Health Services Research Clinical Trial
Official title:
Building Capacity for Specialized Services Through eConsultation
The consultation-referral process is complex, involving several steps including 1) the PCP
recognizing the need for specialist advice/intervention, 2) patient agreement on seeing the
specialist, 3) referral letter and information sent to specialist, 4) appointment booked and
communicated, 5) patient visit(s) with the specialist and 6) communication back to the PCP.
There are many factors during this process which limit the effectiveness and efficiency of
patient care. These include inequitable access for patients and providers, long wait times
before specialist advice received/implemented, delayed communication and mismatched consult
expectations. These gaps result in significant breakdowns in transitions of care,
inappropriate treatment, patient dissatisfaction and potential harm. Moreover, not all
individuals are willing or able to travel to see specialists in a large academic medical
centre even when recommended by the PCP.
Electronic consultation (eConsult) service is a form of asynchronous communication whereby
primary care providers (PCP) and specialists can communicate directly about a patient through
a secure web-based application. eConsult has the potential for improving transitions in care
through improved communication ensuring that patients are seen by the right specialist, when
necessary, with the right information and in a timely manner. The goal of this project is to
evaluate the impact of eConsult on specialist referral rates using health administrative
data.
Research Question: What is the impact of an electronic consultation (eConsult) service on
referral rates from primary care doctors to specialists?
The objective of this study is to assess the impact of eConsult service on referral rates
using a randomized controlled trial (RCT) of eConsult versus usual referral practices. We
hypothesized that access to eConsult would lead to a decrease in referral requests for
face-to-face specialist visits from primary care providers in the intervention group.
Trial Design: This study is a parallel arm RCT that recruited family physicians in Ontario to
use the Champlain BASE™ eConsult service. Physicians will be randomized 1:1 to either the
intervention or control arm between January 31, 2014 and September 26, 2014. Although
originally intended as a stepped wedge RCT, the design was changed to a parallel arm before
and after RCT due to the fact that randomization could not be performed at a discrete time
point for all participants.
Intervention: In 2009 our team began developing, implementing, and evaluating an innovative
eHealth solution called the Champlain BASE™ (Building Access to Specialists through
eConsultation) eConsult service. eConsult is a form of asynchronous communication whereby
primary care providers (PCP) and specialists can communicate directly about a patient through
a secure web-based application. Specifically, PCPs can submit a patient question (usually for
a patient who would otherwise have been referred) to a specialty service via a web-based
portal. They can attach any additional information (e.g. photos, test results, Electronic
Medical Record-generated letter). The case is assigned to a specialist, who receives an email
notification prompting them to access the case via the secure site. Specialists are expected
to provide an answer within one week. They can reply to the question, request additional
information, or recommend a referral, and advise the PCP on other matters such as medication
changes, additional tests, or other critical actions to be completed before the face-to-face
specialty care appointment. PCPs ultimately decide how to apply the specialist's suggestion
and when the case can be closed. Specialists are compensated on a pro-rated hourly basis. The
communication between PCPs and specialists is iterative and the discussion can occur back and
forth until, ultimately, the PCP closes the case. After undergoing registration, which
included orientation and brief training on the use of the service, physicians randomized to
the intervention group will receive access to eConsult right away (pending completion of an
orientation session), while those randomized to the control group will use standard referral
practices for one year after randomization and then will receive an option to use eConsult in
the second year. The intervention period for the treatment group therefore will last one year
following the enrollment/randomization period.The pre-randomization period will be 12 months
in duration for both groups.
Sample size: With 50 physicians in each arm, assuming an average of 800 patients per
physician for a total of 80,000 patients seen, the investigators will achieve 80% power to
detect an absolute reduction in referrals of 6 per 100 patients from a control arm referral
rate of 31 per 100 patients, estimated from a previous study, using a two-sided significance
level of 5% and assuming a between-provider coefficient of variation of 0.38.
Data sources: The following databases from the Institute for Clinical Evaluative Sciences
(ICES, ices.on.ca) will be used to obtain physician and patient characteristics: Registered
Persons Database, containing demographic data for all residents eligible for provincial
health care; Ontario Health Insurance Program (OHIP) billing claims system capturing
approximately 95% of physician services in Ontario; the Client Agency Program Enrolment
Registry and Corporate Provider Database, for patient enrolment with individual primary care
physicians; and the ICES Physician Database, containing physician demographic information,
training, and practice setting. 2006 Statistics Canada Census data will be used to assign
income quintile to patients based on their postal code. These datasets will be linked using
unique encoded identifiers and analyzed at ICES. In addition, the Champlain BASE™ eConsult
utilization data, which is routinely collected by the service, will be used to identify the
physicians in each group (treatment and control) as well as the date of randomization which
was used to identify the relevant 12 month long pre- and post-intervention periods for
referral rates assessment.
Data Analysis: All analyses will estimate Intent to Treat (ITT) effects. Descriptive
statistics will be generated to describe patient and physician characteristics at the time of
randomization for the two groups: eConsult and control. The primary outcome, referral rate
per 100 patients seen to all medical specialties available via eConsult service, will be
analyzed using a repeated measures multivariable random effects negative binomial regression
model. The unit of analysis will be the provider.To account for underlying secular/time
trends in the rate of referrals over the study period, the effect of the intervention will be
expressed as the between-arm difference in the change in referral rates from the pre- to
post-intervention periods (both 12 months in duration).
;
Status | Clinical Trial | Phase | |
---|---|---|---|
Completed |
NCT00692497 -
Electronic Referral and Booking of Outpatient Day Case Surgery Compared With Traditional Referral Routines.
|
N/A | |
Not yet recruiting |
NCT06395207 -
A Short Period of Proactive Community Case Management (ProCCM) to Improve Early Care-seeking for Fever in Sierra Leone
|
N/A | |
Completed |
NCT01296906 -
Population Versus Practice-based Interventions to Increase Immunizations
|
N/A | |
Completed |
NCT02896790 -
From the Model to the Adaptation of a Therapeutic Education Program (TEP) in Cancer Research
|
N/A | |
Completed |
NCT01074762 -
Randomised Controlled Trial of Structured Personal Care of Type 2 Diabetes Mellitus
|
N/A | |
Recruiting |
NCT04291534 -
Quality of Life and Addiction Among Hospital Night Workers
|
||
Completed |
NCT06341738 -
The Efficacy of Digital Educational Interventions on Parental HPV Knowledge and Attitude, and Their Children's Vaccination Rates
|
N/A | |
Not yet recruiting |
NCT06408233 -
Person-Centered Quality Measurement and Management in a System for Addictions Treatment in New York State (Project 3)
|
N/A | |
Completed |
NCT04118452 -
Achieving My Potential: A Randomized, Controlled Trial of a Telephone-Based Developmental Care Coordination System
|
N/A | |
Completed |
NCT03330509 -
Effectiveness of the Supportive and Palliative Care Review Kit (SPARK) for Cancer Patients in the Acute Hospital
|
N/A | |
Not yet recruiting |
NCT06184724 -
Implementation Pilot of Preoperative CGA Before Major Surgery
|
N/A | |
Completed |
NCT04837274 -
Anderson Study 1 - Tart Cherry Study
|
N/A |