Appendix 3.

Findings and subthemes pertaining to the theme

Findings of Studies	Subthemes	Themes
Technology	Electronic referral	The electronic referral system was associated with a reduction in unnecessary follow-up for patients. eReferral facilitated communication between referring clinicians and a specialist reviewer prior to the appointment.[48]
		Electronic referrals improved health-care access and quality.[18]
		Electronic referral system increases efficiency compared to paper referral system due to patients’ choice of date and time.[10]
		Compared to the paper referral process, the implementation of the electronic referral system increases the number of referrals[37]
		Implementation of electronic referral leads to improved quality, completeness of clinical referral information, and efficiency in the referral process.[12]
		The electronic referral system allows specialists to make a pre-consultation exchange to identify the need for consultation.[59]
		Use of the Electronic referrals system has improved efficiency in the referral process and has reduced the work associated with the previous paper based referral system. It has also enhanced communication between the healthcare provider and the patient and family and has improved the security and confidentiality of patient information management.[11]
		Redesigning a paper-based referral system to an electronic referral system is more efficient and safer for patients.[15]
		Specialists can use electronic referral and consultation systems to enhance specialty care delivery with consultative communication that is highly rated by primary care providers (PCPs).[61]
		An internet-based registration system for Retinopathy of Prematurity (ROP) screening resulted in fewer cases of delayed first examination and resulted in fewer babies with advanced ROP.[38]
		The electronic referral system is effective in improving the relationship between primary care and specialists, and reducing the waiting time.[9]
	Coordination	Overcrowding of the tertiary health facilities with problems that can be managed at the lower levels.[27]
		Strengthening the connection between health lefts and hospitals increases the efficiency of primary care.[2]
		A strong collaboration is needed between teaching hospitals and other stakeholders in the referral chain to foster good referral practices and healthcare delivery.[35]
		Improving capacity building at the primary health-care delivery, referral hierarchy, document quality, and emergency transport mechanism is critical for patients.[56]
		Properly functioning health lefts (primary level) can take care of the vast majority of patients’ problems.[32]
		Health Information Technology (HIT) enabled pre-consultation exchange facilitates communication between referring physicians and specialists.[59]
		Interventions such as using standard templates for referral letters may facilitate more effective communication.[16]
		Electronic referrals improve and accelerate the communication process between PHC and the hospital, as well as improve the continuity of patient care.[29]
		Advances in the structure of the referral system to improve the quality of health-care require coordination among the three levels of the referral system.[19]
		The advantages of using an electronic communication system with primary care are: allowing quick answers to general practitioners’ questions, starting treatment on time, and reducing the number of patients referring to hospital clinics.[62]
		By reducing inappropriate initial visits from primary care to secondary care, the capacity to solve patients’ problems in primary care increases.[55]
	Responsiveness	The referral system reduces the delay of seeking care and makes it possible for individuals to monitor access to treatment.[14]
		Increasing health information on the web makes people more aware of their health conditions and treatment options, and also quickly responds to patients’ online requests, significantly increasing patient satisfaction.[47]
		Providing patient information allows specialists to fulfill their obligations and make informed decisions about maintaining the patient’s health, thereby improving the full care continuum.[58]
		Web-based electronic referrals perform significantly better than other types of referrals, with less waiting time and more complete patient information. Wider use of eReferrals is an important first step in simplifying intensive care pathways and providing excellent care.[39]
	Feedback	Postoperative feedback saves on medical costs.[66]
		Feedback improves the quality of referral letters.[67]
		Feedback improves the content of referral letters and may also affect the type of patients referred for investigation by specialists.[68]
Process	Effectiveness	Continuous training of general practitioners leads to improving the quality of referral system services.[20]
		Supporting referral system reforms with regard to the training of health workers; Implementation of referral policies, guidelines, and structural and standard forms is recommended.[6]
		Establishing referral guidelines is effective in reducing unnecessary patient referrals.[46]
	Efficiency	Training of family physicians can increase the appropriate referral rate.[44]
		Modification of electronic health system along with provider training intervention is a way to identify and refer eligible patients.[33]
		Improving management skills of Lady Health Workers (LHWs) for simple medical problems reduces the number of referrals. Also, strengthen communication and counseling skills to reduce a significant portion of unsuccessful referrals.[26]
		To facilitate patient access to physicians who have contracts with the Family Physician Program and Referral Systems at Level 2 and 3; is essential to adopt policies to attract specialists and improve their maintenance[45]
		The family physician program has a positive effect on the performance of health units in terms of access to physicians and midwives.[22]
		The efficacy of the referral services is determined by the gatekeepers’ management of the referral system at the primary-level hospital and the allocation and management of bed resources at the higher-level hospital.[13]
		The efficiency of the referral system is reduced by not following the referral recommendations by the health team.[52]
Organization	Management, policy and planning	The implementation of Lean Six Sigma can lead to a significant improvement in the healthcare referral system.[28]
		Improving referral conditions (by increasing access through communication and transportation systems) and managing disease complications (increasing preparedness) enhance the quality of care and also make the referral system more effective and efficient.[17]
		Government efforts and investments are needed to make the referral system useful in practice.[51]
		Improving infrastructure, implementing a standard referral system monitoring toolkit, training curricula for health workers on referral policies and guidelines, and adequate funding for monitoring and evaluation are recommended for successful referral system implementation.[5]
		The government should enhance the availability of needed resources such as diagnostic equipment, skilled personnel, referral ambulances, drugs, and communication technology to facilitate patient referrals.[65]
	Regulation	Guidelines for elective surgical referral can improve appropriateness of care by improving prereferral investigation and treatment.[34]
		Immediately after the introduction of referral guidelines, appropriate referrals increased by 40%, but this increase was not sustained after 2 years. Therefore, continuous training of general practitioners regarding referral guidelines is essential.[41]
		Improving referral processes and reducing diversity between clinics improved patient access.[21]
		Appropriate operating guidelines and proper monitoring system help to increase information provision and utilization process.[24]
		Criteria-based audits can improve the ability of a regional referral system to deal with emergencies in countries with limited resources.[49]
		Possible modification of referral guidelines will improve referral quality.[20]
	Patient Centricity	Patient-lefted communication improves health and increases the efficiency of care by reducing diagnostic tests and the number of referrals.[14]
Individual	Insurance	Patients with worse economic conditions face barriers to accessing intensive care. Also, patients who are not covered by insurance receive less care.[23]
		The family physician program has a positive effect on insurance coverage.[22]
		One of the reasons for the lack of continuity of care is the insurance coverage of patients.[42]
		The provision of primary health-care and referral system should be strengthened in cooperation with health insurance system reforms.[50]
	Social capital	Both the cognitive and structural forms of social capital significantly affect people’s ability and willingness to adhere to the referral system process. Cautious interaction with social capital will make it a potentially powerful tool for understanding gaps and improving the effectiveness of referral policy.[30]
	Transport	Transport intervals are independently associated with ICU/CCU and hospital lengths of stay at the receiving hospital for critically ill adults transferred to referral lefts.[31]
		Distance traveled, health team skill configuration and Point of care affect patient survival.[36]
		Improving the transportation system for emergency referrals is essential to ensure patient safety during transport.[35]
		Referral transport services have a positive effect on increasing institutional deliveries.[57]
	Awareness, attitude, and satisfaction	Awareness and satisfaction with the way primary health-care services are provided in urban communities and motivation in rural communities affect the implementation of the referral system process.[60]
		Providers and decision makers can use information technology and guidebooks about the referral system to facilitate communication and standardization between health lefts, raise public awareness, and encourage patients to use the referral system.[8]
		Proper counseling and consideration of patients’ preferences during referral is essential to remove barriers to accessing adherence to treatment and improving treatment outcome.[43]
		The higher the level of education, people have more knowledge about the referral system and are more likely to have a correct understanding of the referral system.[25]
	Social influence	Active community engagement will be the key to stimulating better use of referral services.[40]
		Social media minimizes delays in receiving specialist advice and management, especially in acute situations.[53]
		Motivation and encouragement of family and friends is one of the factors in following up the referral.[64]