bridging the gap between patient and referrer requirements in a ...

If the referral fits: bridging the gap between patient and referrer requirements in a tertiary referral unit

Aust NZ J Psychiatry Downloaded from informahealthcare.com by University New South Wales on 10/20/13 For personal use only.

Kerrie Eyers, Henry Brodaty, Gordon Parker, Philip Boyce, Philip Mitchell, Kay Wilhelm, Ian Hickie

Objective: We examined the reasons for which doctors refer and patients request referral to our tertiary Mood Disorders Unit (MDU), focussing on congruence and ‘fit’, and the potential for more efficient use of referral resources. Method: A postal survey of patients (n=265 or 83% responders) and referrers (n=156 or 94% responders) sought views regarding referral and service components. Ratings from 156 matched referrer-patient dyads were compared. Results: Overall, referrers and patients were satisfied with the MDU.There was disparity between what referrers sought and what patients thought were the reasons for referral, and different perceptions of the value of interventions and the amount of improvement. Congruent matched referrer-patient judgements of patient outcome were more likely to correspond with objective clinician ratings than discordant ratings. Satisfaction with MDU contact or intervention was not necessarily linked to improvement; better management of chronic depression was also valued. Referrer and patient responses to open-ended questions highlighted beneficial ingredients of referral. Conclusions: There was considerable lack of fit between referrers’ and patients’experience of the referral. Better communication between referrer and patients can clarify the purpose of referral and possibly lead to increased compliance with medical regimens. Australian and New Zealand Journal of Psychiatry 1996; 30:332-336

Prince Henry Hospital, Little Bay, New South Wales, Australia Kerrie Eyers MA, DipEd. MPH. MAPsS, Administrator, Mood Disorders Unit Kay Wilhelm MD. FRANZCP. Senior Staff Specialist. Division of Psychiatry. Clinical Superintendent. Psychiatry Unit

University of New South Wales, New South Wales, Australia Henry Brodaty Psychogeriatrics

MD.

FRACP.

FRANZCP.

Professor

of

Gordon Parker MD. PhD. FRANZCP, Professor of Psychiatry Philip Mitchell MD, FRANZCP. FRCPsych. Associate Professor lan Hickie MD. FRANZCP. Associate Professor

Department of Psychological Medicine, University of Sydney, Sydney, New South Wales, Australia Philip Boyce MD, FRANZCP, Professor

The Mood Disorders Unit (MDU) is a supraregional, research and clinical tertiary referral service. It uses a multimodal approach to treat both in- and outpatients. Before referrals to the MDU proceed, referrers are requested to forward a detailed profile of their patient’s history and also to outline the objective of the referral. We have provided information about the MDU’s operation and assessment schedule [ 1J, its effectiveness over time [ 2 ] and the management and outcome of patients referred as treatment resistant [3,4]. In previous papers we have examined satisfaction of patients [ 5 ] and referrers [6] separately. In this study, we focus on the agreement or ‘fit’ between referrers


K. EYERS. H. BRODATY. G. PARKER, P. BOYCE. P. MITCHELL. K. WILHELM. I. HICKIE

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and referred patients, matching expectations of. and satisfaction with MDU assessment and management. Also we compare ratings of outcome by patients, referrers and MDU clinicians. The MDU aims to assist in coordinating the management of depression, a chronic and relapsing disease which is frequently associated with somatic complaints [7] and actual physical disorders [8,9]. The MDU aims to establish links both with primary health care providers, such as general practitioners (GPs), who reinforce understanding. monitor the condition and adjust medications, and with specialist practitioners such as psychiatrists, who formulate treatment policy and screen for and manage complications. Its utility is likely to be enhanced if it can help patients articulate realistic expectations and better fit them to referrer aims. This may assist the patient to comply with long-term treatment [9]. While we know that patients and referrers were largely satisfied with the MDU service [5,6]. we wished to examine matched pairs of referrers and patients to determine how congruent their ratings were of expectations. satisfaction and outcome. Thus, if referrers and patients had divergent expectations, this might lead to dissatisfaction. Also, if referrers thought outcome was favourable. but patients did not, it might be reflected in MDU outcome ratings. Specifically, the aims of this study were: (i) to compare referrers’ stated reasons with patients’ perceptions of reasons for referral; (ii) to compare matched referrer-patient ratings of satisfaction and perceived improvement attributed to MDU intervention individually for each referrer and patient; and (iii) to determine whether perceived improvement as judged by matched pairs was reflected in MDU clinician-rated outcome.

Referrer and patient surveys set out to cover the same domains as much as possible and consisted of parallel questions. Ratings were made by both referrer and patient on: what was required of the referral; reasons prompting the referral; how well the MDU dealt with the referral; how much the MDU treatment or contact had resulted in change in the patient’s condition; whether each would use the MDU again and/or recommend it to others; whether the information that was received from the MDU was satisfactory: the MDU information provided; the adequacy of specific aspects of MDU service provision, treatment and plan of management; and whether the MDU’s follow-up arrangements were satisfactory. All were rated on appropriately calibrated Likert scales. Space was also provided for open-ended comments after each section.

Method

Analyses

The sample of interest was derived from the first 308 consecutive patients with a DSM-111-defined depressive disorder assessed at the MDU, and their 156 referrers. These patients were assessed and/or treated during the MDU’s first 3 years of service (i.e. from August 1985 to September 1988). The responses from the 156 referrers were matched with the responses of their first-referred patient.

Dimensional data were analysed using t-tests (twotailed) and one-way analysis of variance. Categorical data were analysed using the Chi-squared test. Agreement between raters was calculated using the kappa statistic [ 1 I].

semi-structured interview [ 11 generating diagnoses; possible risk factors to depression; a rating of adequacy of patient personality; and the Hamilton Rating Scale for Depression [ 101 at index assess-ment and at follow-up (20 and 52 weeks, respectively). Patients completed demographic and self-rating questionnaires assessing psychological morbidity, general functioning and interpersonal relationships [I].

Procedure The 265 patients who responded (83% of the sample) were surveyed in August 1989 [5] and the 156 referrers (representing 88% of the patients and 94% of the referrers) were surveyed in August 1992 (61.

The survey

Results The sample

MDU assessment details Patient assessment procedures at intake included: a

The referrers who responded were 128 men and 28 women: 64 GPs ( 5 5 male. nine female), 78 psychia-

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Comparison by type of referrer indicated that patients referred by GPs were more likely than those referred by psychiatrists to agree with the GPs that their improvement could be ascribed to MDU intervention (X- = 4.2, SD = 1.6 (patients), S = 4.3, SD = 1.5 (GPs); = 10.67; df = 1, p = 0.001, K = 0.4). In contrast, patient and psychiatrist views on improvement were discordant; psychiatrist referrers did not rate their patients’ improvement as highly as did the patients themselves (.U= 3.8, SD = 1.8 (patients), .X = 3.5. SD = 1.9 (psychiatrists); 1.58;df=l,p=0.21;NS, K=0.1).


trists (65 male, 13 female) and 14 others (eight male, six female) comprising four psychologists, three other medical specialists, and seven psychiatric registrars. Responses from these 156 referrers were matched to their first or only referred patient. This patient sub-group comprised 105 women and 5 1 men (mean age = 45.0, SD = 16.9, range = 15-80).

x’

Comparison of referrers’ and patients’ reasons for referral

x’=

There was poor agreement between referrers’ reasons for referring and patients’ views about why they had been referred = 6.0, df = 4, p = 0.19, K = -0.03); the low kappa value reflects the substantial differences between referrer-patient pairs (Table 1 ).

(x’

Comparison of congruent with non-congruent referrer-patient pairs on the value of MDU intervention Previously, we have shown a strong relationship between improvement (measured by the Hamilton ‘difference’ score) and both patient satisfaction [ 5 ] and referrer satisfaction [6]. We now examined whether there was a relationship between improvement and referrer-patient agreement within the matched sub-sample. Referrer-patient pairs who agreed on patient improvement (Group I. n = 85) or lack of improvement (Group 11, n = 17) were then compared with pairs whose ratings disagreed with each other (Group 111, n = 45). Sociodemographic features (age, sex, employment status, education level and whether in- or outpatient) were similar for the three groups. Significant differences in rate of improvement (using the Hamilton ‘difference’ score) were evident between these three groups at 1-year

Comparison of matched referrer-patient pairs on the value of MDU intervention Satisfaction with the MDU intervention for the 156 matched referrer-patient pairs was high for both, with referrers’ mean satisfaction rating (X= 4. I , SD = 0.8) being significantly higher than that of patients (X = 3.8, SD = 1.2, t = 2.35, df = 141, p = 0.02) on a scale that ranged from 1 to 5 (1 = very unsatisfactory, 2 = unsatisfactory, 3 = neutral, 4 = satisfactory, 5 = very satisfactory). Paradoxically, although less satisfied, patients rated themselves as more improved than did their referrers (X = 3.9, SD = 1.7 (patients), X = 3.8, SD = 1.8 (referrers); = 7.3, df = 1, p = 0.006, K = 0.22).

x2

Table I . Referrers and potients: coinparisoil of their reasoiz(s)f o r referral

Reasons for referral as nominated by referrem* and patients** (n=156) Reasons, in order of importance

Second opinion Help with management Takeover and refer on

GP

Psychiatrist

All referrers

Patients

74.2 22.6 3.2

70.7 24.0 5.3

69.9 24.4 5.8

10.9 50.0 35.9

’When you referred a patient to the MDU which of these reasons was most important?’ ** ‘Why did they (the referrer) think that you should come?’


K. EYERS, H. BRODATY. G. PARKER. P. BOYCE. P. MITCHELL. K. WILHELM. 1. HICKIE

f ~ l l o w - ~(Ip= 11.73, I1 = 4.43. I11 = 7.16: F = 4.32. p = 0.02), indicating that referrers and patients who agreed about improvement or lack of it (Groups I and 11) were most likely to be rated in this direction by the MDU clinicians. An overview of some of the most beneficial ingredients as identified by responses to open-ended questions by both referrers and patients included assistance with: (i) accurate diagnosis and the right blend of medication plus advice on prophylaxis to those with chronic recurring depression, especially those that had become ‘treatment resistant’: (ii) shifting expectations of ‘cure’ to accepting an ‘impairment’ model of functioning in chronic or recurrent depression; (iii) depression ‘masked’ by somatic symptoms (where psychosocial interventions aimed at uncovering the depression were useful): (iv) adjustment to the loss of previous roles or transition to a new role; ( v ) depression secondary to a new or developing physical illness; and (vi) psychological interventions, both at individual and family level (needed to resolve ‘unfinished business’ and to break attachment to dysfunctional patterns of interaction).

Discussion In general, both referrers and patients were satisfied with the MDU service and treatment, although open-ended responses from both surveys suggested a wish for improvements such as more rapid communication and more effective implementation of follow-up plans. High response rates, as evidenced by returns from 93% (14Y1.56) of the referrers [6] and 83% (221/265) of the patients [S], indicated that the surveys were representative. The differences in referrers’ and patients’ reasons for referral (Table 1) reflect confusion, with the potential for patient doubt about the referral’s purpose or value. Referral to a specialist or specialist unit may indicate to patients that the disorder is severe or that their referrer is unable to proceed further with treatment [3.12]. Patients may fear the loss of their familiar clinician [I31 or sense their referrer’s frustration with their treatment failure [ 3 ] . The fact that so few patients referred to the MDU were aware of the main reason for referral attests to problems of clear communication between referrer and patient. While these may result from features of the patient’s depression (e.g. lack of motivation or concentration), studies of ineffective referral find

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lower dropout rates if adequate information and reassurance about the nature. purpose and value of the psychiatric referral are offered [ 141 including written material [ 121. The pattern of referral to the MDU had much in common with patterns found in other studies. Twothirds of the referrals were female: a high proportion of patients both felt unwell [IS] and had physical illnesses [81. Patients referred by GPs, in particular, were significantly more physically unwell. This may have been one of the spurs to referral [16], as GPs refer when unsure about the respective contribution of physical and psychological factors [ 171. The relative lack of congruence between referrer and patient ratings of the value of interventions and amount of improvement is of interest. The small variance in the scales used and the clustering of scores in the ‘satisfied’ range in each group mean that there is not much scatter. Hence the differences in mean satisfaction scores for each group seem slight (3.8 patients vs 4. I referrers) yet were significant. Though both referrers and patients rated interventions as beneficial, referrers, in responses to open-ended questions, indicated that they were well satisfied even though their rating of patient improvement was not as optimistic as that given by their patient. Often, they had referred their more challenging patients and were seeking management of a difficult illness rather than expecting substantial improvement. A limitation to the present study is the length of time between surveys. The improvement initially experienced by patients referred to the MDU may well have decreased by the time their referring doctors were surveyed. This could account for the disparity found between referrers and their patients, the patients considering themselves more improved than did their referrer. In defense of this, both satisfaction and improvement were highly rated by both groups. and many of the referrers were frequent users of the service. Despite chronicity and treatment resistance in many patients [3,4], two-thirds of patients seen by the MDU were recovered 3.5 years later 121, comparing favourably with the rates of outcome of depression in other psychiatric settings [4]. We conclude that the forum provided by a tertiary referral service, through clearly outlined treatment goals, a range of treatment options, backup support and coherent management may, by providing a link between referrer and patient, mitigate di:.:>\onance or else facilitate the patient’s transfer to another health-

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care provider. The aims of the MDU include satisfying the expectations of referrer and patient. Assisting patients to come to terms with a chronic and recurring disorder, and replacing a wish for ‘magic’ treatments or outcomes with a sequence of realistic goals can enable patients to forge a more effective partnership with referrers [ 131. Consequently, the ‘healing ritual’ of attendance and advice can increase patient compliance with medication and treatment programs 171. For patients to begin to take control is, in itself, a healing experience. Another way of lessening the dissonance is better communication between referrer and patient. Thus, misunderstanding about the purpose and benefit of referral to specialist care may be overcome, conipliance increased, satisfaction enhanced and the benefits of specialist treatment and/or advice augmented. Intriguingly. dissonance of opinion between referrer and patient about various aspects of a service did not appear to lessen the efficacy of that service.

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Boyce P. Treatment resistant depression in an Australian context. 11. Outcome of a series of patients. Australian and New Zealand Journal of Psychiatry 1994: 28:23-33. Eyers K, Brodaty H. Roy K et ( I / . Patient batisfaction with a mood disorders unit: elements and components. Australian and New Zealand Journal of Psychiatry 1993: 28:279-287. Eyers K, Brodaty H, Roy K. What the doctor ordered’? Referrer satisfaction with a mood disorders unit. Australian and New Zealand Journal of Psychintry 1994: 28:498-504. Svarstad BL. Patient-practitioner relationships and compliance with prescribed medical regimens. In: Aiken LH. Mechanic D, eds. Applications of social science to clinical medicine and health policy. New Brunswick: Rutgers University Press, 1986:438459. Blacker CV, Clare AW. Depressive disorder in primary care. British Journal of Psychiatry 1987: 150:737-75 I . Constantino M. Hoskins PL, Fowler PM d.Interaction between diabetic patients, their general practitioners and a hospital diabetic clinic. Medical Journal of Australia 1991; 155:515-518. Hamilton M. A rating scale for depression. Journal of Neurology. Neurosurgery and Psychiatry 1960; 2356-62. Maxwell AE. Coefficients of agreement between observers and their interpretation. British Journal of Psychiatry 1977; 130:79-83. Blouin A, Perez E, Minoletti A. Compliance to referrals from the psychiatric emergency room. Canadian Journal of Psychiatry 1985: 30:103-106. Bursztajn H, Barsky AJ. Facilitating patient acceptance of 3 psychiatric referral. Archives of Internal Medicine 1985: 145:73-75. Alexander DA. Hillis G. Refei-rals to hospitals by general practitioners [letter]. Britidi Medical Journal 1989; 198:48. Gater R, Goldberg D. Pathways to psychiatric care in South Manchester. British Journal of Psychiatry 1991; 159:90-96. Dovey SM, Garton GR, Tilyard MW. Gurr E. New Zealand general practitioner referral patterns. New Zealand Medical Journal 1993; IO6:465467. Kendell RE. General practitioner treatment of depression. In: Kendell RE. Zealley AK. eds. Companion to psychiatric studies. 3rd ed. London: Churchill Livingstone. 1988.