title: Noncompletion of referrals to outpatient specialty clinics among patients discharged from the emergency department: a prospective cohort study.
abstract: OBJECTIVE
  We sought to characterize patients who are referred from the emergency department (ED) to specialty clinics but do not complete the referral, and to identify reasons for their failure to follow up.
  
  
  METHODS
  A prospective cohort study was carried out over 3 months of patients who were discharged from the ED of a teaching hospital with referral to internal medicine, cardiology or neurology clinics, but who did not complete the referral. Information on demographics, barriers to care and reasons for not completing the referral was obtained through a standardized telephone interview.
  
  
  RESULTS
  Of 171 ED referrals, 42 (24.6%) were not completed. Interviews were completed for 71.4% (30 patients). Of the nonattenders, 80% were functional in English and most had high school (73.1%) or university (60.7%) education. Virtually all (93.0%) interviewees could get to hospital by themselves or have someone take them. Only 42.9% (12 patients) understood why the emergency physician (EP) requested consultation, and 42.9% (12 patients) described EP instructions as poor or fair. Primary reasons for noncompletion of consult were patient choice (46.7%, 95% confidence interval [CI] 27.1%-66.2%), physical or social barriers (13.3%, 95% CI 0.0%-27.2%), communication failure (20%, 95% CI 4.0%-36.0%) and consultant's refusal of the consultation (20% [95% CI 4.0%-36.0%]). All consultant refusals were from one internal medicine clinic, representing 42% (8/19) of ED referrals to that clinic. None of the 6 patients interviewed who were declined consultation was aware that their consultation had been refused.
  
  
  CONCLUSIONS
  Patients discharged by the EP with referral to specialty clinics frequently do not complete the consultation. Causes for failure to follow up relate to patient decision, inadequate or poorly understood discharge information, and system factors. Institutional audits of patients who fail to complete follow-up may reveal unanticipated barriers to care.
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, Canada. steven.friedman@uhn.on.ca
authors.forename: Steven Marc
authors.initials: SM
authors.lastname: Friedman
authors.forename: Jennifer
authors.initials: J
authors.lastname: Vergel de Dios
authors.forename: Kate
authors.initials: K
authors.lastname: Hanneman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data*; D002170:Canada; D015331:Cohort Studies; D003142:Communication; D003625:Data Collection; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D012017:Referral and Consultation / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors