title: Pathways of healthcare utilisation in patients with suspected adolescent idiopathic scoliosis: a cross-sectional study.
abstract: BACKGROUND
  School screening programs for adolescent idiopathic scoliosis (AIS) have been discontinued in Canada and elsewhere because they were not considered cost-effective. In communities lacking such programs, we expect a significant variety of healthcare pathways and timeframes for patient referrals to orthopaedics. The objectives of this study were: 1) to characterise the healthcare pathways of young children with suspected AIS in a population without school screening; and 2) to investigate the relationships between these healthcare pathways and the appropriateness of referrals to specialised orthopaedic clinics.
  
  
  METHODS
  This study concerned all children, ages 10 to 18, referred for an initial visit for suspected AIS to any of the five out-patient paediatric orthopaedic clinics of south-western Quebec (Canada). For the 831 participants, referrals to orthopaedics were characterised as appropriate, late, or inappropriate, based on known risk factors for AIS progression and on treatment indications. Parents documented the circumstances of healthcare use prior to the orthopaedic consultation. Relevant predisposing, enabling, and need variables derived from Andersen's Behavioral Model of Health Services Use were also documented. Healthcare pathways were characterised by developing a taxonomy using multiple correspondence analysis prior to hierarchical classification. Associations between the healthcare pathways and appropriateness of referral were assessed using multinomial regression analyses.
  
  
  RESULTS
  We constructed a taxonomy of five distinct healthcare pathways: 1) Lay/regular source of care interrelation, 2) Other professionals, 3) Lay/consultation discontinuity, 4) Other medical doctor, and 5) Regular source of care continuity. Laypersons played an important role in AIS suspicion (53% of cases), but did not prevent late referrals. Continuity of care, as opposed to numerous uncoordinated consultations, was an effective strategy to prevent late referrals (OR = 0.32 [0.17-0.59]), but was related to increased probability of inappropriate referrals.
  
  
  CONCLUSIONS
  We identified two cardinal characteristics that distinguished the healthcare pathways and related significantly to appropriateness of referral status, namely the role of laypersons and the involvement of the regular source of care. This suggests directions for intervention such as advocating for access to a regular source of care, increasing awareness of the disease to medical practitioners' and improving their knowledge of AIS detection and referral criteria.
authors.affiliation: Research Centre, Sainte-Justine University Hospital Centre, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada. marie.beausejour@umontreal.ca.|University of Montreal Public Health Research Institute (IRSPUM), P.O. Box 6128, Centre-Ville Station, Montreal, Quebec, Canada. marie.beausejour@umontreal.ca.|Department of Surgery, Faculty of Medicine, University of Montreal, P.O. Box 6128, Centre-Ville Station, Montreal, Quebec, Canada. marie.beausejour@umontreal.ca.
authors.forename: Marie
authors.initials: M
authors.lastname: Beauséjour
authors.affiliation: University of Montreal Public Health Research Institute (IRSPUM), P.O. Box 6128, Centre-Ville Station, Montreal, Quebec, Canada. lise.goulet@umontreal.ca.
authors.forename: Lise
authors.initials: L
authors.lastname: Goulet
authors.affiliation: University of Montreal Public Health Research Institute (IRSPUM), P.O. Box 6128, Centre-Ville Station, Montreal, Quebec, Canada. debbie.feldman@umontreal.ca.
authors.forename: Debbie
authors.initials: D
authors.lastname: Ehrmann Feldman
authors.affiliation: University of Montreal Public Health Research Institute (IRSPUM), P.O. Box 6128, Centre-Ville Station, Montreal, Quebec, Canada. roxane.borges.da.silva@umontreal.ca.|Agence de la santé et des services sociaux de Montréal, 1301 Sherbrooke St. E., Montreal, Quebec, H2L 1M3, Canada. roxane.borges.da.silva@umontreal.ca.
authors.forename: Roxane Borgès
authors.initials: RB
authors.lastname: Da Silva
authors.affiliation: University of Montreal Public Health Research Institute (IRSPUM), P.O. Box 6128, Centre-Ville Station, Montreal, Quebec, Canada. rpineaul@santepub-mtl.qc.ca.|Agence de la santé et des services sociaux de Montréal, 1301 Sherbrooke St. E., Montreal, Quebec, H2L 1M3, Canada. rpineaul@santepub-mtl.qc.ca.
authors.forename: Raynald
authors.initials: R
authors.lastname: Pineault
authors.affiliation: Department of Epidemiology Biostatistics and Occupational Health, McGill University, Montreal, Quebec, H3A 0G4, Canada. michel.rossignol@inesss.qc.ca.
authors.forename: Michel
authors.initials: M
authors.lastname: Rossignol
authors.affiliation: Research Centre, Sainte-Justine University Hospital Centre, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada. marjolaine.beaudry@recherche-ste-justine.qc.ca.
authors.forename: Marjolaine
authors.initials: M
authors.lastname: Roy-Beaudry
authors.affiliation: Research Centre, Sainte-Justine University Hospital Centre, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada. hubert.labelle@recherche-ste-justine.qc.ca.|Department of Surgery, Faculty of Medicine, University of Montreal, P.O. Box 6128, Centre-Ville Station, Montreal, Quebec, Canada. hubert.labelle@recherche-ste-justine.qc.ca.
authors.forename: Hubert
authors.initials: H
authors.lastname: Labelle
mesh_terms: D000293:Adolescent; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data; D002648:Child; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D009985:Orthopedics; D010290:Parents; D010372:Pediatrics; D011792:Quebec; D012017:Referral and Consultation; D012307:Risk Factors; D012600:Scoliosis / Q000175:diagnosis* / Q000628:therapy