Dermatology specialty clinics provide access to disease-oriented specialists who enhance research and care of people with complex skin conditions. The referral process is a critical facet of care delivery for complex dermatologic patients. Although previous research has revealed inefficiencies in the specialty-referral process,1-3 interventions to improve referrals to dermatology specialty clinics are lacking, particularly those designed to address the needs of referring providers.
We conducted a quality improvement study, exempt from institutional review board approval, to optimize the referral process at a specialty clinic at the Massachusetts General Hospital that focuses on care delivery to patients at high-risk of developing keratinocyte carcinomas (KCs). Prior studies have supported the value of specialized skin cancer clinics in dermatology care delivery,4 supporting the selection of the high-risk skin cancer clinic for an intervention aimed at improving the referral process.
We gathered 24-months of information on referring practices (2014-2016), including the numbers and reasons for referral. We conducted semi-structured, open-ended qualitative interviews with providers in the top two referring practices (2016-2017) to understand provider needs and barriers. Qualitative analysis of the interviews identified several barriers, including lack of understanding of how to initiate a specialty clinical referral and a lack of knowledge regarding appropriate referral criteria. These barriers were addressed by developing written materials that described the unique services provided by the clinic, delineated a step-by-step guide on making referrals, and included patient-facing skin cancer educational materials (Figure 1).
Figure 1: High-risk skin cancer clinic educational resource.
Patient educational brochure with information about referral criteria, skin cancer risk factors, and unique services provided.
Next, we targeted five, high-volume referring clinics in 2017 with an intervention consisting of an in-person visit by the skin cancer specialty clinic providers with referring providers and staff introducing the newly developed written materials. We then compared the number of referrals pre- and post-intervention, along with the reason for referral (categorized as appropriate, inappropriate and not specified/unknown).
The average number of monthly referrals increased from 11.9 during the pre-intervention period (January-November 2016), to 25.2 in the post-intervention period (December 2017-December 2018) (Figure 2). The monthly referral data reveals that the referral trends are nonlinear with seasonal variation, as shown by increased referrals during the summer months, but the average number of referrals changed approximately two-fold following the intervention. The intervention resulted in an increased number of appropriate referrals (i.e. immunosuppression, hereditary disorders with increased KC risk, ≥4 KCs/year) and fewer inappropriate referrals (i.e. skin cancer screening, family history of skin cancer, suspicious lesion).
Figure 2: Number of referrals to the high-risk skin cancer clinic pre- and post-intervention.
Figure shows the total number of patients referred to the HRSCC per month during the pre-intervention period (January 2016 – November 2016), the qualitative interview and intervention period (December 2016 – November 2017), and the post-intervention period (December 2017 – December 2018), along with the number of appropriate (i.e. immunosuppression, hereditary disorders increasing KC risk, ⩾4 KCs/year) and inappropriate (i.e. skin cancer screening) referrals during each of these periods. Referral reasons that were not specified (i.e., reason not listed) were classified as “unknown.”
Our study focused on identifying and addressing the needs of the referring provider, a key stakeholder in the patient care delivery process. Implementing an intervention rooted in referring providers’ articulated needs enhanced overall referrals, with a rise in appropriate referrals. Future studies should assess the potential consequence of increased referrals on other metrics, such as patient access. Although this study was performed within a specific specialty clinic at a single academic medical center, which may limit generalizability to other settings, our findings suggest that working directly with referring providers to address barriers to referrals may improve the referral process and specialty care delivery.
ACKNOWLEDGEMENTS
We would like to express special thanks to Luell Chapman, Michele Goodwin, and Thomas Senfuma at Massachusetts General Hospital for their assistance in data abstraction and help in drafting the branded material for the high-risk skin cancer clinic.
Funding Sources: This work was supported by the American Academy of Dermatology Resident & Fellow Quality Improvement Project Award (GW) and the National Institute of Arthritis, Musculoskeletal and Skin Diseases (K24AR069760 to MA).
ABBREVIATIONS
- EMR
electronic medical record
- HRSCC
high risk skin cancer clinic
- KC
keratinocyte carcinoma
Footnotes
Conflicts of Interest Disclosure: Dr. Asgari has a research contract with Pfizer Inc., which is relevant to the contents of this manuscript.
This study was exempt from Institutional Review Board approval.
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