title: Referral of chronic hepatitis B patients from primary to specialist care: making a simple guideline work.
abstract: OBJECTIVE
  To evaluate a guideline selecting patients at the primary care level for referral to a specialist, to identify bottlenecks and subsequently implement and evaluate improvements.
  
  
  METHODS
  Retrospective patient files analysis and a prospective cohort study. The study was conducted in Municipal Public Health Service (PHS), University Medical Center. Patients diagnosed with chronic hepatitis B virus (HBV) infection were referred to the PHS. Improvement of bottlenecks were identified in the referral chain, based on the guideline. Number of patients receiving correct advice, number of patients reaching the hospital for specialist care, time between notification of the PHS and final arrival in the hospital.
  
  
  RESULTS
  The guideline for the referral of chronic HBV patients appeared to be appropriate, although one-third of the selected patients was not seen by the specialist. After the intervention more HBV patients (76 versus 61%) received correct advice from the PHS, and the number of HBV patients seen by the specialist increased by 18%.
  
  
  CONCLUSIONS
  The referral guideline works, yet we could improve the efficiency of the guideline increasing the proportion of eligible patients reaching specialist care. In countries where mandatory reporting of HBV infections exists this guideline can be adapted to local health systems.
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
authors.forename: Maria Catharina
authors.initials: MC
authors.lastname: Mostert
authors.forename: Jan Hendrik
authors.initials: JH
authors.lastname: Richardus
authors.forename: Robert A
authors.initials: RA
authors.lastname: de Man
mesh_terms: D015331:Cohort Studies; D005260:Female; D005762:Gastroenterology; D017408:Guidelines as Topic / Q000592:standards; D019694:Hepatitis B, Chronic / Q000628:therapy*; D006801:Humans; D008297:Male; D009426:Netherlands; D018579:Patient Selection; D011320:Primary Health Care; D011446:Prospective Studies; D011634:Public Health; D012017:Referral and Consultation; D012189:Retrospective Studies