Understanding the impact of a multispecialty electronic consultation service on family physician referral rates to specialists: a randomized controlled trial using health administrative data

Clare Liddy, Isabella Moroz, Erin Keely, Monica Taljaard, Catherine Deri Armstrong, Amir Afkham, Claire E Kendall, Clare Liddy, Isabella Moroz, Erin Keely, Monica Taljaard, Catherine Deri Armstrong, Amir Afkham, Claire E Kendall

Abstract

Background: Electronic consultation (eConsult) services are secure online applications facilitating provider-to-provider communication. They have been found to improve access to specialist care. However, little is known about eConsult's impact on family physicians' referral rates to specialty care. The objective of this study was to assess the impact of a multispecialty eConsult service on referral rates from primary care.

Methods: In this parallel-arm, randomized controlled trial, we recruited primary care providers across Ontario not previously enrolled with eConsult. We randomly assigned participants to intervention and control arms. Participants in the intervention arm received access to eConsult for a period of 1 year while those in the control arm received no access to eConsult. The main outcome was specialist referral rate, expressed as the total number of referrals to (1) specialties available through eConsult, and (2) all medical specialties, per 100 patients seen. Multivariable negative binomial regression analysis was used to evaluate the effect of the intervention before and after adjusting for provider characteristics, using health administrative data.

Results: One hundred and thirteen participants were randomized (56 to control and 57 to intervention). For the primary outcome (referrals to eConsult specialties), the results show a statistically significant reduction in the number of referrals in both arms (control-arm Rate Ratio (RR), 0.85, 95% CI 0.79 to 0.91; intervention-arm RR, 0.80, 95% CI 0.74 to 0.85; unadjusted and adjusted RR values almost identical), as compared to the baseline data collected during the 12-month period before randomization, with a non-statistically significant 6% greater reduction in referrals in the intervention arm, compared to the control arm (unadjusted RR 0.94, 95% CI 0.85 to 1.03; adjusted RR 0.93, 95% CI 0.85 to 1.03).

Conclusions: Our randomized controlled trial of a multispecialty eConsult service demonstrated inconclusive results in terms of the impact of eConsult on physician referral rates. Findings are discussed in light of important limitations associated with conducting randomized controlled trials (RCTs) of complex interventions in the primary care context with intent to inform the design and analysis of future trials.

Trial registration: Clinicaltrials.gov, ID: NCT02053467 . Registered prospectively on 3 February 2014.

Keywords: Access to care; Health systems; Primary care; Specialist referral; Wait times.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow of participants through trial
Fig. 2
Fig. 2
Illustration of the study design and intervention time frames

References

    1. Canadian Institute for Health Information . How Canada compares: results from the Commonwealth Fund’s 2016 international health policy survey of adults in 11 countries. Ottawa: CIHI; 2017.
    1. Canadian Intitute for Health Information . Health care in Canada, 2012: a focus on wait times. Ottawa: CIHI; 2012.
    1. Barua B, Esmail N. Waiting your turn: wait times for health care in Canada. Vancouver: Fraser Institute; 2013.
    1. Chen AH, Yee HF. Improving the primary care to specialty care interface: getting from here to there. Arch Intern Med. 2009;169(11):1024–1026. doi: 10.1001/archinternmed.2009.140.
    1. Barua B, Esmail N, Jackson T. The effect of wait times on mortality in Canada. Vancouver: Fraser Institute; 2014.
    1. Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consultation. Open Med. 2013;7(1):e1–e8.
    1. Liddy C, Maranger J, Afkham A, Keely E. Ten steps to establishing an e-consultation service to improve access to specialist care. Telemed J E Health. 2013;19(12):982–990. doi: 10.1089/tmj.2013.0056.
    1. Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers. Telemed J E Health. 2013;19(10):733–738. doi: 10.1089/tmj.2013.0007.
    1. Liddy C, Drosinis P, Deri Armstrong C, McKellips F, Afkham A, Keely E. What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation. BMJ Open. 2016;6(6):e010920. doi: 10.1136/bmjopen-2015-010920.
    1. Liddy C, Drosinis P, Keely E. Electronic consultation systems: worldwide prevalence and their impact on patient care—a systematic review. Fam Pract. 2016;33(3):274–285. doi: 10.1093/fampra/cmw024.
    1. Vimalananda VG, Gupte G, Seraj SM, Orlander J, Berlowitz D, Fincke BG, et al. Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis. J Telemed Telecare. 2015;21(6):323–330. doi: 10.1177/1357633X15582108.
    1. Statistics Canada. Population by year, by province and territory, CANSIM, table 051–001. . Accessed 30 Apr 2018.
    1. Alexander G. eReferral strategy white paper: clearing the communications fog. Ottawa: Champlain LHIN; 2011.
    1. Franks P, Williams GC, Zwanziger J, Mooney C, Sorbero M. Why do physicians vary so widely in their referral rates? J Gen Intern Med. 2000;15(3):163–168. doi: 10.1046/j.1525-1497.2000.04079.x.
    1. Johns Hopkins University. The Johns Hopkins ACG System. . Accessed 30 Apr 2018.
    1. Hooper R, Forbes A, Hemming K, Takeda A, Beresford L. Analysis of cluster randomised trials with an assessment of outcome at baseline. BMJ. 2018;360:k1121. doi: 10.1136/bmj.k1121.
    1. Kaptchuk TJ. The double-blind, randomized, placebo-controlled trial: gold standard or golden calf? J Clin Epidemiol. 2001;54(6):541–549. doi: 10.1016/S0895-4356(00)00347-4.
    1. Liddy C, Moroz I, Keely E, Taljaard M, Mark Fraser A, Deri Armstrong C, et al. The use of eConsult is associated with lower specialist referral rates: a cross sectional study using population-based health administrative data. Fam Pract. 2017;35(6):698–705. doi: 10.1093/fampra/cmy020.
    1. Fives A. The role of random allocation in randomized controlled trials: distinguishing selection bias from baseline imbalance. J MultiDiscip Eval. 2013;9(20):33–42.
    1. Gupta SK. Intention-to-treat concept: a review. Perspect Clin Res. 2011;2(3):109. doi: 10.4103/2229-3485.83221.
    1. Chan BT, Schultz SE. Supply and utilization of general practitioner and family physician services in Ontario. Toronto: Institute for Clinical Evaluative Sciences; 2005.
    1. Soriano Marcolino M, Minelli Figueira R, Pereira Afonso dos Santos J, Silva Cardoso C, Luiz Ribeiro A, Alkmim MB. The experience of a sustainable large scale Brazilian telehealth network. Telemed J E Health. 2016;22(11):899–908. doi: 10.1089/tmj.2015.0234.
    1. Liddy C, Afkham A, Drosinis P, Joschko J, Keely E. Impact and satisfaction with a new eConsult service: a mixed methods study of primary care providers. J Am Board Fam Med. 2015;28(3):394–403. doi: 10.3122/jabfm.2015.03.140255.
    1. Barnett ML, Yee HF, Mehrotra A, Giboney P. Los Angeles Safety-Net Program eConsult system was rapidly adopted and decreased wait times to see specialists. Health Aff. 2017;36(3):492–499. doi: 10.1377/hlthaff.2016.1283.
    1. Kirsh SR, Ho PM, Aron DC. Providing specialty consultant expertise to primary care: an expanding spectrum of modalities. Mayo Clin Proc. 2014;89(10):1416–1426. doi: 10.1016/j.mayocp.2014.04.016.
    1. Whited JD, Hall RP, Foy ME, Marbrey LE, Grambow SC, Dudley TK, et al. Patient and clinician satisfaction with a store-and-forward teledermatology consult system. Telemed J E Health. 2004;10(4):422–431. doi: 10.1089/tmj.2004.10.422.
    1. Olayiwola JN, Anderson D, Jepeal N, Aseltine R, Pickett C, Yan J, et al. Electronic consultations to improve the primary care-specialty care interface for cardiology in the medically underserved: a cluster-randomized controlled trial. Ann Fam Med. 2016;14(2):133–140. doi: 10.1370/afm.1869.
    1. Golberstein E, Kolvenbach S, Carruthers H, Druss B, Goering P. Effects of electronic psychiatric consultations on primary care provider perceptions of mental health care: survey results from a randomized evaluation. Healthcare. 2017; [In press].
    1. Levati S, Campbell P, Frost R, Dougall N, Wells M, Donaldson C, et al. Optimisation of complex health interventions prior to a randomised controlled trial: a scoping review of strategies used. Pilot Feasibility Stud. 2016;2(1):17. doi: 10.1186/s40814-016-0058-y.
    1. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ. 2007;334(7591):455. doi: 10.1136/.

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