Patterns, quality and appropriateness of surgical referrals in Malawi

Objectives Reliable referral systems are essential to the functionality and efficiency of the wider health care system in low‐ and middle‐income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under‐researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned. Methods We conducted a prospective analysis of all inter‐hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014–2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process. Results 1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely. Conclusions Our findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present. Objectifs Des systèmes de transfert fiables sont essentiels au fonctionnement et à l'efficacité du système de soins de santé au sens large dans les pays à revenu faible ou intermédiaire (PRFI), en particulier en chirurgie, car la charge de morbidité augmente alors que les ressources restent limitées et inégalement réparties. Pourtant, il s’agit d’un domaine sous‐étudié. Cette étude visait à fournir une évaluation complète des systèmes de transfert pour la chirurgie dans un PRFI, au Malawi, en vue de faire la lumière sur cet aspect important de la santé publique et de partager les enseignements tirés. Méthodes Nous avons effectué une analyse prospective de tous les transferts inter‐hospitaliers reçus au Queen Elizabeth Central Hospital (QECH) en 2014‐2015. Un sous‐échantillon de 255 transferts a été évalué par troi