Early diagnosis, regular follow-up of chronic
diseases, informing patients, and providing
preventive medicine services are among the primary
objectives of outpatient clinic examinations.
According to the Health Services Utilization
Statistics report, the number of applications to
hospitals affiliated with the Ministry of Health
for 2022 was approximately 375 million.[
4] Due
to the disproportionate increase in the number
of applications, patients are facing challenges in
accessing healthcare services. Patients can receive
appropriate healthcare services only if they can
promptly apply to the right outpatient clinic. The
CPAS developed by the Ministry of Health has
been employed for this purpose since 2010. Despite
its advantages, such as ease of use and the provision
of services via mobile phones, call centers, and
websites, the CPAS is inadequate in preventing
incorrect referrals to outpatient clinics.
This is the first study to examine incorrect
referrals to the cardiovascular surgery outpatient
clinic. In our study, the rate of incorrect referrals
to the cardiovascular surgery outpatient clinic was
11.5%. According to the Ministry of Health data, the
reported rate of referral to an incorrect department
was 6%.[2] In a study evaluating referrals to the
internal medicine outpatient clinic, the reported
rate of incorrect referrals was 3%.[9] Zorlu and
Kavurmacı[10] evaluated the rate of incorrect referrals
among patients who presented to the thoracic surgery
outpatient clinic via CPAS. In their study, the
rate of patients who were referred to the thoracic
surgery outpatient clinic when they should have been
directed to the thoracic diseases outpatient clinic
was approximately 6%. The rate of incorrect referrals
found in the present study is significantly higher than
the rates reported in the previous studies.
The incidence of one in 10 patient visits to
the cardiovascular surgery outpatient clinic as an
incorrect referral has several potential consequences:
(i) delay in diagnosis and treatment of the patient;
(ii) communication issue between the patient and
physician; (iii) loss of labor force; (iv) patients who
present to the correct department may not have the
opportunity to be examined.
In a study conducted by Solmaz and Uluda,[11]
admissions to the cardiology outpatient clinic were
analyzed, and the rates of admissions with noncardiac
complaints were evaluated. The rate of admission
with noncardiac complaints was significantly higher
in the CPAS group than in the no-appointment
group. Similarly, in our study, the rate of CPAS
use was significantly higher in the incorrect referral
group, and CPAS use was associated with a 4.34-fold
increase in incorrect referrals. This situation
contradicts the principles of time management and
the appropriate referral to the right branch, which
are the main objectives of CPAS. The high rate of
correct referrals among patients presenting without
an appointment can be explained by the effective
functioning of in-hospital referral mechanisms. Some
factors that may explain the high rate of incorrect
referrals among patients who made appointments
through CPAS are as follows. First, inadequate
knowledge and low health literacy level of the patient
may explain the appointment to the wrong branch.
The second factor is the confusion in branch names.
The term “cardiovascular surgery” is simpler and more
understandable than “cardiology” when selecting a specialty. Third is the misdirection caused by the
CPAS. Patients who use CPAS by contacting the
182 hotline officials or the “What is wrong with me?”
application may be directed to the cardiovascular
surgery branch instead of cardiology.
Another finding of the study is the relationship
between young age and incorrect referrals. Young age
was associated with incorrect referrals independent
of CPAS use. This could be explained by the
likelihood that patients in the older age group are
more health-conscious or have higher exposure to the
healthcare system.
Steps for improvement identified based on the
findings may contribute to the reduction of incorrect
referrals to the cardiovascular surgery outpatient
clinic. Some changes can be made in this direction.
Professional associations should provide the public
with accurate and understandable information about
cardiovascular surgery and be active on social media
platforms. The confusion in branch names should be
eliminated. Furthermore, assessing the knowledge level
of the 182 hotline employees and collaborating with
professional associations to provide branch-specific
information could lead to improvement. Finally, the
artificial intelligence-supported “What is wrong with
me?” application should be updated and developed to
be consistent with developments in the field of health
professionals and artificial intelligence.
Another intervention that can be implemented
to prevent incorrect referrals, both for patients with
appointments through CPAS and those without
appointments, is the effective use of the healthcare
level system. According to data from the Ministry
of Health, only 40% of the over 850 million
presentations made in 2022 were primary care
admissions.[4] This reveals that direct admissions
to secondary and tertiary care are predominant.
Directing patients to the right specialty and
appropriate health center is among the primary
objectives of family medicine practice.[12] While
there may be certain differences in each healthcare
level, the primary purpose of family medicine
often revolves around the referral chain. Numerous
studies have demonstrated that the implementation
of a referral chain decreases the number of
outpatient clinic visits.[13-15] The implementation
of the referral chain is vital in preventing both
unnecessary and incorrect admissions. According to
Bektemur et al.,[16] 85% of physicians in the family medicine system stated that referral chain should
be implemented, while only 55% believed that
referral chain was feasible in Türkiye. We believe
that improvements in the family medicine system
and modifications to the referral chain system in
Türkiye will be effective in preventing incorrect
referrals.
This study has some limitations. The study was
conducted in a single center. Multicenter studies
examining incorrect outpatient clinic referrals may
contribute to the overall understanding of the results.
In the study, incorrect referral was defined as patients
who should have initially presented to the cardiology
outpatient clinic, which represents the second
limitation of the study. The evaluation of all incorrect
referrals to the cardiovascular surgery outpatient clinic
may result in a rate that is significantly higher than
the rate found in this study. The last limitation of the
study is that it was conducted retrospectively. Surveys
investigating the reasons why patients incorrectly
present to the cardiovascular surgery outpatient clinic
may contribute to revealing the existing problems with
the appointment system.
In conclusion, healthcare workers are serving
beyond their capacity due to the increasing number
of patient admissions every day. This situation
negatively affects both patients receiving services and
healthcare professionals. The increasing demand for
appointments over the years has resulted in a reduction
in examination times. Although CPAS, developed by
the Ministry of Health, is continuously improving
in terms of preventing time wastage and providing
accurate guidance with technological advancements,
it alone is inadequate to prevent incorrect referrals.
Developing systems to prevent incorrect referrals will
ensure that the correct patients requiring services have
access to healthcare earlier and protect health workers
from unnecessary workload.
Ethics Committee Approval: The study protocol was
approved by the Süleyman Demirel University Faculty
of Medicine Clinical Research Ethics Committee (date:
12.01.2023 no: 1.6). The study was conducted in accordance
with the principles of the Declaration of Helsinki.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, design, data
collection and/or procesing: Ö.F.R.; Control/supervision,
analysis and/or interpretation, literature review, writing the
article, critical review, references, materials: Ö.F.R., F.A.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
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