Providing primary health-care is a way to improve the fairness of access to health-care and the efficiency of resource use. Reinforcing primary health-care (PHC) is, also, essential for accessibility and quality of health-care. One of the main elements of primary health-care is the referral system, in which patients can access care in health centers before higher levels of care such as second and third level hospitals are offered. An efficient referral system is an important part of a well-functioning health-care system at the local, provincial, and national level of a country.
According to the definition of the World Health Organization (WHO), “referral can be defined as a process in which a health worker at a one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the assistance of a better or differently resourced facility at the same or higher level to assist in, or take over the management of, the client’s case”.
In order to refer the patients from environmental centers properly, three levels have been considered, that is the first and most pervasive level of the health system is primary care. The second level of the system is secondary hospital care, and finally, the third level, which is the highest level of care offers specialized facilities for the treatment of patients.
An effective referral system ensures that there is a close relationship among all levels of health-care, and that individuals receive the best possible care ever. It also contributes to the cost-effective use of hospital services and PHC. Therefore, a high percentage of patients referred to outpatient clinics in the second level centers can be properly cared for in PHC centers at a lower overall cost. The referral system can be deemed as a measure of the overall performance of the health system and reflects the ability of governments to manage all subsystems and actors involved in the referral process.
To implement an effective and efficient referral system, a combination of factors such as coordination between referral and referral centers, mechanisms/tools/working methods, communication and feedback systems, transportation system, executive protocols, trained personnel, efficient teamwork among all levels, integrated information recording system, accountability, and monitoring performance improvement are required. Various factors affect the effective implementation of the referral system. Different studies have examined each part or level of factors affecting the referral system and to the best knowledge of the authors, there might be no studies that examined the factors affecting the implementation of the referral system at all three levels. Therefore, we decided to design a study using the scoping review method. The main purpose of this study was to identify and analyze studies that have addressed the factors affecting the successful implementation of the referral system. This study helps managers and policy makers of the health system to have an overview of the factors influencing the successful implementation of the referral system.
A scoping review was performed to identify English and Farsi papers that were indexed in PubMed, Scopus, ScienceDirect, Trip Database, Cochrane Library, Embase, Google Scholar, SID, and Magiran until November 2020 using appropriate search strategies. Data was collected from the included studies by a reviewer and was checked by a second reviewer.
Titles, abstracts, and when necessary the full texts of the retrieved papers were checked to include relevant studies.
Empirical studies that explored factors that are affecting the performance of a referral system were included.
The collected data from the included studies about any factor that could affect the referral systems was analyzed using narrative methods.
A total of 1245 studies were retrieved. After screening the titles, abstracts and the full text of selected papers, finally, a total of 63 studies were included [Figure 1 and Table 1].
The characteristics of the 63 included studies are described in Appendix 1.
The factors that affected the implementation of a referral system were classified into 4 groups (themes) including organization, technology, process, and individual. Each theme then were classified into several subthemes, so that a total of 14 subthemes were identified [Appendix 2]. Appendix 3 presents further information about the identified subthemes. A brief summary of each of them and their subthemes is provided below.
Electronic referral: Electronic referral system minimizes unnecessary follow-up for patients, increases quality, reduces waiting time, increases access, efficiency, the number of referrals, and confidentiality of patient information, improves the relationship between first level and specialized care and increases safety for patients, and consequently, enhances efficiency.
Coordination: Coordination between levels of health services in the referral system increases the efficiency of primary care, improves capacity building in the first level of services, increases the quality of documents, adheres to the referral hierarchy, improves the continuity of patient care, improves the quality of health-care, and reduces the number of patients who are referred to hospital clinics.
Responsiveness: The referral system reduces the delay of seeking care and makes it possible to monitor access to treatment for individuals. Prompt handling of patients’ online requests significantly increases patient satisfaction. The widespread use of e-Referrals is, thus, an important step in simplifying intensive care pathways and providing excellent care.
Feedback: Proper feedback saves on medical costs and increases the quality of referral letters. Feedback may also affect the type of patients referred by specialists.
Effectiveness: Continuous training of general practitioners, supporting the referral system reforms, implementing referral policies, and creating standard guidelines and structural forms are among the factors affecting the effectiveness of the referral system.
Efficiency: Factors affecting the efficiency of the referral system include training of family physicians, modification of electronic health registration system, improvement of management skills, taking measures to attract specialists and improve their maintenance, availability of doctors and midwives, and management of the gatekeepers of the referral system.
Management, policy-making and planning: Policy-making and planning of the referral system are government efforts and investments, implementation of the lean Six Sigma, improvement of referral conditions (increasing access through communication and transportation systems), preparedness, infrastructure improvement, implementation of standard referral system monitoring toolkit, curriculum to educate health workers about referral policies and guidelines, and adequate funding for monitoring and evaluation that are evident in the findings mentioned in the management studies.
Rules and Regulations: Rules and regulations of the referral system that were found in the studies are as follows: notifying referral instructions, improvement of referral processes, minimizing the diversity between clinics, notifying operational instructions, appropriate monitoring system, criteria-based, audit and possible revisions to referral guidelines.
Patient-centered communication: Patient-centered communication improves community health and increases the effectiveness of care by reducing diagnostic tests and the number of referrals.
Insurance coverage, social capital, transportation, awareness, attitude, satisfaction, and social influence are individual factors that each affect the referral system in some way.
This study provides a comprehensive information about factors that are affecting the referral systems. There was a wide range of variations in the study design, setting, methods, and findings.
For example, Handayani et al. examined the factors affecting patients’ referral approval and showed that rules and regulations, data security, integration, accountability, effectiveness, efficiency, personal beliefs, and social impact significantly on referral approval.
One of the factors affecting the referral system is the implementation of the electronic referral system that has been studied many times. For example, Azamar-Alonso et al. (2019) conducted a scoping review, which securitized the electronic referral system in health-care, and showed that the electronic referral system was effective in improving the relationship between first-level and specialized care and minimizing waiting time.
According to the obtained evidence, implementation of the electronic referral system, the relationship between health centers and hospitals, gatekeeping management of Referral system, and patient-centered communication are among the factors that result in increasing the efficiency of the referral system. Factors that increase the efficacy of the referral system include the implementation of the electronic referral system, the use of standard templates for referral letters, and increasing access through communication and transportation systems. Also, the factors that ended up with increasing the quality of referral system services are the implementation of electronic referral system, coordination among the three levels of referral system, continuing education of general practitioners, increasing access through communication and transportation systems, and possible modification of referral instructions. In addition, factors that are involved in increased access to referral system services include the implementation of electronic referral system. Improving referral processes and reducing diversity between clinics implement a family physician program and insurance coverage.
The evidence presented in this study showed that each of the factors can have a quantitative and qualitative impact on the successful implementation of the referral system. Hence, identifying the factors that affect the referral system helps to take these factors into account in national and local policies. Monitoring centers and institutions may, in turn, consider factors and analysis of support data to provide a fair and equitable service to all people. The results of this study can provide relatively complete information about the factors affecting the referral system and may be considered in future planning and policy-making. We were also able to identify areas of interest for publishing research on factors affecting the referral system and to introduce relevant topics for further research.
One of the limitations of this study, though, was that many articles addressed the subject of the referral system and the subject dispersion was of higher frequency. As there was a great variety between the factors affecting the implementation of the referral system, the factors affecting the referral system overlapped in some instances.
The present scoping review used a systematic approach to identify studies that have addressed the factors influencing the implementation of the referral system. The most important factors influencing the referral system are divided into 4 main themes (technology, organizational, processes, and individual). Each of these issues includes a number of subthemes that managers and policymakers need to consider before and during the implementation of the referral system. This study paves the way for further interpretation of the existing literature on the factors affecting the referral system. As many factors affect the successful implementation of the referral system and the context of different countries, more studies are needed to decide how different factors affect the implementation of the referral system in different communities.
Factors affecting the successful implementation of the referral system in 4 dimensions are as follows: in the technology dimension (electronic referral system, coordination between levels of health services, responsiveness, and appropriate feedback), in the process dimension (effectiveness and efficiency in actions and programs), in the organizational dimension (management, policy-making and planning, rules and regulations, and patient-centered), and in the individual dimension (insurance coverage, social capital, transportation, awareness, attitude, satisfaction, and social influence).
The study was approved by the local ethical committee (code: IR.TUMS.VCR.REC.1399.329), and the Helsinki Declaration was respected across the study.
All authors contributed to this project and article equally. All authors read and approved the final manuscript.
Financial support and sponsorship
This study is part of the PhD thesis of the first author who is supported by Tehran University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
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