Académie d’Orléans-Tours Université François-Rabelais
FACULTE DE MEDECINE DE TOURS
Année 2014 N’
Thèse Pour le
DOCTORAT EN MEDECINE
Par
WAKED Mashhoor
Né le 18 juillet 1979 à Djeddah – Arabie Saoudite
Présentée et soutenue publiquement le 27 mars 2014TITRE
Obstacles rencontrés par les patients et leurs médecins de famille concernant le recours aux soins secondaires dans la
Ville de Djeddah (Arabie Saoudite)
Jury
Président de Jury : Monsieur le Professeur Dominique PERROTIN
Membres du Jury : Madame le Professeur Anne-Marie LEHR-DRYLEWICZ Monsieur le Professeur Laurent MACHET
Monsieur le Professeur Dominique HUAS
9 décembre 2013
UNIVERSITE FRANCOIS RABELAIS
FAFACCUULLTTEE DDEE MMEEDDEECCIINENE DDEE TTOOUURRSS
DOYEN
Professeur Dominique PERROTIN
VICE-DOYEN Professeur Daniel ALISON
ASSESSEURS
Professeur Daniel ALISON, Moyens Professeur Christian ANDRES, Recherche
Professeur Christian BINET, Formation Médicale Continue Professeur Laurent BRUNEREAU, Pédagogie
Professeur Patrice DIOT, Recherche clinique
SECRETAIRE GENERALE Madame Fanny BOBLETER
********
DOYENS HONORAIRES Professeur Emile ARON (†) – 1962-1966 Directeur de l’Ecole de Médecine - 1947-1962 Professeur Georges DESBUQUOIS (†)- 1966-1972
Professeur André GOUAZÉ - 1972-1994 Professeur Jean-Claude ROLLAND – 1994-2004
PROFESSEURS EMERITES
Professeur Alain AUTRET Professeur Jean-Claude BESNARD
Professeur Patrick CHOUTET Professeur Guy GINIES Professeur Olivier LE FLOCH Professeur Etienne LEMARIE Professeur Chantal MAURAGE Professeur Léandre POURCELOT
Professeur Michel ROBERT Professeur Jean-Claude ROLLAND
PROFESSEURS HONORAIRES
MM. Ph. ANTHONIOZ - A. AUDURIER – Ph. BAGROS - G. BALLON – P.BARDOS - J. BARSOTTI A. BENATRE - Ch. BERGER –J. BRIZON - Mme M. BROCHIER - Ph. BURDIN - L. CASTELLANI J.P. FAUCHIER - B. GRENIER – A. GOUAZE – M. JAN –P. JOBARD - J.-P. LAMAGNERE - F. LAMISSE – J.
LANSAC – J. LAUGIER - G. LELORD - G. LEROY - Y. LHUINTRE - M. MAILLET - Mlle C. MERCIER - E/H.
METMAN – J. MOLINE - Cl. MORAINE - H. MOURAY - J.P. MUH - J. MURAT - Mme T. PLANIOL - Ph.
RAYNAUD – JC. ROLLAND – Ch. ROSSAZZA - Ph. ROULEAU - A. SAINDELLE - J.J. SANTINI - D.
PROFESSEURS DES UNIVERSITES - PRATICIENS HOSPITALIERS
MM. ALISON Daniel ... Radiologie et Imagerie médicale ANDRES Christian ... Biochimie et Biologie moléculaire ANGOULVANT Denis ... Cardiologie
ARBEILLE Philippe ... Biophysique et Médecine nucléaire AUPART Michel ... Chirurgie thoracique et cardiovasculaire BABUTY Dominique ... Cardiologie
Mme BARILLOT Isabelle ... Cancérologie ; Radiothérapie M. BARON Christophe ... Immunologie
Mme BARTHELEMY Catherine ... Pédopsychiatrie
MM. BAULIEU Jean-Louis ... Biophysique et Médecine nucléaire BERNARD Louis ... Maladies infectieuses ; maladies tropicales BEUTTER Patrice ... Oto-Rhino-Laryngologie
BINET Christian ... Hématologie ; Transfusion BODY Gilles ... Gynécologie et Obstétrique BONNARD Christian ... Chirurgie infantile
BONNET Pierre ... Physiologie Mme BONNET-BRILHAULT Frédérique ... Physiologie
MM. BOUGNOUX Philippe ... Cancérologie ; Radiothérapie
BRILHAULT Jean ... Chirurgie orthopédique et traumatologique BRUNEREAU Laurent ... Radiologie et Imagerie médicale
BRUYERE Franck ... Urologie BUCHLER Matthias ... Néphrologie
CALAIS Gilles ... Cancérologie ; Radiothérapie CAMUS Vincent ... Psychiatrie d’adultes CHANDENIER Jacques ... Parasitologie et Mycologie CHANTEPIE Alain ... Pédiatrie
COLOMBAT Philippe ... Hématologie ; Transfusion
CONSTANS Thierry... Médecine interne ; Gériatrie et Biologie du vieillissement CORCIA Philippe ... Neurologie
COSNAY Pierre... Cardiologie
COTTIER Jean-Philippe ... Radiologie et Imagerie médicale COUET Charles ... Nutrition
DANQUECHIN DORVAL Etienne ... Gastroentérologie ; Hépatologie DE LA LANDE DE CALAN Loïc ... Chirurgie digestive
DE TOFFOL Bertrand ... Neurologie
DEQUIN Pierre-François ... Thérapeutique ; médecine d’urgence DESTRIEUX Christophe ... Anatomie
DIOT Patrice ... Pneumologie
DU BOUEXIC de PINIEUX Gonzague ... Anatomie & Cytologie pathologiques DUMONT Pascal ... Chirurgie thoracique et cardiovasculaire EL HAGE Wissam ... Psychiatrie adultes
FAUCHIER Laurent ... Cardiologie
FAVARD Luc ... Chirurgie orthopédique et traumatologique FOUQUET Bernard ... Médecine physique et de Réadaptation FRANCOIS Patrick... Neurochirurgie
FROMONT-HANKARD Gaëlle ... Anatomie & Cytologie pathologiques
FUSCIARDI Jacques ... Anesthésiologie et Réanimation chirurgicale ; médecine d’urgence GAILLARD Philippe ... Psychiatrie d'Adultes
GOGA Dominique ... Chirurgie maxillo-faciale et Stomatologie GOUDEAU Alain ... Bactériologie -Virologie ; Hygiène hospitalière GOUPILLE Philippe ... Rhumatologie
GRUEL Yves ... Hématologie ; Transfusion
GUERIF Fabrice ... Biologie et Médecine du développement et de la reproduction GUILMOT Jean-Louis ... Chirurgie vasculaire ; Médecine vasculaire
GUYETANT Serge ... Anatomie et Cytologie pathologiques HAILLOT Olivier ... Urologie
HALIMI Jean-Michel ... Thérapeutique ; médecine d’urgence (Néphrologie et Immunologie clinique) HANKARD Regis ... Pédiatrie
LEBRANCHU Yvon ... Immunologie
LECOMTE Thierry ... Gastroentérologie ; hépatologie ; addictologie LESCANNE Emmanuel ... Oto-Rhino-Laryngologie
LINASSIER Claude ... Cancérologie ; Radiothérapie LORETTE Gérard... Dermato-Vénéréologie MACHET Laurent ... Dermato-Vénéréologie MAILLOT François ... Médecine Interne MARCHAND-ADAM Sylvain ... Pneumologie
MARRET Henri ... Gynécologie et Obstétrique MARUANI Annabel ... Dermatologie
MEREGHETTI Laurent ... Bactériologie-Virologie ; Hygiène hospitalière MORINIERE Sylvain ... O.R.L.
MULLEMAN Denis ... Rhumatologie
PAGES Jean-Christophe ... Biochimie et biologie moléculaire
PAINTAUD Gilles ... Pharmacologie fondamentale, Pharmacologie clinique PATAT Frédéric ... Biophysique et Médecine nucléaire
PERROTIN Dominique ... Réanimation médicale ; médecine d’urgence PERROTIN Franck ... Gynécologie et Obstétrique
PISELLA Pierre-Jean ... Ophtalmologie
QUENTIN Roland ... Bactériologie-Virologie ; Hygiène hospitalière ROBIER Alain ... Oto-Rhino-Laryngologie
ROINGEARD Philippe ... Biologie cellulaire
ROSSET Philippe ... Chirurgie orthopédique et traumatologique
ROYERE Dominique ... Biologie et Médecine du développement et de la Reproduction RUSCH Emmanuel ... Epidémiologie, Economie de la Santé et Prévention
SALAME Ephrem ... Chirurgie digestive
SALIBA Elie ... Biologie et Médecine du développement et de la Reproduction Mme SANTIAGO-RIBEIRO Maria ... Biophysique et Médecine Nucléaire
MM. SIRINELLI Dominique ... Radiologie et Imagerie médicale THOMAS-CASTELNAU Pierre ... Pédiatrie
Mme TOUTAIN Annick ... Génétique
MM. VAILLANT Loïc ... Dermato-Vénéréologie VELUT Stéphane ... Anatomie
WATIER Hervé ... Immunologie.
PROFESSEUR DES UNIVERSITES DE MEDECINE GENERALE Mme LEHR-DRYLEWICZ Anne-Marie ... Médecine Générale
PROFESSEURS ASSOCIES
MM. HUAS Dominique ... Médecine Générale LEBEAU Jean-Pierre ... Médecine Générale MALLET Donatien ... Soins palliatifs POTIER Alain ... Médecine Générale
MAITRES DE CONFERENCES DES UNIVERSITES - PRATICIENS HOSPITALIERS
Mme ANGOULVANT Theodora ... Pharmacologie fondamentale ; pharmacologie clinique : addictologie M. BAKHOS David ... Physiologie
Mme BAULIEU Françoise... Biophysique et Médecine nucléaire
M. BERTRAND Philippe ... Biostatistiques, Informatique médical et Technologies de Communication Mme BLANCHARD Emmanuelle ... Biologie cellulaire
BLASCO Hélène... Biochimie et biologie moléculaire MM. BOISSINOT Eric ... Physiologie
DESOUBEAUX Guillaume ... Parasitologie et mycologie
Mme DUFOUR Diane ... Biophysique et Médecine nucléaire M. EHRMANN Stephan ... Réanimation médicale
Mme FOUQUET-BERGEMER Anne-Marie ... Anatomie et Cytologie pathologiques M. GATAULT Philippe ... Nephrologie
Mmes GAUDY-GRAFFIN Catherine... Bactériologie - Virologie ; Hygiène hospitalière GOUILLEUX Valérie ... Immunologie
MM. GYAN Emmanuel ... Hématologie, transfusion
MACHET Marie-Christine ... Anatomie et Cytologie pathologiques MM. PIVER Eric ... Biochimie et biologie moléculaire
ROUMY Jérôme ... Biophysique et médecine nucléaire in vitro Mme SAINT-MARTIN Pauline ... Médecine légale et Droit de la santé MM. SAMIMI Mahtab ... Dermatologie
TERNANT David ... Pharmacologie – toxicologie
Mme VALENTIN-DOMELIER Anne-Sophie ... Bactériologie – virologie ; hygiène hospitalière M. VOURC’H Patrick ... Biochimie et Biologie moléculaire
MAITRES DE CONFERENCES
Mmes BOIRON Michèle ... Sciences du Médicament ESNARD Annick ... Biologie cellulaire M. LEMOINE Maël ... Philosophie
Mme MONJAUZE Cécile ... Sciences du langage - Orthophonie M. PATIENT Romuald ... Biologie cellulaire
MAITRE DE CONFERENCES ASSOCIE
Mmes HUAS Caroline ... Médecine Générale RENOUX-JACQUET Cécile ... Médecine Générale M. ROBERT Jean... Médecine Générale
CHERCHEURS C.N.R.S. – INSERM
M. BOUAKAZ Ayache ... Chargé de Recherche INSERM – UMR CNRS-INSERM 930 Mmes BRUNEAU Nicole ... Chargée de Recherche INSERM – UMR CNRS-INSERM 930
CHALON Sylvie ... Directeur de Recherche INSERM – UMR CNRS-INSERM 930 MM. COURTY Yves ... Chargé de Recherche CNRS – U 618
GAUDRAY Patrick ... Directeur de Recherche CNRS – UMR CNRS 7292 GOUILLEUX Fabrice... Directeur de Recherche CNRS – UMR CNRS 7292
Mmes GOMOT Marie ... Chargée de Recherche INSERM – UMR CNRS-INSERM 930 HEUZE-VOURCH Nathalie ... Chargée de Recherche INSERM – U 618
MM. LAUMONNIER Frédéric ... Chargé de Recherche INSERM - UMR CNRS-INSERM 930 LE PAPE Alain ... Directeur de Recherche CNRS – U 618
Mmes MARTINEAU Joëlle ... Chargée de Recherche INSERM – UMR CNRS-INSERM 930 POULIN Ghislaine ... Chargée de Recherche CNRS – UMR CNRS-INSERM 930
CHARGES D’ENSEIGNEMENT
Pour la Faculté de Médecine
Mme BIRMELE Béatrice ... Praticien Hospitalier (éthique médicale) M. BOULAIN Thierry ... Praticien Hospitalier (CSCT)
Mme CRINIERE Lise ... Praticien Hospitalier (endocrinologie) M. GAROT Denis ... Praticien Hospitalier (sémiologie) Mmes MAGNAN Julie ... Praticien Hospitalier (sémiologie)
MERCIER Emmanuelle ... Praticien Hospitalier (CSCT)
Pour l’Ecole d’Orthophonie
Mme DELORE Claire ... Orthophoniste MM. GOUIN Jean-Marie ... Praticien Hospitalier
MONDON Karl ... Praticien Hospitalier Mme PERRIER Danièle ... Orthophoniste
Pour l’Ecole d’Orthoptie
Mme LALA Emmanuelle ... Praticien Hospitalier M. MAJZOUB Samuel ... Praticien Hospitalier
Remerciements
Cette thèse doit son existence à plusieurs personnes. Avant de commencer, je voudrais présenter mes excuses à ceux que je ne n'aurai pas remercier comme il se doit. Enfin, il y a ceux pour qui les mots ne suffisent pas!
Mon travail de thèse s'est déroulé dans le cadre de la convention internationale entre l'université François Rabelais et l'université de Djeddah, Arabie Saoudite sous la direction de
Monsieur Majed ALGHAMIDI. Je le remercie de m'avoir fait confiance et de m'avoir proposé un sujet dethèse très intéressant.
Je tiens à exprimer mes plus vifs remerciements à Monsieur Dominique PERROTIN pour l'honneur qu’il me fait de présider le Jury de ma thèse et pour la grande attention qu’il porte à mon travail. Qu'il trouve ici l'expression de toute ma gratitude.
Je tiens à exprimer ma profonde gratitude à Monsieur Dominique HUAS
pour sa grandedisponibilité, sa patience et toutes les opportunités qu'il m'a données au cours de cette thèse. Il a toujours su m'indiquer de bonnes directions de recherche. Nos échanges continuels, si riches, ont sûrement été la clé de la réussite de ce travail. Je tiens à exprimer toute ma reconnaissance avec qui j'ai eu un énorme plaisir à travailler.
Je suis très reconnaissant à Madame Anne Marie DRYLEWICZ et Monsieur Laurent MACHET de m'avoir fait l'honneur d’accepter d'être membres de jury de cette thèse et pour le temps qu'ils ont consacré à lire ce manuscrit et pour toutes leurs remarques qui m'ont permis de clarifier certains points. J'en suis très honoré.
Un grand merci à tous mes collègues (que ce soit en France ou en Arabie Saoudite), Professeurs, secrétaires ainsi que les personnels administratifs et techniques (réseaux informatiques,
bibliothèques, etc.) pour leur enthousiasme qui a contribué à cette ambiance de travail agréable et propice à la recherche (surtout Dr Amal ALGHAMIDI et Dr Clotilde LOISON ) .
Ma mère, mes sœurs, mes frères, ma femme et mes enfants, je voudrais vous dire aujourd'hui à quel point je suis heureux de vous avoir à mes côtés, pour l'amour que vous me portez, pour votre soutien et votre patience, qui m'ont permis de poursuivre mes études jusqu'à aujourd'hui. Les mots ne suffisent pas pour exprimer ma gratitude. Alors, plus simplement, du fond de cœur, merci.
Quant à mes pensées les plus intimes elles vont bien sûr à la mémoire de mon père, je lui dédie
ce mémoire.
A mes parents.
A ma femme et mes enfants.
A mes frères et sœurs.
A tous ceux que j'aime et qui m'aiment.
SERMENT D’HIPPOCRATE
E n présence des Maîtres de cette Faculté,
de mes chers condisciples et selon la tradition d’Hippocrate,
je promets et je jure d’être fidèle aux lois de l’honneur et de la probité dans l’exercice de la Médecine.
Je donnerai mes soins gratuits à l’indigent,
et n’exigerai jamais un salaire au-dessus de mon travail.
Admis dans l’intérieur des maisons, mes yeux ne verront pas ce qui s’y passe, ma langue taira les secrets qui me seront confiés et mon état ne servira
pas
à corrompre les mœurs ni à favoriser le crime.
Respectueux et reconnaissant envers mes Maîtres, je rendrai à leurs enfants
l’instruction que j’ai reçue de leurs pères.
Que les hommes m’accordent leur estime si je suis fidèle à mes promesses.
Que je sois couvert d’opprobre et méprisé de mes confrères
si j’y manque.
Abstract
Background: The referral system is crucial for providing comprehensive services across different levels of health care institutes. Despite its longstanding application in conjoint with the primary health care implementation, yet, it doesn’t reach up to the expected level in most instances. Reviewed literature revealed that little is known about the obstacles facing it. Therefore, the current study aimed at exploring obstacles facing both patients and their treating family physicians in application of the referral procedure s in Jeddah city.
Subjects and methods: Through a cross section design all family physicians in the primary health care centers in Jeddah city were invited to fill a pre designed self-administered questionnaire prepared to explore obstacles facing them in application of referral system. Similarly, a random sample comprised of 402 patients who were selected from a randomly chosen eight health centers, were requested to fill a questionnaire prepared for the same purpose.
Results: Seventeen present of the patients expressed that they are confronting
difficulties on referral, out of them, there were 20 who said that they find
difficulty in fixing appointments with the referral hospital. More than one third
of the patients are not keen to be seen by their same family physicians as one
third of them don’t think that there is a difference between FP and GP and
almost equal percentage don’t know that FP are as competent as specialist in the
Almost all physicians agree that interrupting continuity of feedback for the referral is a major obstacle; and the overwhelming majority agree that lack of outside phone line that could facilitate direct contact with specialists and consultants in the hospitals are substantial obstacles for referral system.
Conclusion: The main obstacles facing referral system are misconception of the patients about the role and capabilities of their family physicians with inconsistent follow up, difficulty in getting appointment and lack of direct means of communication between the family physicians and specialists in the hospitals.
It is recommended to raise awareness of the community about the role and
capabilities of the family physicians and to supply the health centers with
appropriate facilities ensuring salient appointment procedures and direct contact
between primary care physician and hospital specialists and consultants.
Table of content
Liste des professeurs de la Faculté de Médecine ……… . ……...2
Acknowledgements(Remerciment)... 7
SERMENT D’HIPPOCRATE………...…9
Abstract ... 10
1. INTRODUCTION: ... 14
Research Problem ... 16
Research rationale ... 17
Aim of the study ... 17
Research objectives ... 17
2. Literature Review:... 18
3. MATERIAL AND METHODS
:………..…23
3.1 Study area: ... 24
3.2 Study design : ... 24
3.3 Study population : ... 24
3.4 Sampling : ... 25
3.4.1 Sample size: ... 25
3.4.2 Sampling techniques: ... 25
3.5 Data collection tools and techniques: ... 26
3.5.1 Data collection tools ... 26
3.5.2 Data collection technique: ... 27
3.6 Data entry and analysis : ... 28
3.7 Pilot study: ... 28
3.8 Ethical considerations: ... 29
3.9 Study period: ... 29
3.10 Budget: ... 29
4. Results: ... ……… . 30
5. Discussion ... 45
Conclusion ... 54
6. Recommendations ... 55
7. References……… . … 57
8. Appendix... 61
List of tables Table 1 :- Demographic characteristics of the patients (n= 04 2). ... 32
Table 2 :- Performance of referral and referral hospitals. ... 34
Table 3 :- Performance of referral according to sectors. ... 35
Table 0 :- Difficulties confronted by patients in referral. ... 36
Table 5 :- Preferences of the patients to be seen by the same family physician... 38
Table 6 :- Demographic characteristics of the physicians (n=53). ... 40
Table 7 :- Availability of resources supporting referral process . ... 41
Table 8 :- Agreement of the physicians with the preferable ways of contact. ... 41
Table 9 :- Actions taken by the physician towards patients when deciding to refer patients. ... 42
Table 14 :- Agreement of the physicians regarding items whose absence resemble obstacle for referral. ... 43
List of figures Figure : 1 Self reported chronic diseases among participants ... 33
Figure : 2 Commenest causes of referral. ... 33
Figure : 3 Confronting difficulties in referral by sectors. ... 37
Figure : 0 Response of the physicians to the claim that lack of investigation
facilities is a main reason for referral. ... 44
Introduction
1
1. INTRODUCTION :
The health care system is divided into organized sectors in order to provide services and reach people at all levels. It starts from primary health care centers (PHC centers) and ends by hospitals and specialized centers which provide tertiary care. At the first level of health care system both General practitioners and Family physicians have the capability to deal with most cases attending their PHC clinics, but for some reasons like lack of experience or facilities, complicated cases and the patient preferences, they are enforced to refer some cases to a higher level. Therefore the linkage between different level of Health care system with continuous cooperation between health care providers is crucial in providing optimum health care for the people of any country
(1), this coordination as well as benefits gained by the patients strengthen the professional relationship between health care workers at different levels
(1).
Referral system is defined as a process in which the physician at a lower
level of the health service (PHC centers) who has inadequate skills or
experiences and/or fewer facilities to manage a clinical condition, seeks the
assistance of a better equipped and/or well trained specialists, with better
resources at a higher level, to guide him in managing or to take over the
management of a particular episode of a clinical condition in a beneficiary
(2).
Typically, the referral process starts from PHC centers to a higher level
(1),
however, referral could also occur as back referral when patients are referred
from higher level to the original primary health care center along with the essential follow-up advices. Effective communications are needed in both the forward and backward referrals from every level of the facility, with respect to the referrals containing descriptive findings and the required actions in order to minimize risks, repetition and misunderstandings
(1). Moreover, unnecessary overloading of referral centers negatively affects the care of referred cases, which actually required hospital care, due to competition with primary care cases
(3).
1.1 Research Problem
The presence of a gap between the family physicians and their patients (who
needs following up) leads by the time to decreased confidence among the
family doctors, thus, losing one of the main goal of their presence which will
affect the quality of medical system in our country. Despite longstanding
implementation of the referral system between different levels of health care
institutes in Saudi Arabia after it had been proven to be an effective approach to
ensure considerable quality of care in addition to cost effectiveness, yet, the
reviewed literature pointed to the paucity of researches conducted to evaluate
this system and explore obstacles precluding or hinder the provision of such
service at acceptable level of quality. Therefore, this study will focus on
identifying the obstacles that facing both family physicians and the referred
patients to obtain a complete referral cycle ending by returning of referred patients to their family physicians.
1.2 Research rationale
During residency period for twelve months in family medicine program in France, the researcher realized that there is considerable level of trust between family physicians and their patients which is not the case in the primary health care centers in Saudi Arabia. As this is the field in which the researcher will continue the rest of his practical life, it was crucial to investigate thoroughly the level of caring and the strength of following up from perspective of referral system.
1.3 Aim of the study
To improve the referral system starting at the family doctors at the level of primary health care at Jeddah city and accordingly improves quality of follow up and management of their patients.
1.4 Research objectives
1. To determine obstacles facing family physicians for following up their patients after referral.
2. To determine obstacles facing referred patients to complete their management
with their family physicians at the PHC centers after completing the objective of
their referral.
Literature Review
2
Initiating Facility
The client and their condition
Protocol of care
Provide care and document
Decision to refer
practicalities Referral
Outward referral form
Communicate with receiving facility
Information to the client
Empathy
Referral register
Receiving Facility
Receive client with referral form
Treat client and document
Plan rehabilitation
practicalities Referral
Back referral form
Feedback to initiating facility
Referral register
Supervising Organization
Monitor referrals
Ensure back referral
Feedback and training for facility staff
Feedback to central level
Overall Health System
Network of service providers
Adherence to referral protocols
Transport, communication and other resources
1.
2. Overall Health System
2. Literature Review:
According to WHO Referral System Guide, an effective referral system ensures a close relationship between all levels of the health system and helps to ensure people receive the best possible care closest to home. It also assists in making cost-effective use of hospitals and primary health care services
(4).
Figure 1. Referral system flows
In order to have a broader view of the mechanism of referral system we will review some examples in different countries.
2.1 Global review of referral system:
Most patients who consult the Primary Care Physician (PCP) is dealt with entirely within their clinics, while some of them needed to be referred to other specialist, 2,6% in France, 8,1% in Norway and 4-6% in most of European countries
(5).
In some countries like UK patients needed to be referred by their family physician to specialist. While in Eastern Europe, most countries operated with a system of polyclinics with different specialists whom patients could access directly. But most of these countries changed their system since 1990 by trained cadres of PCPs to control and limit the access to specialist
(5). In USA, 38% of population has a PCP who acts as a gatekeeper
(6).
The gatekeepers (physicians authorizing referrals to specialists) are usually
regulating and restricting unnecessary free access to specialists; however, the
health maintenance organization created a new plan that allow the patients to
consult directly the specialists in which the point of service plan give them the
option to use services approved by their gatekeeper or, at increased cost to
themselves, to refer themselves to any physician within or outside the plan (but
only 5% per year use this option)
(6).
The advantage of this gate keeper system is not only appear to be more cost effective than health system based on specialist care , but they also produce better health outcome
(5).
2.2 Referral system in Saudi Arabia:
The Ministry of Health in Saudi Arabia has intended to deliver a complete and combined service for its people by issuing a referral system as one of its most important strategies in order to bring the health care services to its best use
(2). In order for this system to be effective, all patients should first be seen by primary health care physicians who decide whether a referral to secondary care is necessary. Hence, an admission to hospital care is conducted only through primary health centers, with the exception of emergency circumstances
(7). Applying a referral system will not only lead to better health results for the patients, but also to financial savings. This is because the proper implementation of the referral system is expected to minimize duplication of services and inefficient use of the resources
(8).
In the second half of the year 1989, the concept of referral systems was first
employed for the Saudi health care system in Riyadh, but it was initially
introduced in 1986
(9). Nevertheless, there is a lack of data about the effect of
referral systems to the health services in Saudi Arabia. Communication between
general practitioners and specialists can only be conducted by referral letters
(9).
2.3 Routine referral is usually made to:
Seek expert opinion regarding a patient.
Seek admission and management of a patient.
Seek facilities for investigation
(2) . Poor relationship with patient leading to need for second opinion
(5).
Response to request from the patient or the caregiver in certain cases
(5).
Reassurance for the doctor or the patient
(5).
MATERIAL AND METHODS
3
3. Material and methods 3.1 Study area:
This study was carried out in Jeddah which is the second largest city in Saudi Arabia; it is the main sea port of the Kingdom on the Red Sea and main gate through which most of the pilgrims arrive by air and sea to perform Umrah, Hajj or to visit the two holy mosques. Area inhabited is more than 1,500 km, and population is more than 3.4 million.
In Jeddah there are around 12 governmental hospitals, and 42 primary health care centers in addition to more than 30 private hospitals and 128 polyclinics.
The study will be conducted in the ministry of health primary health care centers in Jeddah city which have four supervisory sectors (Briman, Assalamah, Albalad and Ameer Majed sector) that involve 43 PHC centers and around 273 physicians, 61 of them are family physicians and 212 are GPs.
3.2 Study design :
A cross-sectional descriptive study.
3.3 Study population :
Sample of referred patients from the same selected PHC (s),and primary health
care Family physicians working in the PHC centers of the ministry of health in
3.4 Sampling :
3.4.1 Sample size:
3.4.1.1. Sample size of the patients: Using the statistical program EPI ver.6.4 for calculation of sample size, provided that there is no expected frequency for the outcome, therefore the percentage accounted for 50% to get the maximal sample size and by using the worst acceptable percentage as + 5%, and using the confidence level of 95% and the power of 80%, the calculated sample size accounted for 384 which was rounded to 400 patients.
3.4.1.2. Sample size of the physicians: All the primary health care physicians who are working in the PHC centers, ministry of health in Jeddah city at the period of the study will be considered eligible for inclusion in the study and will be invited to participate.
3.4.2 Sampling techniques:
Fifty patients were selected by systematic sampling from each designated center (n=8) making a total of 400 patients. Patients were selected as every second patient at whom the inclusion criteria were fulfilled.
In the second stage, as all physicians were decided to be included in the study,
so sampling technique was applied only in allocating the patients who must be
included in the study. A multistage sampling was adopted to select eight centers
in the first stage as two centers from each sector; these centers were allocated by simple random sampling using “Random Number Table”.
Inclusion criteria of physicians:
All family physicians available at the time of the study . Exclusion criteria of physicians:
Dentists and general practitioners and family physicians in vacation at the period of the study.
3.5 Data collection tools and techniques:
3.5.1 Data collection tools
Two different tools had been used for data collection, one for referred patients, and the other for family physicians.
A. Referred patients ’ questionnaire:
An anonymous self-administered questionnaire had been designed in Arabic language by the researcher based on review of pertinent literature filled by the researcher and other well trained colleagues at their PHC centers by face a face presentations with patients presented at waiting rooms during the period of data collection, after asking them if they had a past history of referral to a hospital.
The final questionnaire included the following sections:
Socio-demographic data of the respondent such as age, gender,
Data about the past referral: purpose of referral, who decided the referral and obstacles faced by the patient for completing the referral.
Patients’ trust in their family physician in addition to their knowledge about the importance of family physicians
B. Physicians' questionnaire:
An anonymous self-administered questionnaire designed in English language by the researcher based on review of pertinent literature and reviewed by experts for structure and content validity.
The final questioner included the following sections:
Socio-demographic data of the family physician: such as age, gender and years of experience.
Experience with the procedure of referral: this included obstacles they face at level of communication with secondary or tertiary care, number of patients, frequency of consultations, topics discussed with patients, shortage or lack of some facilities and their effects in referral cycle as an obstacle.
Familiarity with related referral system protocol.
3.5.2 Data collection technique:
The researcher assisted by his colleagues distributed the self-administered
questionnaire during the working hours; caring not to disturb the physicians
while they were providing their routine work.. For the rest number of referred
patients we had to fill their questionnaires through face to face interview in the waiting areas or at the clinics of chronic diseases where most of the patients had at least one past history of referral.
3.6 Data entry and analysis :
Data entry and statistical analyses was done using SPSS (Statistical Package for Social Scientists) ver.16.0. Quality control was assured at the stages of coding and data entry. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables. Chi Square test was used for verification of the significance in the differences between groups regarding the frequency of the different outcomes which were all categorical. Statistical significance was considered at p-value <0.05.
3.7 Pilot study:
• A pilot study had been conducted in one PHC center to test the validity of the questionnaire.
• Modifications done according to the pilot results, where we noticed
unclearness of some points, so we reformulated them and in addition, we
added the lack or shortage of treatments in some PHC centers as an
obstacles that can be affect the referral system.
3.8 Ethical considerations:
Written permission from Joint Program of Family& Community Medicine had been obtained before conduction of the research.
Written permission from concerned authority in MOH PHC had been obtained too.
Permission was collected from the regional Institutional Research Board (IRB) in the health directorate in Jeddah Governorate.
Individual consent is a prerequisite for data collection.
It was written on the front page of the questionnaire that (answering questionnaire means agreement of participation in the study).
All information will be kept confidential and will not be accessed except for the purpose of scientific research.
The researcher did his best not to disturb the participants work in their clinics.
3.9 Study period:
1. Preparatory period ( 6-8 weeks )
◦ Selecting the title and doing the literatures review
◦ Taking the permission
◦ Preparing the questionnaire
◦ Pilot study 2. Field work ( 4-6 weeks )
◦ Data collection
◦ Data entry and analysis 3. Writing the report (2-4 weeks) 3.10 Budget:
The research is self-funded.
Results
4
4. Results
The results are presented in two main section; the first section describes results of the data pertaining to patients while the second section is describing data for the physicians.
4.1 Patients
To achieve the study objectives, 402 patients were selected randomly from eight PHCCs .Fortunately, and with the aid of my colleagues we completed the filling of questionnaires by the end of the last day of the three weeks expected for the data collections.
The best files registrations among the 8 randomly selected PHC centers were
at ALZAHRAA, where we collected 21/50 questionnaires by calling the
referred patients by phone and ALSAFFA 2 where we succeeded in reaching
13/50 patients.
Section 1: Results of the data pertaining to patients 1. Characteristics of the patients:-
1.1 Demographic characteristics
Characteristics n %
Age groups:
<20 years 41 10.2
21-30 years 67 16.7
31-40 years 89 22.1
41-50 years 81 20.1
>50 years 124 30.8
Marital status:
Married 290 73.8
Unmarried 83 21.2
Widowed 10 2.5
Divorced 10 2.5
Education level:
Read and write 15 4.3
Primary 51 14.8
Preparatory/secondary 167 48.4
University 112 32.5
Occupational status:
Governmental 72 17.9
Education sector 33 8.2
Health sector 4 1.0
Private sector 34 8.5
Others 259 64.4
Table 1:- Demographic characteristics of the patients (n= 04 2).
1.2 Presence of chronic diseases
Figure 1 : Self-reported chronic diseases among participants
2. Commonest main causes of referral
Figure 2 : Commenest causes of referral.
Yes 221 55,0%
No 181 45,0%
105 58
53 39 26 21 16 14
70
26,1%
14,4%
13,2%
9,7%
6,5%
5,2%
4,0%
3,5%
17,4%
0 20 40 60 80 100 120
Internal medicine consultation Orthopedic consultation Ophthalmology consultation Obtetrics and Gynecology Cardiology consultation ENT consultation Surgical consultation Dermatology consultation Others
3. Characteristics of the referral:-
Performance of referral/referral hospitals No. %
Referral according to request of the patients:
Yes 160 39.8
No 242 60.2
Physicians explain reasons of referral:
Yes 339 84.3
No 63 15.7
Physicians ask the patients to come back to know outcome of referral:
Yes 216 53.7
No 186 46.3
Referral hospitals:
King Fahd general hospital 152 37.8
King Abdul Aziz general hospital 104 25.9
Thaghr general hospital 12 3.0
Ophthalmology hospital 53 13.2
Obstetrics and Gynecology hospital 28 7.0
Aziza obstetric hospital 7 1.7
Diabetes and hypertensive control center 16 4.0
Others 30 7.5
Table 2:- Performance of referral and referral hospitals.
The table shows that more than one third of the patients (39.8%)
indicated that the referrals were done upon their request. Although the great
majorities of the patients (84.3%) addressed that the treating physicians
explained to them the reasons for referral, a much lower percentage (53.7%)
pointed out that their physicians asked them to come back again to know the
Sectors
Sector1 Sector2 Sector3 Sector4
No. % No. % No. % No. % P*.
Referral upon patients’
request
Yes 23 23.2% 31 30.7% 52 51.5% 54 53.5%
No 76 76.8% 70 69.3% 49 48.5% 47 46.5% <0.001
Physicians explain reasons of referral
Yes 84 84.8% 96 95.0% 78 77.2% 81 80.2%
No 15 15.2% 5 5.0% 23 22.8% 20 19.8% 0.003
Physicians ask referred
patients to come back
Yes 69 69.7% 67 66.3% 46 45.5% 34 33.7%
No 30 30.3% 34 33.7% 55 54.5% 67 66.3% <0.001
P* based on Chi Square test
Table 3:- Performance of referral according to sectors.
The table illustrates that higher percentages of physicians in sector3 (51.5%)
and sector4 (53.5%) are referring according to the request of patients if
compared to physicians in sector1 (23.2%) and sector2 (30.7%). On the other
side, the percentages of physicians who explaining for their patients the reasons
for referral were higher in sector1 (84.8%) and sector2 (95%) compared to those
in sector3 (77.2%) and sector4 (80.2%). Similarly, the percentages of physicians
who are asking their patients to come back again to know the results and
outcome of referral were higher in sector1 (69.7%) and sector2 (66.3%) if
compared to those in sector3 (45.5%) and sector4 (33.7%). All these differences
are statistically significant p<0.05.
Confronting difficulties in referral
Confronted difficulties No. %
Confronted difficulties (n=402):
No 335 83.3
Yes 67 16.7
Types of difficulties (n=55)
Difficulty in appointment 20 36.4
Difficulty in transportation 13 23.6
Conflicts in timing 8 14.5
Far away hospital 7 12.7
Not convinced by referral 7 12.7
Table 4:- Difficulties confronted by patients in referral.
The table shows that 67 (16.7%) of the patients who expressed that they are confronting difficulties on referral and thus they didn’t complete there referral.
Figure 3 : Confronting difficulties in referral by sectors.
The table shows the discrepancy in the proportion of patients who indicated that they are confronting difficulties in referral according to sector.
The lowest percentage was found in sector1 (6.1%) and the highest percentages were recorded in both sector2 (20.8%) and sector4 (21.8%) and these differences are statistically significant p<0.05.
6,10%
20,80%
17,80% 21,80%
93,90%
79,20% 82,20%
78,20%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
80,00%
90,00%
100,00%
Sector1 Sector2 Sector3 Sector4
Chi Square= 11.256 df=3 p=0.010
Yes No
View of the patients about family physicians
Preferences of the patients No. %
Prefer to be seen by the same family physician:
Yes 254 63.2
No 148 36.8
Reasons for not insisting to be seen by the same family physician (n=148)*
No difference between FP and GP 53 35.8
No difference in diagnosis 52 35.1
Prefer to be seen by any available physician to
save time. 47 31.8
Don’t know that FP is as competent as specialist
in the hospital. 34 23.0
Not important to be seen by the same FP 22 14.9
* Total percentages exceeded 100% for multiple choices by same patient
.
Table 5:- Preferences of the patients to be seen by the same family physician.
From the table, it can be seen that more than one third of the patients
(36.8%) are not insisting to be seen and followed up by the same family
physician. When asked about the reasons; one third of the patients (35.8%)
indicated that they didn’t perceive a ny difference in the practice of family
physician and general practitioner. Meanwhile, it was found that (31.8%)
addressed that they prefer to be seen by any available physician to save time.
4.2 Family physicians
We succeeded also by the end of our period of data collection to complete
filling 53 out of 65 questionnaires from FPs working at PHC centers at the
ministry of health at Jeddah city who are distributed in 27 PHC centers
from the list of 42 centers presents at Jeddah. We filled our questionnaires
from 23 PHC centers because the FP in the rest of four centers were in
their annual vacations. There were four closed PHC centers for the purpose
of maintenance, two centers were not yet opened but scheduled with the
list of PHC centers and in eight PHC centers, there were no family
physicians; and it were covered only with GPs and residents. Apart from
these problems, the physicians as well as he patients were generally
cooperative and friendly.
Section 2: Results of the data pertaining to physicians 2.1 Demographic characteristics
Characteristics No. %
Gender:
Males 7 13.2
Females 46 86.8
Age groups:
25-29 years 1 1.9
30-39 years 30 56.6
40-49 years 20 37.7
50+ years 2 3.8
Years of experience as FP:
1-4 years 25 47.2
5-10 years 23 43.3
11-15 years 2 3.8
>15 years 3 5.7
Table 6:- Demographic characteristics of the physicians (n=53).
The table shows that females constituted the majority of the family
physicians in the health centers (86.8%) and the great majority of them in the
age groups between 30 and <50 years (94.3%).
2.2 Resources supporting referral process
2.2.1 Available Resources supporting referral process
Facilities No. %
List of hospital and specialty whom you can refer to 42 79.2
Ambulance for emergencies referrals 31 58.5
Written policy for referral procedures 23 43.4
Outside phone line 9 17.0
Referral employee 9 17.0
Table 7:- Availability of resources supporting referral process.
It was remarked that only 17% of FP expressed that there is outside phone line (most of them are the manager of the PHC center).
2.2.2 Preferences of the physicians to contact with the referral hospital.
Facilities SA A Neutral DA SD
Telephone 43(81.1%) 8(15.1%) 1(1.9%) 1(1.9%) ---
Fax 18(34.0%) 23(43.4%) 10(18.9%) 1(1.9%) 1(1.9%)
E-mail 19(35.8%) 21(39.6%) 10(18.9%) 2(3.8%) 1(1.9%)
Letter 9(17.0%) 9(17.0%) 18(34.0%) 11(20.8%) 6(11.3%)
Referral office 37(69.8%) 9(17.0%) 5(9.4%) 1(1.9%) 1(1.9%)
SA (Strongly agree) A (Agree) DA (Disagree) SD (Strongly disagree)
Table 8:- Agreement of the physicians with the preferable ways of contact.
The table demonstrates that the overwhelming majority of the physicians
(96.2%) prefer to contact with the referral hospital through telephone followed
by referral office in the hospital (86.8%).
Actions undertaken by physicians towards patients when deciding referral of the patients.
Items No. %
Discussing with the patient the reasons and importance
of referral 53 100.0
Explaining side effects and risks in case of non-referral 52 98.1 Ensuring the follow up at PHCC after finishing the aim
of referral 45 84.9
Making sure that the patient know the location of
referral building 39 73.6
Making sure that the patients knows Where he should go
there (to which department at the hospital) 39 73.6 Giving the patient an appointment to check with him the
result (reports) of his referral 35 66.0
Inquire about the way of transport of patient to get there
and if that represent an obstacle for him/here 30 56.6 Record the feedback note (if done) when it is returned. 25 47.2 Table 9:- Actions taken by the physician towards patients when deciding to refer patients.
The table all the family physicians are discussing the reason and
importance of referral for their patients, and almost all of them (98.1%) are
explaining the unwanted outcome in case of non-referral. Meanwhile, less than
one half of them (47.2%) are recording the feedback note returned from the
hospital after referral of the patients.
2.2.3 Obstacles related to absence of resources and facilities supporting referral process.
Items No. %
Continuous feedback for the referral 50 94.3%
Availability of Hospitals Referral office Numbers for
coordination 45 84.9%
Outside line phone in family physician office 41 77.4%
Referral employee ( to book appointment for patients in
hospitals) 40 75.5%
List of secondary and tertiary hospital with each
specialty needed for referral 35 66.0%
Referring life threatening cases to other hospital outside
the center district 34 64.2%
Radiology investigation 34 64.2%
Written referral protocols 33 62.3%
Laboratory investigations 29 54.7%
Ambulance for emergencies referrals 28 52.8%
Medication (Drugs) 28 52.8%
Written management protocols for most common
emergencies present to PHCC 23 43.4%
Training on the quality of filling the referral form 21 39.6%
Table 10:- Agreement of the physicians regarding items whose absence resemble obstacle for referral.
The table shows that the overwhelming majority of the physicians
(94.3%) believe that the interruption in continuity of feedback for the referred
cases represent obstacle for the referral system. Meanwhile, it was noted that the
majority of the physicians (84.9%) gave importance to the necessity for the
presence of coordinating office in the hospital which is responsible for
organizing and facilitating the process of referral. While absence of some
simple resources such as direct phone line was seen as an obstacle for referral by 77.4%.
Figure 4
:Response of the physicians to the claim that lack of investigation facilities is a
Finally, in the last question of physician questioner, it was remarked that almost all physicians 52(98.1%) agree that if it is possible to sit in a round table with the specialists from different specialties in periodic meetings (for ex. every 3-4 moths) to discuss the refer cases and the main causes of referral, it will help to put protocols for referral.
Yes 33 62,3%
No 20 37,7%
Discussion
5
5. Discussion
The current study aimed at assessment of the referral system in the primary health care centers in Jeddah city and exploring the obstacles facing the patients and their treating family physicians as well in completing the cycle of the referral process.
Some delay in collecting the data was confronted at the beginning of the field work, because of two main reasons:
The timing, where we started our data collections at the last two weeks of the summer holidays which coincided with engagement of most of the parents with their kids in preparing for finalizing the processes of their school entry through medical checkup; so the majority of the visitors were children.
The second reason was to find patients who fulfill the inclusion criteria. It was difficult to track patients through files which were lacking important information such as valid phone numbers, others were not updated and others were wrong phone numbers.
Typically, the continuum of health care provided to patients necessitates
presence of referral system which ensures their referral back to the initial
contact
(8). To accomplish this continuity, a set of interlacing activities and
approaches are critically needed. For instance the presence of channels for
one side and the specialists in the hospitals on the other side is crucial for achieving one of the main objectives of deploying the referral system which is the proper utilization of resources
(11). For example, it was found that the direct communication between primary care physician and specialists in USA resulted in that almo st two thirds of the cases (64%) didn’t need referral and could be managed at the primary care level
(10). Therefore, it was not astonishing to find that almost all of our physicians prefer direct phone call to discuss referral with the specialists and the majority of them agree that absence of outside line phone which facilitate direct contact with specialists in the hospitals is considered a main obstacle. Nevertheless, the problem is that only 17% of our physicians have access to direct outside phone line that could compromise the quality of the referral system.
Better appointment tracking had been mentioned as one of the necessary practices needed to ensure improvement of the referral system and compliance of the patients with planned referral instructions
(11). In this context several modules had been suggested, for example electronic appointment
(11;12)as web based appointment which were found superior to the paper based appointments
(13).
