocorticoids (15%), and rituximab and/or tocilizumab (12%). Few patients underwent orbital radiation (4%) or surgical intervention (4%). IV glucocorticoids (33% vs. 12%), biologics (26% vs. 10%), orbital radiation (11% vs. 3%), and ocular surgery (12% vs. 3%) were used more often in severe versus moderate cases (all P < 0.001). However, severe disease was less responsive to therapy (very responsive to therapy: 28% vs. 49%, P < 0.001). CONCLUSIONS: Participating physicians were primarily responsible for just over one-half of TED diagnoses, but solely treated <40% of patients. Severe TED was treated more often with surgery and systemic immunologic therapies than moderate disease, but was less likely to respond to treatment. These results reinforce that moderate-to-severe TED is difficult to treat with an unmet medical need in the United States.

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BACKGROUND: An effective referral system is essential for a high-quality health system that provides safe surgical care while optimizing patient outcomes and ensuring efficiency. The role of referral systems in countries with under-resourced health systems is poorly understood. The aim of this study was to examine the rates, preventability, reasons and patterns of outward referrals of surgical patients across three levels of the healthcare system in Northern Tanzania. METHODS: Referrals from surgical and obstetric wards were assessed at 20 health facilities in five rural regions prospectively over 3 months. Trained physician data collectors used data collection forms to capture referral details daily from hospital referral letters and through discussions with clinicians and nurses. Referrals were deemed preventable if the presenting condition was one that should be managed at the referring facility level per the national surgical, obstetric and anaesthesia plan but was referred. RESULTS: Seven hundred forty-three total outward referrals were recorded during the study period. The referral rate was highest at regional hospitals (2.9%), followed by district hospitals (1.9%) and health centers (1.5%). About 35% of all referrals were preventable, with the highest rate from regional hospitals (70%). The most common reasons for referrals were staff-related (76%), followed by equipment (55%) and drugs or supplies (21%). Patient preference accounted for 1% of referrals. Three quarters of referrals (77%) were to the zonal hospital, followed by the regional hospitals (17%) and district hospitals (12%). The most common reason for referral to zonal (84%) and regional level (66%) hospitals was need for specialist care while the most common reason for referral to district level hospitals was non-functional imaging diagnostic equipment (28%). CONCLUSIONS: Improving the referral system in Tanzania, in order to improve quality and efficiency of patient care, will require significant investments in human resources and equipment to meet the recommended standards at each level of care. Specifically, improving access to specialists at regional referral and district hospitals is likely to reduce the number of preventable referrals to higher level hospitals, thereby reducing overcrowding at higher-level hospitals and improving the efficiency of the health system.

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