The quality of feedback from outpatient departments at referral hospitals to the primary care providers in the Western Cape: a descriptive survey

Figures & data

Table 1: Characteristics of primary care facilities (n = 141)

Variables	n (%)
Location of primary care facility:
Metropole	65 (46.1)
West Coast	22 (15.6)
Cape Winelands	30 (21.3)
Overberg	0 (0.0)
Garden Route	24 (17.0)
Who made the appointment:
Family physician	48 (34.0)
Medical officer	50 (35.5)
Community service medical officer	17 (12.3)
Intern	2 (1.4)
Clinical nurse practitioner	2 (1.4)
Referral hospital doctor	16 (11.6)
Private practitioner	3 (2.1)
Unknown	3 (2.1)
Reasons for referral:*
Not sure of diagnosis	43 (30.5)
Not sure of treatment	29 (20.6)
Need for special investigation	50 (35.5)
Need for additional management	72 (51.1)
Need to access specific medication	18 (12.8)
Patient request	2 (1.4)
Other	4 (2.8)

*More than one reason can apply per referral.

Table 2: Characteristics of referral hospitals (n = 141)

Variables	n (%)
Level of hospital where patient seen:
District hospital	25 (17.7)
Regional hospital	40 (28.4)
Tertiary hospital	72 (51.1)
Other	4 (2.8)
Type of discipline referred to:
Internal medicine	37 (26.2)
Medical sub-specialities	35 (24.8)
Surgery	9 (6.4)
Surgical sub-specialities	29 (20.6)
Gynaecology	12 (8.5)
Orthopaedics	9 (6.4)
Psychiatry	2 (1.4)
Paediatrics	2 (1.4)
Family medicine	1 (0.7)
Unknown	5 (3.5)

Table 3: Quality of the referral letter (n = 99)

Variables	n (%)
Is the whole letter legible and easy to read?	98 (99.0)
Is the letter respectful and collegial?	97 (98.0)
Is the patient’s name stated?	97 (98.0)
Is the patient’s folder number stated?	96 (97.0)
Is the date the letter was written stated?	96 (97.0)
Is the practitioner’s name stated (not just signature)?	89 (89.9)
Is the practitioner’s contact number stated?	42 (42.4)
Is the reason for referral clearly stated (what is expected of the OPD)?	90 (90.9)
Is the practitioner’s assessment or diagnosis stated?	87 (87.9)
Is the patient’s history described?	94 (94.9)
Are the clinical examination findings described?	82 (82.8)
Are the results of side room tests or investigations stated?	79 (79.8)
Is any treatment for the problem described?	68 (68.7)
Is the patient’s usual prescription listed?	54 (54.5)
Is the patient’s past medical history stated?	88 (88.9)
Is the presence or absence of allergies stated?	11 (11.1)
Are any lifestyle factors noted (e.g. smoking tobacco, alcohol intake)?	31 (31.3)
Does the letter contain any individual information (e.g. what has been said to patient, patient’s perspective)?	20 (20.2)
Does the letter contain any other contextual information (e.g. family, household, housing, occupation, income, grants)?	30 (30.3)

Table 4: Patients’ feedback on their experience of being referred at primary care facility (n = 83)

Variable	n (%)	Quotations
No problems with process	57 (68.7)	‘Everything went very well, the doctor helped me very much.’ ‘Patient is satisfied with service. His referral letter was done in May and he got an appointment for June.’ ‘Because they consulted with the family physician, patient got the gastroscopy and respiratory appointment the same day. Very happy about this.’
Improve process of obtaining the appointment date	14 (16.9)	‘Took very long to get appointment (6 months). Doctors had to phone multiple times to get an appointment. Would like to be given an appointment on the day of referral for a date appropriate in the future.’ ‘Was referred multiple times by fax without getting an appointment with a date on the day of referral from primary care.’ ‘Letter to neurology was send via the clerk. No appointment date in months.’ ‘Letter done and faxed but she never had appointment. Do not feel fax system awaiting appointments work well.’
Provide appointment date via information technology	6 (7.2)	‘Send them SMS on the phone because sometime we lose the card they give us.’ ‘Use of social media e.g. WhatsApp.’ ‘Use e-mail.’
Be given an earlier appointment date	4 (4.8)	‘The patient is not sure—was told in May 2017 that hospital is fully booked—only got an appointment in May 2018.’ ‘Long-time waiting for appointment for a 2 year period to hospital. Will take 2 years to get replacement of knees.’ ‘Initially had an appointment at hospital 10 months from date of seeing the doctor, but was worried to wait so long. Family physician made a sooner appointment.’

Table 5: Nature of feedback from hospital (n = 141)

Variable	n (%)
Did the hospital provide feedback to the primary care provider?	81 (57.4)
Did the primary care provider spend time obtaining feedback?	45 (31.9)
What was the source of information?
Letter	55 (39.0)
Telephone	8 (5.7)
Patient	73 (52.5)
Information technology, e.g. ECM, ECCR, email	24 (16.9)
Prescription	21 (14.9)
Copy of hospital notes/folder	8 (5.6)
Results of investigations	2 (1.4)
Did feedback influence the management plan at this visit?	77 (54.6)

Table 6: Quality of written feedback from referral hospital (n = 81)

Variables	n (%)
Is all the written feedback legible and easy to read?	80 (98.8)
Is the feedback respectful and collegial?	65 (80.2)
Is the patient’s identity clearly stated?	81 (100.0)
Is the date on which they were seen clearly stated?	81 (100.0)
Is the hospital practitioner’s identity stated (not just signature)?	75 (92.6)
Are the hospital practitioner’s contact details stated?	50 (61.7)
Has the reason(s) for referral been addressed?	69 (85.2)
Is the hospital’s assessment or diagnosis stated?	80 (98.8)
Is the hospital’s recommended management or prescription stated?	81 (100.0)
Are the results of any investigations or procedures stated?	48 (59.2)
Are instructions given regarding ongoing primary care (i.e. what the primary care provider should do going forward)?	56 (69.1)
Is the further role of the hospital clear (i.e. patient discharged, to be seen again)?	51 (62.9)

Table 7: Patients’ feedback on their visit to OPD at the referral hospital (n= 89)

Variable	n (%)	Quotations
Was satisfied with the OPD visit	37 (41.6)	‘Patient is satisfied. Staff explained everything to him.’ ‘Felt happy with management at hospital. Many patients helped before him.’ ‘At hospital, felt they were friendly and helpful.’
Shorter and fairer queues with shorter waiting times	24 (27.0)	‘Should pre-draw folder. Waits in very long queue to get folder to get to right place. Queued many times.’ ‘Specialist arrived at 12h00, waiting at OPD since 08h00.’ ‘Fitting in patients within specific time slot to reduce the waiting time at the hospital.’
Better and more respectful communication from doctors	6 (6.7)	‘I did not understand everything the doctor was saying. Looked like she was in a hurry.’ ‘The doctors do not listen to the patient or speak to them so one can understand.’ ‘Was there from 6 am. Dr came 08:30 and there was no assistant to help. When he went in the patient felt doctor were in a hurry. Told him that he did not have to come here.’ ‘He felt like he was just a number and it was not considered that his condition is serious. Waited very long to get appointment and when he got there he was not taken seriously. Feels he is not being explained exactly what is going on.’ ‘Hospital staff can at least be a little more sensitive and compassionate towards patients despite fatigue.’ ‘They always say they will send information to the doctor and do not tell you as the patient what is wrong.’
Better and cheaper forms of transport	15 (16.9)	‘Transport from home clinic to hospital could be arranged. No money for taxi.’ ‘Provide patient with transport.’ ‘Having my own transport.’ ‘Transport had a stretcher in bus, limited seats, patients had to sit on floor of bus.’
Better organisation of visit	7 (7.8)	‘The people by reception must tell you which clinic to go, because sometimes you go wait long by the wrong clinic and the hospital is very big.’ ‘They did not give me the correct instructions for the tests done before the appointment and then blamed me for this.’ ‘Reminder in form of SMS [text message].’

Table 8: Agreement of patients with statements regarding key aspects of their OPD visit

Variable	Fully agree n (%)
I needed to be referred to the hospital outpatients (n = 98)	95 (96.9)
I know why I was referred to the hospital outpatients (n = 98)	92 (93.9)
At the end of the visit I knew what the hospital doctor thought was wrong with me (n= 98)	63 (64.3)
The hospital doctor addressed the reason for my referral (n = 96)	71 (74.0)
I know what treatment the hospital doctor recommended (n = 97)	71 (73.2)
I know the results of my tests at the hospital (n = 87)	58 (66.7)
I know what operations or procedures were done at the hospital (n = 59)	42 (71.2)
I know if I need to go back to the hospital (n = 97)	79 (81.4)
The hospital doctor answered any questions that I had (n = 92)	65 (70.7)
The hospital doctor explained what the clinic needs to do now (n = 96)	51 (53.1)

Table 9: Factors related to the quality of written referrals and feedback.

Variable	Median percentage score Median % (95% CI)	p-value
District responsible for the referral letter:
Cape Winelands	70.6 (47.4–93.7)	< 0.001
Garden Route	89.5 (89.5–94.7)
West Coast	61.1 (57.9–68.4)
Metropole	68.4 (68.4–73.7)
Practitioner responsible for the referral letter:
Nurses	57.9 (−)	< 0.001
Junior medical officers	68.4 (68.4–79.0)
Medical officers	63.2 (61.1–68.4)
Family physicians	84.2 (84.2–89.5)
Level of hospital giving feedback:
District hospital	91.7 (91.7–100.0)	0.004
Regional hospital	75.0 (72.7–91.0)
Tertiary hospital	87.1 (75.0–91.7)
Type of discipline giving feedback:
Medicine	90.9 (83.3–91.7)	0.206
Surgery	75.0 (72.7–91.7)
Obstetrics and gynaecology	90.0 (75.0–100.0)
Psychiatry	80.0 (−)
Other	82.6 (81.8–83.3)