|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 4 | Page : 173-177
Qualitative evaluation of the contents of physicians' referral to the Physiotherapy Department of a Teaching Hospital in Nigeria
Daniel O Odebiyi1, Ummukulthoum Bakare2, Oluseun A Fapojuwo2, Oluwatoyosi B Owoeye1, Rotimi O Kareem2
1 Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine of the University of Lagos, Lagos, Nigeria
2 Department of Physiotherapy, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||14-Oct-2016|
Daniel O Odebiyi
Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine of the University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: The content of physicians' referral (PR) for physiotherapy is very crucial with respect to physical diagnosis and treatment decisions. It is an indicator of the level of clinical decision making required for proper physiotherapy management of patients. Objectives: To investigate the contents of the PRs to the Department of Physiotherapy of a Teaching Hospital. Materials and Methods: A total of 326 PR for physiotherapy received from four Medical Departments (63 Medicine, 90 Orthopaedics, 81 Paediatrics, and 92 Surgery) of the Teaching Hospital over a period of 3 months were analyzed using a structured data selection sheet. Clinical information such as patient's name and age, diagnosis, brief summary of pathology, prescribed modality, referring unit, date of referral, name, and signature of referring physicians were extracted. Data are presented using frequency distribution and percentages. Chi-square was used to determine the association between variables with significance set at P < 0.05. Results: In the majority of the PR, a brief summary of the pathology of the patients (230, 70.6%) and the referring units (259, 79.4%) were included. The majority (239, 73.3%) of the PR included diagnosis in their referral; (212, 65.0%) and (142, 43.6%) of the PR contained physiotherapy prescription and physicians' name, respectively. Conclusion: Most of the PR did not contain adequate or complete information based on a standard referral format, and most physicians use physiotherapy on "prescription basis" rather than on "consultation basis." A detailed PR for physiotherapy may encourage the use of physiotherapy on a consultation basis.
Keywords: Clinical information, physicians′ referral, physiotherapy, Teaching Hospital
|How to cite this article:|
Odebiyi DO, Bakare U, Fapojuwo OA, Owoeye OB, Kareem RO. Qualitative evaluation of the contents of physicians' referral to the Physiotherapy Department of a Teaching Hospital in Nigeria. J Clin Sci 2016;13:173-7
|How to cite this URL:|
Odebiyi DO, Bakare U, Fapojuwo OA, Owoeye OB, Kareem RO. Qualitative evaluation of the contents of physicians' referral to the Physiotherapy Department of a Teaching Hospital in Nigeria. J Clin Sci [serial online] 2016 [cited 2021 Sep 23];13:173-7. Available from: https://www.jcsjournal.org/text.asp?2016/13/4/173/192282
| Introduction|| |
Physicians are at the "top of the pyramid" of health care professionals, they, therefore, have a profound influence on other health professions including physiotherapy. , As a result, patients still rely on physicians for recommendations to other health care professionals including physiotherapy, although physiotherapy is now universally acknowledged as an "autonomous profession." According to Headrick et al. almost everyone who seeks medical care interacts with more than one health care professional and other health professionals are usually invited through the use of "medical referral." Therefore, a good knowledge of "medical referral" dynamics, viz-a-viz its contents, is very vital as "medical referral" serves as a tool for communication among health care professionals. 
It has been observed that there is a continuous increase in the number of patients referred to the Department of Physiotherapy of the studied Teaching Hospital by physicians from the different specialties in the hospital. In most cases, some of these referrals seem to provide little clinical information about the patient requiring further treatment from other health care professionals, Furthermore, the contents of the majority of physicians' referrals (PRs) for physiotherapy appear to use physiotherapy as a "prescription" rather than on consultation basis which is usually done with an appropriate referral.  The use of physiotherapy on consultation basis is now being practiced in the developed world, particularly in countries where physiotherapy is acknowledged as an autonomous profession. ,
According to Asem  the contents of an appropriate PR for physiotherapy should generally include the name and age of the patient being referred, the name and signature of the referring physician including the unit/department and the diagnosis of the clinical condition as well as a brief summary of patients' clinical condition. PR for physiotherapy should also include information on the patients' medications and specific requests such as weight bearing, mobilization as well as any concerns or contraindications for physiotherapy modalities or techniques. This information will assist the physiotherapist in his/her clinical decision making concerning the ideal physiotherapeutic approach/modality to employ. Studies have shown that physiotherapists are well trained and qualified to make clinical judgments in order to identify patient problems within their scope of practice. ,
Although inter-professional working, powered by appropriate PRs, is central to good patient care, however, there are barriers to effective inter-professional work. These include differences in cultural and historical background of a profession among others. , For instance, Physiotherapy Education at the University of Lagos started in 1971 with a 3-year diploma program. It was then a unit under the Department of Paediatrics; this was changed to a Bachelor's degree program in 1977. This is not unlikely to have generated a kind of interaction that has lingered for so long. Furthermore, the mode of referral then was, more or less, one of using physiotherapy as a prescription. However, all these should have been phased out, particularly considering the stage to which the profession has developed currently. Physiotherapy is now widely used on a consultation basis with a detailed "medical referral." This study was therefore designed to analyze qualitatively, the contents (i.e., clinical information) of the PRs to the Physiotherapy Department of a Tertiary Hospital in South-Western, Nigeria.
| Materials and methods|| |
The study was conducted in the Department of Physiotherapy of a Teaching Hospital in Lagos, South-Western Nigeria. It is one of the foremost Tertiary Hospitals, and because of its location in the former capital of the country, it is the biggest national referral center in Nigeria with 769 beds. The Department of Physiotherapy comprises of four units-Medicine, Orthopaedics, Paediatrics and Surgery and attends to an average of 42 patients per clinic day.
A total of 326 written PRs for physiotherapy, received by the four units (63 Medicine, 90 Orthopedics, 81 Pediatrics, and 92 Surgery) were examined using a structured data selection sheet. There was separate data collection sheet for each unit. Clinical information such as patient's age, diagnosis, a brief summary of patients, patient's pathology, the inclusion of prescription, referring unit, date of referral, the name of referring physicians, and signature were examined.
The required information was extracted and is presented using descriptive statistics of frequency distribution, percentages, and bar chart.
| Results|| |
A total of 326 PRs were received by the four units of the Physiotherapy Department during the period of the study. The highest number of PR (92, 28.2%) was received by the Surgery unit while the lowest PR (63, 19.3%) was received by the Medicine unit [Figure 1].
|Figure 1: Frequency distribution of physician's referrals from the different medical specialties|
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[Table 1] shows the frequency distribution of the content of in-patient PRs for physiotherapy : t0 he majority of the PR included patient's age (266, 81.6%), diagnosis (239, 73.3%), date of referral (226, 70.7%), and the signature of the referring doctors (245, 75.2%). Few of the PR included a brief summary about the patients (96, 29.4%), the names of the referring doctors (142, 43.2%), and the referring department/units (67, 20.6%), respectively. Of the 326 PR received during the period of the study, 212 (65.0%) included prescription in the PR, with the majority (70, 76.1%) being the PR received by the Surgery unit [Table 2].
|Table 1: Frequency Distribution of the Content of In-Patient Physician's Referrals for Physiotherapy|
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|Table 2: Frequency distribution of inclusion and non inclusion prescription in the Contents of physician's referrals for physiotherapy|
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[Table 3] shows the frequency distribution of the contents of PRs for physiotherapy; the Surgery unit recorded the highest inclusion of age (92, 28.2%), diagnosis (81, 24.9%), and referral date (69, 21.2%), respectively. The PR received by the Pediatric unit recorded the highest number of inclusion of the referring units/departments (33, 10.1%). The majority (Orthopedic - 73, 22.4%; Surgery - 72, 22.1%; and Pediatrics - 62, 19.0%) of the PR received by the different units were signed with the exception of those received by the Medicine unit (38, 11.7%). Of the few PR that included a brief history of the patient referred, Medicine unit recorded the highest (49, 15.0%). Of the PR that included prescription, the Surgery unit recorded the highest (70, 21.5%), followed by the Orthopedic Unit (24, 7.4%).
|Table 3: Frequency distribution of contents of physician's referrals for physiotherapy|
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| Discussion|| |
The primary aim of this study was to qualitatively analyze the clinical information contents of the PRs to the Physiotherapy Department of a Tertiary Institution in Lagos, Nigeria. This study was prompted by the recently observed increase in the level of utilization of physiotherapy by physicians, who are still at the peak of the pyramid of health; particularly in this part of the world where the practice of the first-contact physiotherapy is not encouraged. There is, however, a growing increase in the number of physiotherapy referrals by physicians. 
The finding that the highest number of PR was received by the Surgical unit implied that the Surgery unit of the Department of Physiotherapy of the Teaching Hospital had more workload when compared to the other units, followed by the Orthopedic unit. Therefore, having more hands in these units may be beneficial to both the patients and the physiotherapists. The finding that the Surgery unit had the highest number of PR may be due to the fact the Department Surgery of the Teaching Hospital is believed to be the largest department as it is believed by most of the staff.
The Paediatric unit of the Department of Physiotherapy of the Teaching Hospital received the least PR during the period of the study. Interestingly, the content of the majority of PR received by the Pediatric unit revealed more clinical information, viz-a-viz age, diagnosis, brief summary, physicians' name, referring unit, and physicians' signature, when compared with the information contained in the PR received by other units. This may not be unconnected with the fact that the present Department of Physiotherapy started as a unit in the Department of Paediatrics.  This may explain the ease with which the Department of Paediatrics is getting adapted to the new trend of medical referrals particularly as it regards referrals for physiotherapy. Furthermore, the original referral form for physiotherapy, used at inception [Figure 2] encourages the use of physiotherapy as a "prescription" rather than on "consultation basis." This is because the form had a column where the referring physician is expected to specify the treatment required on the PR [Figure 2]. This practice mode of referral must have been passed down to the present generation of physicians; however, this does not conform to the new trend of medical referrals internationally. A more friendly physiotherapy referral form that will contain basic information about the patient, through which the patients can easily be identified, like the one shown in [Figure 3], will be helpful in encouraging the utilization of physiotherapy on "consultation basis."
|Figure 2: The first physiotherapy request form for Lagos University Teaching Hospital (LUTH 1971 - 1977)|
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The results also showed that the majority of the physicians who referred patients to the Department of Physiotherapy included basic information about the patient in their PR, including patients' age, diagnosis, date of referral, and the signature of the referring physician. These are basic information through which patients in the wards can easily be identified. This finding is in line with the trend in the literature, and it agrees with the finding of Quartey et al.,  who in their study on the content of analysis of the PRs to the Department of Physiotherapy at Korle-Bu Teaching Hospital, Accra Ghana reported that "diagnosis" is included in PR of in-patients when compared to that of the out-patient referrals.
The finding that the majority of the PR received by the Physiotherapy Department of the Teaching Hospital did not include the referring unit/department was not helpful to the physiotherapists. Most times, the physiotherapists guess the probable referring unit/department from the wards that the referrals are received. This practice should be discouraged as it can be counterproductive and may put the patients and their relations at a disadvantage and unnecessarily increase the amount of time required to treat or manage the case at hand.
About 50% of the total number of PR received by the Department of Physiotherapy included prescription as part of the content of the PR, where the referring physicians indicated the types of physiotherapeutic modalities to use. This is the most common in PR received by the Surgery unit of the Department of Physiotherapy. In other words, the majority of this category of referring physicians used "physiotherapy" as a prescription rather than on consultation basis which should have been the case. Studies have shown that physiotherapists are well trained and qualified to make clinical judgments in order to identify patient problems within their scope of practice. ,,, This finding corroborated by the finding of Odebiyi et al.,  who in their study on the evaluation of physicians' mode of referral of patients for physiotherapy reported that physicians in Nigeria use "physiotherapy" as a prescription rather on a consultation basis.
| Conclusion and recommendations|| |
Findings from this study showed that the contents of PRs (CPRs) received from the Paediatrics Department revealed more clinical information compared to PR from other departments. However, most of the PR did not contain adequate or complete information based on a standard referral format. It is also evident that most physicians use physiotherapy on "prescription basis" rather than on "consultation basis." It should be noted that a detailed PR for physiotherapy will assist and bridge the communication gap between physicians, physiotherapists and other members of the multidisciplinary health management team in order to give the patients the best of care. A well-structured and detailed "PR form" should be developed for the use of referrers. This may enhance the use of proper referral system for physiotherapy. Heads of hospitals should also encourage the practice of detailed and properly documented referrals for better communication between health professionals. Physiotherapists working in facilities where the referral system is used should endeavor to seek avenues where they could discuss with the referring physicians and other health professionals on the proper referral system for physiotherapists. This can be achieved through organized departmental or hospital seminars, personal communication, and/or ward rounds.
The authors are grateful to Mr. Temitope Ajayi, final year physiotherapy student, for the designing of the model physiotherapy referral form.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]