Referral of a diabetic patient is not just a form full of unnecessary data, but it is a work of art representing the most valuable data, which can help the patient when he/she met the specialists. Referral is an important activity. The long journey with diabetes can be interrupted by inappropriate referral forms. For example, ignoring the emotional reaction to the diagnosis of diabetes or one of its complications can affect the process of gaining medical data from the patients.
The referral process is initiated by the Primary Health Care Centers (PHCs) physicians. The aim of the referral system is to request help in the diagnosis or management of health problems which failed to be solved at the level of the PHC center. The referral form should be clear and complete. It should be filled out by the physician or trained medical staff. The referral form is given to the patients or to the accompanying medical staff in case of urgent referral.

Four hundred and thirty referral forms were collected between Jan 2002-Dec 2003 (178 male and 252 female). The sample covered all Gurayat primary health care centers.

The sample was stratified according to the number of the PHCs, into 16 classes [table 1]. From each class a randomized selection was performed, using the simple systemic method at ratio of 2:1.

Two hundred and fifteen referral forms were selected (89 male and 126 female). Data written in the referral forms was classified into two parts; administrative and medical. A scheme of standards required to be filled in the referral form was designed depending on the standards of medical care of diabetic patients published on the Annual Medical Recommendation 2004, by the American Diabetes Association and the recommendations published by the Quality Assurance in primary health care manual produced by the Quality Assurance committee of the Saudi Ministry of Health in 1992 .

The designed Scheme contained the following points:

Administrative section:

This section covers the following points:
Name of the PHC center, Patient name, Family medical record number, Direction of the referral, Date of the referral and Name with signature of the physician

The Medical section covers the following points:

1. Personal history: (name, age and sex)
   
2. Chief complaints
   
3. Medical history: (present illness, relevant past history either medical or surgical, family history, social history, diet history, physical activity history, drug history and reproductive history)
   
4. Investigation: (recent investigations, previous 3 fasting blood glucose tests results or previous HbA1c results if available, history of previous abnormal investigations - dates and action taken)
   
5. Examinations include recent examinations related to diabetes, previous positive examinations related to diabetes.

Performance on each part was calculated using home personal computer statistical software.

Two hundred and fifteen (215) referral forms were reviewed (89 male, 126 female), the administrative part was filled in 94.18% of the sample while only 22.48% of the sample filled the components of the medical part [table 5&6). None of the selected sample contained data about history of physical practices or foot examination [table 2].

Diet history and its pattern were found only in 0.01% of the sample (3 patients). None of the referral forms included the height of the patient (0%) ,while only 8 referral forms included weight of the patient (0.037%) [Table 3].

While blood pressure was an important variable on the diabetic patient referral forms, blood pressure was recorded in 157forms only (73.02%) [Table 4]

Only twelve patients (0.05%) were referred urgently while 177 patients (82.32%) were electively referred and 26 patients (12.09%) were not titled [table 5]

A referral form is the mirror which reflects the picture of the diabetic patient at the level of primary health care. Usually the PHC medical team has social interactions with the patients. This distinct relation if organized and utilized in a proper manner will provide great help and facilitate the patient referral process to a specialist consultation ⁽¹⁾.

In our study, we planned to answer the following questions:

Did the referral forms reflect the state of the diabetic patient at the moment of referral?
Is the information (administrative and medical) clear and complete?

Analysis of the information included in the referral forms proved that the administrative part is sufficiently performed (94.18%) while the medical part is not performed properly (22.48%).

The great difference between the administrative and medical performance was very obvious (71.7%). This difference related to different causes, some related to the person filling out the referral form; others to the patient; and others were varied reasons.

The skill of history taking was decreased in some physicians due to different reasons. Little chance for attending training workshops or courses greatly affects physicians, particularly those who work in remote areas. Only 21.39% succeeded in take the medical history in a proper manner while only 36.74% succeeded in writing the chief complaints of the patient, properly ⁽²⁾.

Only 63.26% wrote the diagnosis instead of the patient complaints, in the place where they should have written the complaints ⁽²⁾.

Variability of health programs at the level the PHCs, limit the time given to the care of chronic diseases, so the medical care team may forget /neglect important clues in the patient history or examination ⁽¹⁾. Both history of physical activity and foot examination were not included in any referral form reviewed, while only 3 forms contained data about diet ⁽³⁾⁽⁴⁾.

The term of body mass index (BMI) was not used in any referral form, even height was not recorded in any referral form while weight was recorded in only 8 forms. The body mass index is an indicator for obesity which is a very important risk for the development of diabetes, or it can affect the degree of control or even facilitate the developing of chronic complications of diabetes ⁽⁵⁾.

Deficiency of medical equipment may be taken as a cause of decreased medical performance, but in our study, we found that lack of interest is stronger explanation.

Some components of the medical performance does not need special investigation, like foot examination. Diabetic foot problem are a preventable condition as long as foot care is continuously encouraged. Annual foot examination should be performed by PHCs physicians, or by trained staff and trained patients at home ^{(3) (4)}. Poor interpretation of the type of referral and contrast between the contents of the referral form was noticed in 0.03% of our sample (data included in the referral form was not correlated with the type of referral).

Of our sample, 82.32% were electively referred. These patients can be managed easily at the level of PHCs. In 40% of the electively referred patients physicians stated clearly that the referral was made upon request of the patient (the manual of Quality Assurance of PHC allow only =<5% of the patients to be referred by their own request) ⁽¹⁾.

Disturbance of the patient-doctor relationship and the growing of negative feelings between them, force the patient and the doctor to use this system in an inappropriate manner ⁽⁶⁾.

The bad compliance of the patients was responsible for false data registered in the referral form ⁽⁶⁾. Some patients do not give a true picture of their illness or their drug regimens or the duration of fasting required for their investigations. Illiteracy and lack of health education may make the history taking or examinations very difficult processes ⁽⁷⁾. Circulating wrong beliefs among the community about the examinations or investigations will affect the accuracy of data presented in the referral form. Some patients believe that blood withdrawal for investigations is a harmful process, so better to avoid it. Under this belief they may refuse to do any blood investigations or pretend to have self monitoring system at their homes and gave imaginary results. Others avoid regular investigations to escape facing the fact that their blood glucose is not controlled. Regular investigations are an important clue in helping the PHC physician reflect the real picture about the degree of control of his/her patient ⁽⁸⁾ .

Speaking about diet is a very difficult activity in the PHCs especially if there is not a dietitian responsible for this job. Analysis of the local food and commenting on its suitability for diabetic patients is another difficult job, needing a trained person. Diet control is on of the important components of management of diabetes ⁽⁹⁾ .Only 3 doctors in our sample gave details about diet and its efficacy in controlling their patient.

Physical activity is another component located beyond the thinking of the PHCs physicians. None of the referral form contained any data about this part of management, although physical activity was proven to decrease the level of blood glucose in diabetic patients ^{(10) (11)}.

Blood pressure is also an important sign which needed careful observation. Elevated blood pressure is a high risk factor for development of coronary heart diseases in diabetics or being a component among the other components needed to develop an insulin resistance syndrome ^(12)(13)(14). Systolic blood pressure is using as a component in many charts designed to calculate the predictive risk rate to develop coronary artery diseases in future ⁽¹²⁾.

The better efficiency at the administrative part was due to the fact that regular observation and inspection focuses on this part mainly. Sometimes this part was filled by non- medical staff, so both medical and non-medical staff checked this part before the referral was sent to the specialists. This part is given top priority over the medical part ⁽¹⁵⁾.

A concept that the medical part will be reviewed again by a specialists or consultants is common among PHCs physicians and that may make them less accurate in filling out the medical data, but for the administrative part, it will not be checked again due to differences in medical records.

Conclusion: The referral forms did not reflect a clear picture of the patients referred, and marked deficiencies in the medical part of the referral form were noticed while the administrative part was sufficiently performed.

Training programs should be encouraged. Selective training workshops should be organized and strong health education should be initiated.
Regular inspection and evaluation of a random sample of the referral forms will reflect mistakes and allow physicians to improve themselves.
Special referral forms for diabetic patients should be designed.
Click here to view example of standard referral form

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