Comparison of the quality of patient referrals from physicians, physician assistants, and nurse practitioners.

OBJECTIVE: To compare the quality of referrals of patients with complex medical problems from nurse practitioners (NPs), physician assistants (PAs), and physicians to general internists. PATIENTS AND METHODS: We conducted a retrospective comparison study involving regional referrals to an academic medical center from January 1, 2009, through December 31, 2010. All 160 patients referred by NPs and PAs combined and a random sample of 160 patients referred by physicians were studied. Five experienced physicians blinded to the source of referral used a 7-item instrument to assess the quality of referrals. Internal consistency, interrater reliability, and dimensionality of item scores were determined. Differences between item scores for patients referred by physicians and those for patients referred by NPs and PAs combined were analyzed by using multivariate ordinal logistical regression adjusted for patient age, sex, distance of the referral source from Mayo Clinic, and Charlson Index. RESULTS: Factor analysis revealed a 1-dimensional measure of the quality of patient referrals. Interrater reliability (intraclass correlation coefficient for individual items: range, 0.77-0.93; overall, 0.92) and internal consistency for items combined (Cronbach α=0.75) were excellent. Referrals from physicians were scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each of the following items: referral question clearly articulated (86.3% vs 76.0%; P=.0007), clinical information provided (72.6% vs 54.1%; P=.003), documented understanding of the patient's pathophysiology (51.0% vs 30.3%; P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001), appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient to referring health care professional (67.8% vs 41.4%; P<.0001). Referrals from physicians were also less likely to be evaluated as having been unnecessary (30.1% vs 56.2%; P<.0001). CONCLUSION: The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.

The transition from an analog to a digital echocardiography laboratory: the Mayo experience.

Our echocardiography laboratory has completed the transition from an analog to a digital imaging laboratory. The process involved a thorough analysis of the practice and design of a complete digital solution. After an effective implementation of a robust reporting solution, the transition to digital imaging ensued. The implementation plan for digital imaging enabled the transition to be made without adversely affecting the practice, which has an average daily examination load of more than 200 patients. Full-load testing simulations were required on high-end image processing review workstations, high-speed local area network connections to each imaging suite, and new clustered imaging servers. We had to test the ability of approximately 100 ultrasound machines with 3 idiosyncratic ultrasound platforms to allow digital image transfer to the new imaging servers over the local area network. Our sonographer, allied health, and physician staff of more than 250 persons had to be trained to adapt to important changes that the digital echocardiographic image acquisition and review platform would have on their specific roles in the laboratory. The efficiency of the implementation, reporting, and imaging resulted in improved staff resource allocation. The lessons learned may benefit laboratories with a similar interest in making the transition to a digital imaging laboratory with minimal effect on patient scheduling and staff satisfaction. The effect of the transition to a completely digital laboratory on operating expenses, imaging, and reviewing systems and the impact on the clinical practice of echocardiography at our institution are presented, with emphasis on the particular aspects of transitioning to digital imaging.