Assessing the Quality and Determinants of Referrals From General Practitioners (Primary Care Physicians for Adults) to Specialist Physicians in the Cyprus Healthcare System
Author(s)
Ifigenia Kammitsi, MSc1, Michalis Protopapas, MSc1, Anastasis Sioftanos, Dr2, Emanuella Georgiou, Dr2, Savvas C Savva, Dr2, Mamas Gregoriou, MSc1, Petros Neofytou, MSc1, Stella Hadjikyriacou, MSc1, Paraskevi Kinni, MSc2, Georgios Nikolopoulos, PhD2.
1Health Insurance Organisation, Nicosia, Cyprus, 2Medical School, University of Cyprus, Nicosia, Cyprus.
1Health Insurance Organisation, Nicosia, Cyprus, 2Medical School, University of Cyprus, Nicosia, Cyprus.
OBJECTIVES: The Health Insurance Organization (HIO) of Cyprus, after five years of implementing the General Healthcare System (GHS), focuses on improving healthcare quality, strengthening financial management, and optimizing resources. As part of these efforts, performance indicators have been introduced to assess the appropriateness of referrals from Personal Physicians of Adults (PPAs- General Practitioners) to Specialist Physicians (SPs). This study evaluates the quality of referrals and examines factors influencing referral performance, recognizing that high-quality referrals are essential for ensuring effective, timely, and cost-efficient access to specialist care.
METHODS: Two sampling strategies were applied: (1) representative sampling and (2) targeted sampling based on a monthly Key Performance Indicator (KPI - top 7% of referrers, i.e., those generating the most referrals). For each selected PPA, a random sample of 60 referrals from the previous month was assessed. Referrals were scored across three domains: clinical actions prior to referral (max: 23 points), clarity of referral reason (max: 7 points), and referral appropriateness (max: 20 points), yielding a total score of 50 points, with a satisfactory performance threshold set at 30 points. Statistical analyses included descriptive statistics, t-tests, and multivariable linear and logistic regression models (STATA 18), accounting for clustering by PPA.
RESULTS: Between September 2023 and July 2024, 13,457 referrals from 208 PPAs were evaluated. PPAs who failed the KPI threshold had significantly lower (p<0.05) mean scores (18.53) than those in the representative sample (22.90). Only 4.1% of the first group achieved above-threshold performance, compared to 24.6% in the representative sample. Regression models showed referral quality was positively associated with patient age and negatively with physician age. Among those who failed to meet the 7% KPI, younger and female physicians performed better.
CONCLUSIONS: Referral quality varied significantly across PPAs. Results highlight the need for targeted training and performance monitoring to improve referral practices across adult primary care.
METHODS: Two sampling strategies were applied: (1) representative sampling and (2) targeted sampling based on a monthly Key Performance Indicator (KPI - top 7% of referrers, i.e., those generating the most referrals). For each selected PPA, a random sample of 60 referrals from the previous month was assessed. Referrals were scored across three domains: clinical actions prior to referral (max: 23 points), clarity of referral reason (max: 7 points), and referral appropriateness (max: 20 points), yielding a total score of 50 points, with a satisfactory performance threshold set at 30 points. Statistical analyses included descriptive statistics, t-tests, and multivariable linear and logistic regression models (STATA 18), accounting for clustering by PPA.
RESULTS: Between September 2023 and July 2024, 13,457 referrals from 208 PPAs were evaluated. PPAs who failed the KPI threshold had significantly lower (p<0.05) mean scores (18.53) than those in the representative sample (22.90). Only 4.1% of the first group achieved above-threshold performance, compared to 24.6% in the representative sample. Regression models showed referral quality was positively associated with patient age and negatively with physician age. Among those who failed to meet the 7% KPI, younger and female physicians performed better.
CONCLUSIONS: Referral quality varied significantly across PPAs. Results highlight the need for targeted training and performance monitoring to improve referral practices across adult primary care.
Conference/Value in Health Info
2025-11, ISPOR Europe 2025, Glasgow, Scotland
Value in Health, Volume 28, Issue S2
Code
HSD10
Topic
Health Service Delivery & Process of Care, Patient-Centered Research, Real World Data & Information Systems
Disease
No Additional Disease & Conditions/Specialized Treatment Areas