Second opinions and tertiary referrals in neurology: A prospective observational study

Academic Medical Centre, Dept. of Neurology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
Journal of Neurology (Impact Factor: 3.38). 10/2008; 255(11):1743-9. DOI: 10.1007/s00415-008-0019-3
Source: PubMed


The number of neurological second opinions (SO) and tertiary referrals (TR) is increasing. The main purpose of this study was to assess whether a day-care admission made a meaningful contribution to standard neurological outpatient care, for a wide range of second opinions and tertiary referrals.
All new patients attending an academic neurological day-care clinic in a 6-month period were investigated. Before admission, all previous medical correspondence and ancillary investigations were reviewed. On the day of admission, extensive time was available for clinical evaluation and additional ancillary investigations and an attempt was made to come to a final diagnosis. Demographic characteristics, duration of symptoms, patient satisfaction, new diagnoses and treatment consequences were studied.
300 patients (183 SO and 117 TR) were evaluated. In total 103 patients (35 %) received a new diagnosis (26 % SO vs. 48 % TR, p < 0.001) and 69 (67 %) of these had therapeutic implications. A new treatment advice was given to a total of 149 patients (50 %), which was similar in both groups (48 % vs. 53 %). Second opinions were considered medically less relevant than tertiary referrals (39 % vs. 64 %, p < 0.001). The number of new diagnoses differed largely between various diagnosis categories. Especially somatoform disorders and radicular syndromes were often newly diagnosed.
A high number of second opinion and tertiary referral patients benefits from a day-care admission in a neurological outpatient clinic. Careful selection for referral of patients who will benefit from daycare admission may even enlarge the diagnostic and therapeutic yield.

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    • "These rates are similar to those found for expert second opinions in pathology, with reported discrepancy rates of 7–66% (including changes from a benign to a malignant diagnosis or vice versa) resulting in a change in patient management in 1–28% [17-28]. There is much less literature on the effect of expert second opinions in clinical practice, but one study [29] has shown discrepancy rates for diagnosis and patient management of 35% and 67%, respectively. "
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    ABSTRACT: Objective Patients with head and neck cancer frequently present to academic tertiary referral centers with imaging studies that have been performed and interpreted elsewhere. At our institution, these outside head and neck imaging studies undergo formal second opinion reporting by a fellowship-trained academic neuroradiologist with expertise in head and neck imaging. The purpose of this study was to determine the impact of this practice on cancer staging and patient management. Methods Our institutional review board approved the retrospective review of randomized original and second opinion reports for 94 consecutive cases of biopsy proven or clinically suspected head and neck cancer in calendar year 2010. Discrepancy rates for staging and recommended patient management were calculated and, for the 32% (30/94) of cases that subsequently went to surgery, the accuracies of the reports were determined relative to the pathologic staging gold standard. Results Following neuroradiologist second opinion review, the cancer stage changed in 56% (53/94) of cases and the recommended management changed in 38% (36/94) of patients with head and neck cancer. When compared to the pathologic staging gold standard, the second opinion was correct 93% (28/30) of the time. Conclusion In a majority of patients with head and neck cancer, neuroradiologist second opinion review of their outside imaging studies resulted in an accurate change in their cancer stage and this frequently led to a change in their management plan.
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    • "And, this technology is found most of the time only in extensively populated cities, especially in areas of the world with limited resource investment in health care, such as Latin America — LA [13]. On the other hand, limited knowledge about neurological diseases exhibited by general practitioners usually leads to high numbers of second opinions and referral to tertiary facilities of patients suffering these conditions [14]. Finally, countries like the United Kingdom — UK or Colombia are claiming physicians' scarcity [15] [16]. "
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    ABSTRACT: Despite availability of neuroepidemiological data, urban-rural differences on neurological diseases have almost never been considered. Our goal is to identify differences in the frequency of neurological conditions between a rural and an urban sample from central Colombia. We compared frequencies of neurological encounters of an urban sample from Bogotá (N=2932), to our rural sample from Tunja (N=2664), collected both circa to 2000. The classification of neurological conditions used is based on the 9th revision of the International Classification of Diseases, clinical modification. A clustered sampling was used. Information collection was performed in a format designed for this purpose and already used in Colombia. Highly significant statistical differences (p<0.0001) were found for cerebrovascular diseases, seizure disorder, headache, Parkinson's disease and other movement disorders, and, inflammatory (infectious) conditions. Neurodevelopmental disorders (p=0.0029), dizziness and balance problems (p=0.0018), and neuropathies (p=0.0007), also showed statistically significant differences. Our study showed significant differences on all categories and diagnostics between the samples. Cerebrovascular disease the most frequent reason of neurological consultation in the rural sample could be confounded by sociodemographic (aging of the population, urbanization process), or the concomitant presence of medical (chronic pulmonary) and/or environmental (air pollution) conditions.
    Journal of the neurological sciences 07/2012; 320(1-2):56-60. DOI:10.1016/j.jns.2012.06.009 · 2.47 Impact Factor
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    • "There were no exclusion criteria. The organization of the day-care admission and the patient characteristics have been described previously [6]. In short, the day-care clinic provides tailored care for patients referred for a neurological SO or TR. "
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    ABSTRACT: Although the number of neurological second opinions (SOs) and tertiary referrals (TRs) is increasing, only little is known about expectations and patient satisfaction in this group of patients. Therefore, the purpose of this study was to explore expectations of patients who get a neurological SO or TR and to assess patient satisfaction in these groups of patients. All new patients attending an academic neurological day-care clinic in a 6-month period were investigated. Demographic characteristics, duration of symptoms, expectations and motivation, new diagnoses and treatment consequences were studied, and patient satisfaction with the previous physician and the day-care clinic physician was assessed. Three hundred consecutive patients (183 SOs and 117 TRs) were evaluated. SO patients were younger (47 years vs. 51 years), and their duration of symptoms was longer (24 vs. 13 months) than TR patients. Most patients expected a new diagnosis or treatment (60%). SO patients were equally as satisfied with the day-care clinic consultation as TR patients (overall satisfaction using a VAS-score ranging 0-10: 7.4 vs. 7.5; p = 0.81), and significantly less satisfied with the referring physician (overall satisfaction: 5.6 vs. 7.0; p < 0.001). SO patients, in particular, were more satisfied with the degree of information and emotional support provided by the consulting neurologist as compared to the referring physician. Receiving a new diagnosis and/or treatment advice did not influence satisfaction. A day-care admission for neurological SO and TR leads to an increase of patient satisfaction, irrespective of making a new diagnosis or initiation of a new treatment.
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