The referral system for non-communicable diseases in Saudi Arabia: Identifying strategies for better healthcare coordination

Abstract

Introduction The Saudi healthcare system was established in 1926, and consisted of three levels of service: (i) primary; (ii) secondary; and (iii) tertiary healthcare that are currently available through the Ministry of Health (MOH) network. The primary healthcare (PHC) system serves as a gatekeeper to secondary and tertiary healthcare. The referral system, or the process between primary and secondary care, is essential in the management of healthcare systems, as well as chronic non-communicable diseases (NCD). The World Health Organization (WHO) Global NCD Action Plan 2013-2020 was aimed to … strengthen and organise services … access and referral systems around close-to-user and people-centred networks of primary health care are fully integrated with the secondary and tertiary care level of the healthcare delivery system, including quality rehabilitation, comprehensive palliative care and specialised ambulatory and inpatient care facilities. In Saudi Arabia, the demand for secondary care in a hospital has been increasing through high referral rates and emergency department (ED) non-urgent case visits. In the recent National Transformation Program (NTP), Vision 2030, the reform and restructure of PHCs was a priority, that is, to ease access to healthcare, to reduce the inefficient use of healthcare services, and to improve the quality of PHCs. Some of the program’s objectives were to improve patient satisfaction of PHCs and to reduce the number of inappropriate referrals by PHCs. Therefore, three aims of this PhD research are: (i) to assess patient satisfaction, experience of PHCs and care coordination in Saudi Arabia; (ii) to evaluate the attitudes and decision-making of physicians in regard to referral system; and (iii) to identify conceivable interventions/systems of referral by targeting NCD in Saudi Arabia. Method A mixed method approach is used to answer three research questions: (i) How do patients rate the quality of care received in PHCs by measuring their satisfaction and experience?; (ii) How do physicians make decisions on referrals to secondary care?; and (iii) How do physicians evaluate the referral system? To answer the first research question, two phases were implemented, involving 157 patients recruited through the Sharik initiative from 10 regions of 13 regions of Saudi Arabia. Phase 1 applied a cross-sectional study by using a Patient Satisfaction Questionnaire (PSQ-18) (Arabic) to measure the overall satisfaction of PHCs and to assess its correlation to sociodemographic characteristics of patients. Phase 2 involved a cross-sectional study by using the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) (Arabic) to measure the overall experience ratings and assess its correlation to sociodemographic characteristics of patients. In the Research Question 2, a cross-sectional study, the Ambulatory Sentinel Practice Network (ASPN) tool was incorporated to explore and assess the attitudes and decisions made by physicians regarding referrals in PHCs. A sample of 68 physicians were recruited from 15 PHCs. To answer Research Question 3, 19 physicians were recruited from 15 PHCs for inclusion in a semi-structured interview using the Referral System Assessment and Monitoring (RSAM) tool to evaluate the referral system from their perspective and to synthesise their views on seven successful factors for integrated care from a total of 10 factors. Results Research Question 1: Phase 1 (Quantitative) PSQ-18 consisted of 18 items constituting seven domains: (i) general satisfaction; (ii) technical quality; (iii) financial aspects; (iv) interpersonal manner; (v) communication; (vi) time spent with the doctor; and (vii) accessibility and convenience. The relationship between sociodemographic factors (age, gender, income, education and marital status, health status and the type of PHCs) and seven domains of PSQ-18 and total satisfaction (from seven domains ranging from 18-90) were assessed in bivariate tests and multiple linear regressions. In the bivariate analysis, age, gender, education. marital status, and health status were associated with the some of the domains of satisfaction. Age was associated with financial aspects domain with a p value of p=0.040. Gender was associated with two domains interpersonal manner and communication with p value of p=0.024 and p=0.045 respectively. Education was associated two domains technical quality and financial aspects with p values of p=0.012 and p=0.003 respectively. Marital status was only associated with communication domain with a p value of p=0.012. The health status was associated with interpersonal manner with a p value of p=0.018. In the multiple linear regression, none of the sociodemographic factors predicted general satisfaction, time spent with doctor, and accessibility and convenience domains. However, education, marital status and health status predicted technical quality, interpersonal manners, communication and total satisfaction. Marital status was a strong predictor of technical quality, communication and total satisfaction. Research Question 1: Phase 2 (Quantitative) Using CG-CAHPS, the relationship between a patient’s sociodemographic factors (age, gender, income, education, marital status, health status and the type of PHCs), the quality of physician/patient communication, care coordination and overall ratings in PHCs were assessed. Sociodemographic factors were not associated with overall ratings except for the type of PHCs. Communication and care coordination items were associated with overall ratings. In the multiple linear regression, the model revealed that a total of 81% of the overall rating (satisfaction) could be attributed to the predictors included. The communication domain had the highest number of predictors on the overall ratings. The highest predictor of the overall rating was physicians answering their patients’ questions, followed by time spent with the physician, type of PHC, and the ability of the physician to listen carefully, to explain things clearly and to show respect. The weakest predictors were from the care coordination domain followed by the healthcare provider’s and physician’s knowledge of the patient’s medical history. Research Question 2: Phase 3 (Quantitative) A total of 68 physicians participated in this study from 15 PHCs from five health regions in Riyadh city. Approximately 39.7% of patients received two or more referrals in their visits. Over 51% of patients’ reasons for visiting PHCs were to obtain a referral. More than half of the physicians (55.9%) stated they referred patients who needed advice on diagnosis and treatment, followed by direct surgical management/treatment and a need for multidisciplinary care. Abdominal pain was the highest condition being referred to by physicians (5.8%). Around 32.2% of physicians considered the quality of feedback as ‘very important’ when selecting a clinic or hospital. One quarter of physicians (25%) viewed the technical capacity of the consultative centre to be ‘very important’. A small percentage (11.8%) of physicians viewed patient requests to present at a clinic as a ‘very important’ aspect while 44.1% of physicians viewed it as ‘somewhat important’. Research Question 3: Phase 4 (Qualitative) Nineteen physicians from 15 PHCs were interviewed in this study. In synthesising the interviews, seven of the 10 principles of successful integrated care were used because they are feasible in the current Saudi healthcare system for referrals: (i) comprehensive services across the care continuum; (ii) patient focus; (iii) geographic coverage and rostering; (iv) standardised care delivery through inter-professional teams; (v) performance management; (vi) information systems; and (vii) organisational culture and leadership. There were major problems with each aspect of the information system. Physicians reported that the feedback procedure was almost non-existent. Although referral protocols and guidelines existed, these were not available in all PHCs. The system relied on accurate knowledge about the referral network, but directories of hospitals in the network were not available in all PHCs. Some physicians were dissatisfied about their patients’ role in the referral letter that was generated only ‘Upon Patient’s Request’. Data of the referrals were collected and analysed in most PHCs. However, evaluation reports were not shared with PHCs. Conclusion Using the PSQ-18 questionnaire, the results confirmed that sociodemographic factors affect the satisfaction score of PHCs in the bivariate and multiple linear regression. However, sociodemographic factors do not play any role in the overall rating when using the patient experience (CG-CAHPS) questionnaire. Furthermore, physician/patient communication and the type of PHC is fundamental in predicting overall ratings of PHCs in the bivariate and multiple linear regression. With regard to physicians making decisions on referrals, the study showed different ‘medical’ and ‘non-medical’ reasons for referrals in PHCs. In addition, there were system-related reasons for referrals that could be emphasised, since the availability of such services in PHCs plays a major role in referrals. In evaluating the referral system, results suggested that improvement to the referral system is necessary, in particular, appointments to support efficient time management, provision of an up-to-date directory of hospitals, training for physicians from PHCs and an increased awareness of the significance of feedback from hospitals.