Referral patterns between the child health service, general practitioners, and secondary healthcare: A prospective descriptive study in the Netherlands

Abstract

Background: In the Netherlands, preventive child health service (CHS) screening plays an important role in the early detection of congenital, developmental, physical, and mental disorders. Objective: To obtain insight into the referral patterns of children from CHS to general practitioners and from general practitioners to medical specialists. Methods: Prospective study over 6 months in a semi-urban area in the Netherlands. All correspondence from the participating doctors was sticker marked and, after each contact, a registration card was sent to a central secretariat. The referral stream between general practitioners and specialists or allied health professionals was extracted from a central database. The general practitioners and the participating paediatricians were asked to complete a questionnaire about the quality and necessity of the referral. Results: Out of an estimated 2600 examinations, 45 children were referred to their general practitioners for further examination. The problems of eight children were settled by the GP, 10 children were referred to allied health professionals, and 24 children were referred to specialists. The median time span of showing up at the GP's office was 6.5 days. Sixteen per cent showed up long after having been referred by the CHS. The parents of three children did not comply. Of the 397 referrals from GPs to medical specialists and allied health professionals, 8.5% were initiated by the CHS.

Conclusion: The amount of referrals from the CHS to GPs and of referrals from GPs to medical specialists and allied health professionals initiated by the CHS is low in terms of absolute percentages. Most referrals by the CHS were considered useful.

• Child health service
• general practice
• children
• preventive care

Introduction

At the beginning of the twentieth century, the death rate of babies and children was high due to malnutrition, poor living conditions, infectious diseases, and large delays in medical attention. Many opportunities for prevention and (early) cure were missed. To protect children against preventable diseases and to detect diseases at an early, treatable stage, the child health service (CHS) was established in the Netherlands in 1901 [1]. This service provides screening, preventive health examinations, immunization, and health education (e.g., advice about safety measures and nutrition) [2], [3].

All children in whom disorders are detected by the CHS are referred to a general practitioner. In the Netherlands, the general practitioner is the so-called “gatekeeper” of the health system [4], [5]. All residents of the Netherlands are registered with their own general practitioner, who is usually easy accessible. The general practitioner considers the identified disorder or physical defect. If necessary, the child is treated by the GP or referred to a paediatrician, another medical specialist, or an allied health professional, while feedback is given to the CHS [4–7]. Both the CHS and the role of the general practitioner differ from the situation in the UK and many other countries [8–22]. An important difference between the Netherlands and many other countries is the fact that there is a strict division between preventive and curative medicine. The physicians of the CHS can only signal problems; they are not allowed to treat patients. All paediatricians in the Netherlands are hospital based.

Little is known of the efficacy of periodic screening in the child health service system [2], [11] and of the efficiency of the referral chain from the child health service system to general practitioners to specialists [2], [3], [18]. There are some studies concerning cost efficacy [3], baby healthcare [2], [9–14], [16], gatekeeping [21–26], the sentinel function of the general practitioner concerning referrals [4], [5], [27], referrals of children to specialists [5], [6], [27], and the link between GPs and paediatricians [6]. Nevertheless, we were not able to find peer-reviewed studies about the referral stream between the child health service, general practitioner, and paediatrician. Therefore, we performed a small prospective study to answer the following questions:

• How many of the screened children are referred to their general practitioner, for what reason, and what profit does it yield?

• Are children actually followed up on the referrals and, if so, within what time span?

• What percentage of referrals from general practitioners to specialists and allied health professionals is initiated by the child health service?

Methods

Dutch healthcare system

In the Dutch healthcare system, the child health service (CHS) is divided into preschool (age 0–4 years) and school (age 4–19 years) healthcare. Preschool (well-baby clinics) and school (community health services) healthcare are provided by different organizations. Preschool children are examined at 15 standard age intervals: twice at home and 13 times at the well-baby clinic. Children who attend regular school are seen at four standard age intervals between 5 years and 14 years of age by school doctors or nurses. Some organizations perform the health examinations at school, whereas others invite children and their parents to the community healthcare centre. Children who attend special education receive one health examination every 2 years before the age of 8 years, and after the age of 8 years up to the age of 19 years they receive one health examination every 3 years. The CHS is based on a well-organized call-and-recall system. About 95% of children in the Netherlands attend these screening examinations [3]. All these activities are carried out using government funds, without extra costs for parents. The specialization time for child health service physicians is 2 years.

Patients

In the region of Leiden in the Netherlands, four health centres for family practice with a total of 30 general practitioners participated. Doctors from the child health service working in these centres and paediatricians of the three hospitals in this region participated in the study. In the first 6 months of 2002, we monitored all referrals and the subsequent communication from the child health service to the general practitioner, and from the general practitioner to the paediatrician. At these four centres, 6730 children from 0–12 years of age were registered, out of a total of 45 300 registered patients. Adolescents older than 12 years of age were excluded because many of them go to secondary schools in other neighbourhoods, and would thus be screened outside the area of ascertainment. We estimated that 2600 children were seen by the CHS during the study period. This estimation was based on numbers provided by the child health service. Since not all children examined by the CHS were registered in the participating health centres for primary care, we also extracted from the central database the amount of children in each age group. By using the screening frequency at various ages and the assumption that 95% of Dutch children attend the screening examinations of the child health service [2], [3], we calculated the amount of screened children and came to the same estimate of 2600 screened children.

Organization of the study

The parents of the children who were referred by the child health service to the general practitioner were asked to participate in the study. The medical ethics committee of Leiden University Medical Centre approved the design. Informed consent was obtained from all participants. All correspondence to and from these doctors in the chain—child health service, general practitioner, and paediatrician—was sticker marked, and after each contact the child had with one of these professionals, a registration card was sent to a central secretariat. The referral stream between general practitioners, specialists, and allied health professionals was extracted from the central database of the general practitioners’ health centres. Both the general practitioners and the paediatricians were asked to complete a short questionnaire about the quality and the necessity of the referrals. The CHS physicians tried, in case of “no show”, to find out what the reason was for not following up on the referral.

Results

In 45 of the estimated 2600 examinations (1.8%), the CHS found disorders needing further examination. These children were referred to their GP (Table I). Eight problems were settled by the GP either by treatment, by a wait-and-see policy, or through reassurance. Ten children were referred to allied health professionals for mainly developmental delay, and 24 children were referred to medical specialists.

Table I.  Follow-up information of the children referred by the child health service to the general practitioner.

Settled by general practitioner		asthma (and eczema)	2
		weakness	1
		otitis externa	1
		defecation problems	1
		hernia umbilicalis	1
		phimosis	1
		fungal infection	1
	total			8
Referred by the general practitioner to allied health professionals	physiotherapist/remedial therapy	writing disorders	2
		motor disorders	3
		back problems	1
	speech therapist	speech disorders/delay	3
	dietician	eating disorder	1
	total			10
Referred by the general practitioner to medical specialists	paediatrician	growth disorder	4
		growth disorder and gastro-oesophageal reflux severe constipation	1
	ophthalmologist	refraction disorders (astigmatism 2, severe hypermetropia 1)	10
	ENT	hearing problems	4
		tympanic membrane perforation	1
	orthopaedic surgeon	hip dysplasia	1
		scoliosis	1
	surgeon	hernia inguinalis	1
	total			24
Non compliance with referral				3
Total				45

Five out of six referrals to paediatricians on request of the CHS were for growth disorders. The sixth child, a 1-year-old boy, had severe constipation, which responded well to a cow-milk-free diet. In the group of children referred to medical specialists, the largest group (n=10) was referred to ophthalmologists for visual problems. Ear/hearing problems were also a prominent reason for referring children. All five children referred to ENT specialists after screening by the CHS had hearing or ear problems. Referrals to orthopaedic surgeons mainly concerned hip dysplasia and postural problems.

The parents of three children ignored the advice of the child health service to visit their general practitioner. The parents of two children with motor problems did not consider treatment necessary; a third child, who was referred to his general practitioner with the suspicion of a neurological disorder, never showed up despite a reminder letter. Two children were already under treatment with a specialist for the disorders found, and the parents made an appointment directly with their specialist without first consulting their general practitioner.

Referral patterns by the general practitioner

In the study period, the GPs referred a total of 397 children: 295 to medical specialists and 102 to allied health professionals. These numbers include referrals initiated by the child health service (Table II). The most prominent was the group referred to paediatricians (85 children). Thirty-nine children were referred for an acute illness, and 46 children for non-acute disorders. In the acute group, disorders of the digestive and respiratory systems and fever/infections were most prominent. In the non-acute group, it was noted that four children with psychological/mental disorders were referred to a paediatrician. In the groups referred to an ENT specialist (5/83) and an ophthalmologist (10/36), the amount of referrals initiated by the child health service was smaller than the number of referrals initiated by the GP. Most referrals were for children in the age group 3–7 years (Figure 1).

Figure 1.  Number of referred children by the CHS (y-axis) according to age group (x-axis, years).

Table II.  Referral pattern from general practitioner to medical specialist and allied health professionals: number of referrals initiated by the child health service.

Referrals of GP to:	Total	Initiated by the child health service
Cardiology	1	–
Surgery	22	1
Dermatology	18	–
ENT	83	5
Neurology	3	–
Ophthalmology	36	10
Orthopaedic surgeon	13	2
Plastic surgery	2	–
Paediatrics	85	6
Psychiatry	7	–
Rehabilitation	2	–
Urology	11	–
Allied health professionals
Physiotherapy/remedial therapy	51	6
Speech therapist	42	3
Dietician	9	1
Psychotherapy	12	–
Total	397	34

Feedback on the quality of referral

For the 39 children who visited a general practitioner after referral from the child health service, 29 general practitioners completed the questionnaire about the referral. In 27 cases, the general practitioner judged the referral useful, in one case doubtful, and in another not useful. Six times it was noted that the referral letter contained too little information; in two of the six, the lack of an accompanying growth chart was mentioned.

Time span

The median time span of showing up at the general practitioner's office after a referral by the child health service for 36 children was 6.5 days, with a range from the same day to 7 months. For three children, we were not able to trace the time span. A relatively large group (16%) showed up a long time (2–7 months) after child health service advice to see the general practitioner; three children (6%) did not show up at all. The waiting time for an appointment with a paediatrician is 2–6 weeks, but in acute or urgent cases it is always possible to have the child examined immediately. The median time it took until the general practitioner received a full written report about a referred child was 66 days [14].

Discussion

Although the child health service has existed for over a century, there are limited data on the results of its examinations and referrals [2], [3], [13]. Assuming that our estimation of the children between birth and 12 years of age screened by the CHS is valid, the percentage of children referred to the general practitioner for further examination was only 1.8%. However, one has to take into consideration that the screened population consists in principle of a healthy group of children. Therefore, it is logical that the majority of referrals comprised disorders which usually remain undetected by parents, such as refraction disorders and growth problems [1], [14]. For this group of patients, screening by the CHS seems efficient. In the Netherlands, the CHS is considered useful, since all vaccinations and the majority of screening programs for early detection of metabolic disorders such as phenylketonuria are carried out by the CHS, and most disorders found by the CHS usually remain undetected by parents.

Most parents paid a visit with their children shortly after the referral, but the late-arrival (16%) and no-show (6.6%) groups need extra attention. Approximately 9% of referrals to a medical specialist or paramedic were initiated by the child health service. Because the group of children we found was small and the percentages are based on a weighted estimation of the screened children, this percentage only gives an indication of the effect of the screening by CHS on referrals by GPs.

For the disorders for which children were referred by the GP to a paediatrician, it is noteworthy that all referrals for growth disorders were instigated by the child health service, in contrast to none of the referrals to psychiatrists or psychotherapists. This suggests that the CHS may be better equipped to detect physical problems than psychosocial problems. An alternative explanation is that mental problems are mainly seen in adolescents, who were not included in our study.

Most referrals were considered useful by medical professionals. Since only one referral was considered not to be useful and only one doubtful, we were not able to confirm the often-heard complaint that many referrals from the CHS are false alarms. It is difficult to anticipate what would have happened if the identified disorders had been diagnosed at a later stage or not at all. In some cases (such as those with a secondary growth disorder and hip dysplasia), serious problems or disability would probably have been the result. In the cases with growth disorders, the referral accelerated further diagnostic procedures.

Based on our findings, we suggest the following improvements to the referral system. First, the observation that all children with visual problems who were detected by the CHS were referred to an ophthalmologist and all children with a development delay to either a physiotherapist or a speech therapist suggests that efficiency would be increased if one were to give the CHS the opportunity to refer directly to ophthalmologists, physiotherapists, and speech therapists. Second, the finding that some referred children are seen very late or not at all by the general practitioner suggests that some sort of control system would be helpful. This may be feasible when, in the future, referrals are directly sent from the CHS to the GP by a computerized e-mail-based system. In such a system, more information, such as growth data, can be given, and late arrival or no show can be detected by building in a warning system.

With respect to the communication process between various physicians, we found a high percentage of feedback information from the general practitioner to the CHS. The low percentage of feedback from general practitioners to the child health service which we observed in a previous study in the same area could merely be explained by the fact that this was a retrospective study in which not all feedback data were precisely registered [25].

In conclusion, less than 2% of the children from 0 to 12 years seen by the child health surveillance were referred to their general practitioner and seen in a median time interval of 6.5 days. About 9% of the referrals of children from general practitioners to medical specialists and allied health professionals were initiated by the child health service. All referrals from the general practitioner to the paediatrician for growth disorders were initiated by the child health service. Most referrals were considered useful. A computer-based referral system in which both the CHS physician and the GP can monitor the referral is likely to improve the efficiency of the referral system.

Acknowledgements

We are grateful for the help of the general practitioners, paediatricians, and youth health doctors for their participation. We gratefully acknowledge financial support by ZON-MW, the Leiden University Medical Centre, TNO-PG, and the Province of South Holland. We are grateful for the assistance of N. Dijkstra and A. Vogels for logistical support.