Priority-setting for referrals from primary care providers to rheumatologists

American College of Rheumatology, 2008 Annual Scientific Meeting

A Fitzgerald, C De Coster, R Naden & T Noseworthy

Purpose: The Department of Medicine, University of Calgary, and the Calgary Health Region sponsored a Medical Access to Services Project to improve patient access and flow through medical subspecialties. Process redesign included a single-access entry point and priority-setting of referrals. This paper describes the development of a Priority Referral Score (PRS) used to rate relative urgency of referral to rheumatologists by primary care providers (PCPs).

Methods: A multi-methods, interactive and iterative process was used. Tool development included: a literature review for any pre-existing tools or criteria; establishment of a clinical panel comprising rheumatologists and family physicians, co-chaired by a rheumatologist and a family physician; development of 33 case vignettes which reflected the spectrum and levels of urgency of conditions seen in rheumatology practice; rank-ordering of cases using clinical judgment; dissection of vignettes for a set of diverse and independent criteria used by PCPs and rheumatologists in priority-setting; convergence and distillation of criteria to a limited number of mutually- exclusive criteria; assignment of weights to levels within criteria; reranking of cases using the criteria; examination for sources of variability; and revision of criteria until ranking consensus was achieved. The weighting of criteria and sub-categories was achieved by repetitive discrete choice experiments with clinicians judging relative urgency in a series of approximately 50 pair-wise comparisons, using 1000minds Software*. The PRS was a composite sum of the weighted criteria.

Results: While diagnosis specific examples exist, the literature review failed to identify any set of priority-setting criteria for the spectrum of patients referred from PCPs to rheumatologists. The deliberative process resulted in a tool with 8 criteria, each with two to four categories within.. The Spearman correlation was 0.80 between the clinical rank-ordering of the case vignettes and the rank-ordering using the draft PRS. Guidelines for use of the tool have been developed, including a description of high-urgency ‘red flag’ cases for which the referral tool is not applicable.

Conclusions: A priority-setting score (PRS) has been developed for judging the relative urgency for referral of patients by primary care providers to rheumatologists across a spectrum of diagnoses. The tool has strong face validity amongst a panel of primary care providers and rheumatologists practising across Canada and is simple to use. Further reliability, validity and pilot-testing in clinical practice are in progress.