Optimizing classical hematology referrals: Development and early evaluation of an enhanced referral intervention

Abstract Background Classical hematology has a shortage of providers, leading to extended wait times from the time of referral to the initial hematology consult appointment and delays in definitive diagnosis and management. We developed an “enhanced referral” process for the 9 most common referral types to our classical hematology clinic to improve patient triage, initiate primary care-based treatments more rapidly, and increase the effectiveness of the initial consult appointment, while remaining user-friendly for the referring providers. This study aims to evaluate the enhanced referral process. Methods The enhanced referrals included brief education about the selected topic, a requested workup to be completed prior to consultation appointment, guidance on the management of nutritional deficiencies, and guidelines for when to directly contact a hematologist for more emergent issues. The enhanced referrals were sent to the referring clinicians. We also sent a letter to patients explaining the enhanced referrals process. We retrospectively evaluated referrals for the targeted diagnoses for the first 6 months after implementation of the enhanced referral process. In addition, we conducted a 14-question survey (including one open-ended question) to understand acceptability by referring providers, which we sent either by email (internal to our health network or by fax (external to our health network). Analysis was descriptive. Results We received 158 referrals from 127 unique providers across three states. Frequencies of referring diagnoses were anemia (n = 49, 31%), monoclonal gammopathy (35, 22.2%), iron deficiency (16, 10.1%), neutropenia (15, 9.5%), thrombocytopenia (12, 7.6%), hyperferritinemia (10, 6.3%), erythrocytosis (6, 5.1%), thrombocytosis (8, 5.1%), and hemoglobinopathy (5, 3.2%). Referrals came mostly from primary care clinicians (137, 86.7%) and over half (83, 52.5%) came from within our health network. At the time of data collection, 94 (64.6%) appointments were completed or scheduled. Sixteen (10.1%) were canceled by the patient, 6 (3.8%) did not show up their scheduled appointment, 15 (9.5%) were unreachable by schedulers, 7 (4.4%) were determined to be unneeded based on clinician feedback, and 2 (1.3%) were canceled by the referring office. Of 139 referrals for whom we asked for additional laboratory workup, 79 (56.8%) responded. Of 35 who were sent a second letter requesting additional workup, 14 (40.0%) responded. Of referring clinicians, 18 (14%) completed the survey, including 17 internal to our health network and 1 external to our health network. Survey participants had variable time in practice: 5 (27.8%) had 5 years, 6, (33.3%) had 6-10 years, and 4 (38.9%) had 10 years. Of participants, 11 (61.1%) approved of the enhanced referrals program, while 22.2% were neutral, and 16.7% did not approve. Ten (55.5%) agreed or completely agreed with the statement “I like the enhanced referrals program”. For the statements, “the program seems fitting” and it “seems like a good match with the stated goals”, 12 (66.7%) and 11 (61%) agreed or completely agreed, respectively. Only one participant responded that they disagree that it is a good match. Asked whether the program is “doable”, 13 (72%) agreed or completely agreed and 3 (16.7%) disagreed or completely disagreed. For the statement, the enhanced referrals process “seems easy to use”, 3 (16.7%) disagreed or completely disagreed, and 10 (55.6%) agreed or completely agreed. Of those who responded to the open-ended question, several noted that they were ordering laboratory studies that they feel uncomfortable interpreting. One clinician wrote they are “concerned that patients won't get the care... not sure they will be scheduled even if labs are done”, and another stated their patient “just had lab work done and often live far” from the lab facility. Conclusions Our study provides insight into the adoption, fidelity, and acceptability of our enhanced referral process and will inform ongoing tailoring of its implementation. Additionally, we plan to evaluate the sustainability over time as well as effectiveness at reducing time to appointment and the efficiency of the hematology appointment. We are currently working to incorporate the enhanced referrals process within the electronic health record.