What can we learn by investigating communication breakdown in outpatient referrals in Latin America?

By Ingrid Vargas, Irene Garcia-Subirats, Amparo-Susana Mogollon Pérez, Marina Ferreira-de-Medeiros-Mendes, Pamela Eguiguren, Angelica-Ivonne Cisneros, María-Cecilia Muruaga, Fernando Bertolotto and María Luisa Vázquez[1]

It is difficult when you get a referral form like this: “vascular” That’s all! Where is the clinical information of the patient? And the exams? What medication has s/he been taking? It becomes quite difficult to proceed in these conditions” (Secondary care doctor, Brazil)


In healthcare systems where primary care plays the role of gatekeeper, doctors are expected to provide relevant data in a timely manner by sending referral or reply letters whenever they refer a patient to the other care level. Using clinical correspondence correctly is vital if we want to ensure adequate patient follow-up and avoid medical errors, test duplications, delays in diagnosis and unnecessary referrals. This is especially true when this type of correspondence is the only existing mechanism for communication between care levels.

Latin American context

In many Latin American countries the use of referral and reply letters has long been a cause for concern, as their successive attempts to improve and regulate clinical referral systems illustrate. Moreover, this issue is frequently addressed in current national health policies that promote healthcare networks based on primary care as the patient’s care coordinator.

But have these efforts to improve been successful? The results of our study, based on a survey of doctors working in public healthcare networks of six Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico and Uruguay) point to significant shortfalls in their referral systems, both in terms of use and content. Primary care (PC) doctors, in particular, claim that in many cases they either don’t receive a reply letter or they receive it too late to make a clinical decision about their patient. They also complain that when they do receive them, the information given is often limited regarding the patient’s clinical history, test results, prescribed  medication, and even, in some cases, the reason for referral.

What is the impact of this communication breakdown between PC and secondary care (SC) doctors on quality of care? While further research is needed to measure the magnitude of the problem, in a previous qualitative study that we carried out in similar Latin American contexts, PC doctors pointed out that not having a definitive diagnosis, or instructions for the correct treatment, led to interruptions in treatment, medical errors and repeated referrals of the patient to outpatient secondary care. On the other side of the coin, SC doctors complained about having to restart the diagnostic process, generating a delay in diagnosis and treatment, as well as greater healthcare expenses due to the duplication of diagnostic tests.

Why is the use of clinical correspondence in Latin America so deficient when it is the main means of communication between PC and SC doctors?

The results of this study provide some clues. Firstly, when we asked doctors why they think they do not always receive a letter from the other care level, they often assumed that the doctors of the other level have neither the time nor the inclination to write and send them, especially in the case of SC doctors replying to referral letters. The patient failing to deliver it is another frequent reason given in all six countries. In Colombia, moreover, they pointed out that insurers and hospital providers often keep hold of the letters for administrative purposes (to authorize or invoice clinical services), so they either fail to reach their intended destination or arrive too late to make important clinical decisions.

So what interactional factors can help to foster more effective correspondence between doctors of different care levels? One of the most relevant findings of our study is that SC doctors are more likely to send reply letters when they know the PC doctors personally, trust in their clinical skills, and recognize their role as coordinators of patient care across levels. After all, they are probably more aware of how important it is to reply to PC doctors’ referral letters to enable them to fulfil their role in the patient’s follow-up.

What lessons can we learn from our results?

The strategy that is now being discussed to improve clinical correspondence between doctors consists of multifaceted interventions that combine the use of standardized referral forms, guidelines for their use, performance feedback for doctors, on-site training and active organizational support for changes in practice through the involvement of stakeholders. For the networks studied, and other similar contexts, we also recommend changes in administrative procedures in order to avoid using the patient as the means of delivery and ensure that the information arrives in good time. However, perhaps the most important recommendation we can make based on our results is to act directly on the factors that determine doctors’ use of the mechanism. First, SC and PC doctors should receive training to improve their understanding and appreciation of a healthcare model based on PC as the patient’s care coordinator. Second, but no less important, is that we need strategies to encourage more direct, personal contact between PC and SC doctors (e.g. participating in joint clinical sessions to discuss roles, follow-up plans, etc.), which can transform anonymous professional relationships into close working partnerships.

These results form part of a wider research project (Equity- LAII) that aims to evaluate the effectiveness of alternative healthcare integration strategies in public healthcare networks of six Latin American countries, financed by the European Commission.

Image credit: Suzie Tremmel

[1] Consortium for Health Care and Social Services of Catalonia (Spain); Universidad del Rosario (Colombia); Instituto de Medicina Integral Prof. Fernando Figueira (Brasil); Universidad de Chile; Universidad Veracruzana (México); Universidad Nacional de Rosario (Argentina); Universidad de la República (Uruguay)


No comments yet.

Leave a comment