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Patterns of referral to the orthopedic specialist clinic of Macau Government Hospital
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     【Abstract】 Objective To understand the patterns of referral to the orthopedist specialist out-patient clinics facilitates better planning of out-patient services and the referring parties will be able to identify their training needs.Methods Collect total 264 referral letters received Sep-Dec 2005 by orthopedist out-patient clinic of C.H.C.S.J. Statistics and analysis the contents of letters that included referral sources,object,diagnoses, and whether once have record of patients name, sex, orthopaedic physical examination, orthopaedic radiology study and whether ever describe received treatment or result of treatment.Results The common sources of referral were Health Center (62.5%; 165/264), Government Hospital (35.6%; 94/264), Emergency Department (1.5%; 4/264) and private practitioners (0.4%; 1/264).The two major objects for referral are to seek orthopedist for help the disease diagnoses (40.5%) and disease management (50.7%), but there are 5.7% (15/264) cases have not describe referral object clearly. Osteoarthritis 30.4% (92/303) is the most common referral diagnoses, but there are 30.4% cases (92/303) can not make preliminary diagnoses, so “Chief Complain” is regarded as the “Referral Diagnoses”. In these cases that make a “Chief Complain” as a referral diagnoses (n=80) that 83.75% (67/80) have no records of orthopaedic physical examination and up to 80% (64/80) have no any records of orthopaedic radiology study. In cases that already made a preliminary diagnoses (n=162) that 34%(55/162) of cases have record of orthopaedic physical examination and 74%(120/162) of cases have record of orthopaedic radiology study. The study suggested 30.4% of cases can not make preliminary diagnoses may be associated with poor inspection and study before referral to orthopedic clinic. There are up to 90.15% (238/264) of total cases that have no recorded that describe whether ever received course of treating or result of treatment. The referral doctors name is difficult to distinguish is 32.5% (86/264) and 10% (26/264) of cases have no record of patients sex and 10.60% (28/26) no describe patients age.Conclusion The study reflect the referral patterns from various sources is helping in organising medical services and identify training needs.The referral parties have to clear write referral letters and also must perform enough inspection and study before referral. Orthopedist out-patient clinic should focus on major referral problems and coordination of the various referral parties and could offer the lecture of the common orthopaedic disease or adopting the reference referral guide for referral unities.

    【Key words】 referral letters;orthopedist specialist out-patient clinics

    INTRODUCTION

    The orthopedist out-patient clinic of Government Hospital (C.H.C.S.J) represents a major portion of the workload of orthopedic services in Macau. The impact of new cases should not be ignored, as the time spent on a new case could be two to three times that of an old case. Reducing the waiting time for new cases has always been a concern of the referral unities and specialist. To study the patterns of referral to the orthopedist specialist out-patient clinics facilitates better planning of out-patient services and the referring parties will be able to identify their training needs. So that medical care is delivered more effectively and efficiently, special under the limited resources.

    METHODS

    Collect all referral letters received since Sep 2005 to Dec 2005 by orthopedist out-patient clinic of C.H.C.S.J was included in this study. Statistics and analysis the contents of letters that included referral sources, referral object, referral diagnoses, and whether once record of patients name, sex, orthopaedic physical examination, orthopaedic radiology study and whether ever describe received treatment or result of treatment. Relatively uncommon referral diagnoses (including post operation problems, osteoporosis, joint dislocate) that did not fall into the common categories were classified as “others”.

    RESULTS

    A total of 264 referral letters were received over the 4 months period. The common sources of referral were Health Center (62.5%; 165/264), other department of Government Hospital (35.6%; 94/264), Emergency Department (1.5%; 4/264) and private practitioners (0.4%; 1/264). The referral diagnoses from the first two sources are show in Table 1,2. The referrals from all sources are summarized in Table 3. There are 30.4% cases (92/303) can not make a preliminary diagnoses, so “Chief Complain” is regarded as the “Referral Diagnoses”. These condition especially referral from Hospital 39.21% (40/102) more than referral from Health Centres 25.5% (50/196).

    The referral objects from the first two sources are show in Table 4 to 5 and from all sources are summarized in Table 6. Statistical analysis all referral letters (n=264) find that the majority letters have no records of orthopaedic physical examination 70.83% (187/264). There have records of orthopaedic radiology study 57.57% (152/264) and have no records of orthopaedic radiology study are 42.42% (112/264). Have no recorded that describe the whether ever received course of treating or result of treatment is up to 90.15% (238/264). The other results from the first two sources are show in Table 7 to 8.

    In these cases that make a “Chief Complain” as a referral diagnoses (n=80),we found that 83.75% (67/80)of cases have no records of orthopaedic physical examination and up to 80% (64/80) have no any records of orthopaedic radiology study. In cases that already made a preliminary diagnoses (n=162), we found that 34%(55/162)of cases have record of orthopaedic physical examination and 74%(120/162) have record of orthopaedic radiology study.

    The referral doctors name is difficult to distinguish amounts to 32.5% (86/264) and referral from hospital (47.8%; 45/94) is more common than referral from Health Centres (25%; 41/165). There are 10% (26/264) of letter has no record of name of patients and 10.60% (28/26) of letter has no record of patients age. The above two situations hospital (no record of patients sex 88.46%; 23/26, no record of patients age 92%; 23/25) is more common than Health Centres (no record of patients sex 3.8%; 1/26, no record of patients age 0%; 0/25).

    DISCUSSION

    Because this study was based on the contents of the referral letters, it was not possible to criticism whether the referral diagnoses were substantiated or whether the referrals were justified. The common sources of referral were Health Center (62.5%) and Government Hospital (35.6%), so it is important to coordinate and communicate with these two units.

    The study reflects the current referral patterns and common referral disease of various parties and the major clinical problems encountered at an out-patient orthopedic clinic of government hospital. For example the most common reason referral for management is osteoarthritis or degenerative joint disease 30.4% (92/303).These provide information that can be used for the referring parties will be able to identify their training needs. The referral pattern also provides some background information to all parties concerned. The orthopedist out-patient clinic should focus on major referral problems and coordination of the various referral parties, so that medical care is delivered more effectively and efficiently.

    The two major objects for referral are to seek orthopedist for help the disease diagnoses (40.5%) and disease management (50.7%) (Table 4-6). Only 2% (5/264) due to patient expects and 2% (5/264) because of others reason. But there are 5.7% (15/264) cases have not describe referral object clearly and that will cause the orthopedic clinic unable to judge the urgency of the referral case and arrange the suitable time for making an appointment.

    There are 30.4% cases (92/303) can not make a preliminary diagnoses, so “Chief Complain” is regarded as the “Referral Diagnoses”. These condition especially referral from Govern ment Hospital 39.21% (40/102) more than referral from Health Centres 25.5% (50/196). In these cases that make a “Chief Complain” as a referral diagnoses (n=80), we find that 83.75% (67/80) have no records of orthopaedic physical examination and up to 80% (64/80) have no any records of orthopaedic radiology study. In cases that already made a preliminary diagnoses (n=162), we found that 34%(55/162)of cases have record of orthopaedic physical examination and 74%(120/162) have record of orthopaedic radiology study. The study suggested 30.4% of cases can not make a preliminary diagnoses may be associated with poor inspection and study before referral to orthopedic clinic; because clear history taking, physical examination and proper radiological studies are the three major parts of diagnosing the muscle skeleton disease[1]. So the referral parties maybe have to strengthen in this respect.

    There are 50.7% cases are referral to orthopaedic clinic seek for management of disease. Degenerative joint disease 30.4% is the most common reason that referral for management. There have no record that describe whether ever received treatment (for example pain killer or physical therapy) or result of treatment in 90.15% (238/264) cases. This may cause the orthopedist to be unable to judge the condition correctly and completely. Except to strengthen training of staff to improve understanding the field of common disease management, and orthopaedic department also can offer the lecture of the common disease or adopting the reference referral guide for referral unities.

    The referral doctors name is difficult to distinguish amounts to 32.5%, and hospital (45/94; 47.8%) is more common than Health Centres (41/165; 25%). No record of patients sex amounts to 10% and no record of patients age amounts to 10.60%. The above situations Hospital is more common than Health Centres. The study warning that the referral doctor necessary attention to writes ones own name clearly and have to make record of patients sex and age. In order to orthopedic clinic can link smooth with referral parties and furthermore make the orthopedic specialist understand clearly and complete about patients base information.

    CONCLUSION

    The study reflects the current referral patterns and common referral disease of various parties and the major clinical problems encountered at an out-patient orthopedic clinic of Government Hospital. These provide information that can be used for the referring parties will be able to identify their training needs. The referral pattern also provides some background information to all parties concerned. Orthopedist out-patient clinic should focus on major referral problems and coordination of the various referral parities, so that medical care is delivered more effectively and efficiently.

    The referral parties have to clear write referral letters and including the basic information of patient; and also must perform enough inspection and study before referral. Orthopaedic clinic can offer the lecture of the common orthopaedic disease or adopting the reference referral guide for referral unities.

    REFERENCES

    1. John J.Gartland. Fundamentals of orthopaedics 4/e. Yi Hsien Publishing Co.,Ltd, 2001,15.

    1. Department of Health Center, Macau SAR, China; Tel: (+853)-413178; E-mail: zinsinejustin@yahoo.com.tw

    2. C.H.C.S.J Orthopaedic Department, Macau SAR, China; Tel: (+853)-3902110

    (Editor Guo Hui-ling)(LUO Tze-chao,CHAN Wai-sin)