Appropriateness of referrals to a urogynecology practice

Abstract

Introduction and hypothesis

The urogynecology subspecialty relies on appropriate referrals from their referral base. We sought to provide guidance for optimizing appropriate referrals to urogynecology by comparing pre-referral characteristics between appropriate and inappropriate referrals.

Methods

This retrospective cohort study examined predictors of appropriate urogynecology referrals. Appropriateness categorization was based upon pelvic floor disorder (PFD) symptoms and signs provided by the referring provider. Patients with both a PFD symptom and sign were considered “appropriate.” Patients with neither a PFD symptom nor sign were considered “inappropriate.” PFD symptoms were: vaginal bulge, voiding or defecatory dysfunction. PFD signs were: vaginal vault prolapse, urethral hypermobility, mesh/sling exposure, elevated post-void residual, positive standing stress test, abnormal urinalysis or urine culture-proven infection. Continuous and categorical data were analyzed with ANOVA and chi-square test, respectively. A logistic regression model to predict appropriateness was developed from variables identified from the bivariate analysis.

Results

Bivariate predictors of an appropriate referral for 1716 study subjects were older age, prior overactive bladder medication use, MD/DO referrer source and OBGYN, urogynecology or urology referrer specialty. Our logistic regression model correctly classified referrals as appropriate in 93.6% of cases.

Conclusions

Age, anti-cholinergic medication use, referrer source and specialty are pre-initial visit predictors of urogynecology referral appropriateness. The predictor-generated model was successful in predicting referral appropriateness. Potential bias from information transfer issues, lack of pre-referral evaluation and referring provider unfamiliarity with urogynecology are possible reasons for inappropriate referrals and potential areas for improvement.

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References

  1. 1.

    Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–6. https://doi.org/10.1001/jama.300.11.1311.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Steers WD. Establishing the subspecialty of female pelvic medicine and reconstructive surgery in the United States of America. Arab J Urol. 2013;11(2):113–6. https://doi.org/10.1016/j.aju.2013.01.003.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Geynisman-Tan J, Brown O, Mueller M, Leader-Cramer A, Dave B, Bochenska K, et al. Changing referral patterns to urogynecology. Female Pelvic Med Reconstr Surg. 2017. https://doi.org/10.1097/SPV.0000000000000416.

  4. 4.

    Barr SA, Crisp CC, White AB, Malik SA, Kenton K. FACE: female pelvic medicine and reconstructive surgery awareness campaign: increasing exposure. Female pelvic medicine & reconstructive surgery. 2018;24(2):115–9. https://doi.org/10.1097/SPV.0000000000000500.

    Article  Google Scholar 

  5. 5.

    Mazloomdoost D, Westermann LB, Crisp CC, Oakley SH, Kleeman SD, Pauls RN. Primary care providers’ attitudes, knowledge, and practice patterns regarding pelvic floor disorders. Int Urogynecol J. 2017;28(3):447–53. https://doi.org/10.1007/s00192-016-3134-1.

    Article  PubMed  Google Scholar 

  6. 6.

    Nagelkerke NJD. A note on a general definition of the coefficient of determination. Biometrika. 1991;78(3):691–2. https://doi.org/10.2307/2337038.

    Article  Google Scholar 

  7. 7.

    Arboretti Giancristofaro R, Salmaso L. Model performance analysis and model validation in logistic regression. Statistica. 2007;63(2):375–396. https://doi.org/10.6092/issn.1973-2201/358.

  8. 8.

    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010.

    Article  Google Scholar 

  9. 9.

    Obeid JS, McGraw CA, Minor BL, Conde JG, Pawluk R, Lin M, et al. Procurement of shared data instruments for research electronic data capture (REDCap). J Biomed Inform. 2013;46(2):259–65. https://doi.org/10.1016/j.jbi.2012.10.006.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39–68. https://doi.org/10.1111/j.1468-0009.2011.00619.x.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626–31.

    CAS  Article  Google Scholar 

  12. 12.

    Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Continence program for women research group. Neurourol Urodyn. 1995;14(2):131–9.

    CAS  Article  Google Scholar 

  13. 13.

    Barber MD, Kuchibhatla MN, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol. 2001;185(6):1388–95. https://doi.org/10.1067/mob.2001.118659.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005;193(1):103–13. https://doi.org/10.1016/j.ajog.2004.12.025.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Fertig A, Roland M, King H, Moore T. Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates? BMJ. 1993;307(6917):1467–70.

    CAS  Article  Google Scholar 

  16. 16.

    Jacups SP, McConnon KM. Reducing ear, nose and throat (ENT) waitlists: implications of a referral audit. Health Policy. 2018. https://doi.org/10.1016/j.healthpol.2018.12.007.

  17. 17.

    Hsu EY, Schwend RM, Julia L. How many referrals to a pediatric orthopaedic hospital specialty clinic are primary care problems? J Pediatr Orthop. 2012;32(7):732–6. https://doi.org/10.1097/BPO.0b013e31826994a4.

    Article  PubMed  Google Scholar 

  18. 18.

    Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. women: 2010 to 2050. Obstet Gynecol. 2009;114(6):1278–83. https://doi.org/10.1097/AOG.0b013e3181c2ce96.

    Article  PubMed  Google Scholar 

  19. 19.

    Kirby AC, Luber KM, Menefee SA. An update on the current and future demand for care of pelvic floor disorders in the United States. Am J Obstet Gynecol. 2013;209(6):584 e581–5. https://doi.org/10.1016/j.ajog.2013.09.011.

    Article  Google Scholar 

  20. 20.

    Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians Nonsurgical Management of Urinary Incontinence in women. Ann Intern Med. 2014;161(6):429–40. https://doi.org/10.7326/m13-2410.

    Article  PubMed  Google Scholar 

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Correspondence to Rujin Ju.

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Ju, R., Guanzon, A.M., DeWitt, J. et al. Appropriateness of referrals to a urogynecology practice. Int Urogynecol J 31, 1675–1682 (2020). https://doi.org/10.1007/s00192-019-04100-x

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Keywords

  • Urogynecology
  • Referrals
  • Sub-specialist
  • Appropriate
  • Female pelvic medicine and reconstructive surgery