Lack Of Feedback Information On Referred Children From The Community Hospitals In India: Preliminary Observations

Introduction
Poorly developed transport and referral system, private health sector providing care to a significant proportion of population, insufficient public health infrastructure, and inequitable distribution of wealth, have resulted in a complex situation for practicing paediatrics in India.(1),(2) Community based paediatricians are generally excluded by the public health care system, and work in isolation in India.(3) The author, a community based paediatrician in north India, collected prospective data on 39 consecutive patients referred by him from secondary level hospitals to tertiary level hospitals for paediatric sub-specialty care. The data was collected from three districts in north India, Noida and Agra in the state of Uttar Pradesh, and Faridabad in the state of Haryana. The three referring hospitals were similar settings; secondary care hospitals catering to peri-urban population, where people had to make out-of-pocket payments to utilize the services. The data was uniformly collected from the three towns (13 children each), and equally distributed over the period of data collection (July 2003 to December 2004 and March 2006 to June 2007). Details on baseline characteristics, spectrum of diseases, acuity of sickness (defined as needing urgent or non-urgent action), affordability of private care, whether a link could be established, and sector of health care where referred was recorded in a diary maintained by the author. Acuity of sickness was based on an earlier non-invasive validated “SICK� score, on Indian children. (4) Affordability of care was evaluated by asking parents of their occupation, residence (patients from urban slums and small farmers were considered not to be able to afford private care), insurance status, and giving them a reasonable estimate of the likely expenses they would incur in the private health sector. If the parents showed prompt willingness to go to the private sector, they were considered as able to afford private care.

Thirty-nine children with variable diagnoses were studied (Male: female ratio 3.3:1) (Table/Fig 1). The median age of children excluding newborns was 2.5 years (IQR 0.9 – 7.5 years). There were eleven newborns (28.2%), and six (15.3%) infants. Twenty-six (66.7%) children were referred to public hospitals (Public: private sector ratio 2:1). “Feedback� about progress/outcome was known only for fourteen (35.9%) children. Link prior or post referral was established in only eight (20.5%) children. “Feedback� was given significantly less for children referred to a public health sector [{9/13(69.2%) Vs. 5/26(19.2)}, ODDS ratio 9.4, 95%CI 2.04-43.6, p=0.004). Referral to a public sector hospital correlated strongly with “lack of feedback information�(r=0.44, 95%CI 0.14-0.67, p=0.006).

The above-cited observations highlight referral patterns of paediatric patients needing specialized services by a practicing paediatrician in the health system prevalent in India. Community based paediatricians are generally the first/secondary level health care providers, and thus it becomes imperative that “feedback� on outcomes of referred children be given to them to make audits and necessary improvements(4).

Feedback in the present series of referrals was established either by telephoning the referred hospital, referral hospitals gave the feedback themselves, telephoning the relatives, or the relatives were asked to come for follow up, if possible. Relatives of all referred patients carried mobile phones (even from the poor-social class!), so communication with them as a confounder was unlikely. The facilities for paediatric sub-specialty services for children were available at almost equal distances from the referring hospitals, thus lessening the possibility of referral to a confounder.

Also, as all referrals were made without the prior knowledge of the hospital or referred doctor, so biases in the observations were minimized. The decision to referral to a private/public sector was dependent on the proximity of available services, level of sickness of the newborn/child, socioeconomic status, and wishes of parents. Contact details and proper referral slips were sent in all the referred children, so it was anticipated to receive the feedback from the referred hospital. But as this was not observed, it leads to the speculation that “feedback� being known more in the private health sector, might be due to lesser work-load and more responsive staff. More responsiveness of staff in the private sector may reflect the efforts of these physicians to form a network, and increase the patient work-load in a highly competitive private health sector of India.

If “lack of feedback information� is assumed as a proxy for poor public-private collaboration in the current series of referral, another important hypothesis which needs to be tested, is that the lack of public-private collaboration is the weak link in the delivery of the quality specialized services for children in north India.

Further qualitative research using a questionnaire survey of community based paediatricians about problems faced by them, as well as quantitative research on referral patterns from the community in India, is needed. This will provide useful insights on whether observations made in the current work highlight a usual care pattern or not.