Why Don't Patients Referred by a Family PhysicianVisit a Specialist? A Study in Golestan Province in Northern Iran

Utilizing electronic referral (eReferral) system while enhancing the eciency and quality of medical services may improve the access level to specialized services and reduce patients' wait times; however, some patients do not follow the the eReferral system guidelines. The present study aims at guring out why outpatients referred by family physicians to specialists do not visit specialists. The present cross-sectional study was conducted in the hospitals wherein eReferral system was implemented as a pilot plan in the calendar year started on 21 March 2019. The sampling was done in two phases: 1) proportionate stratied sampling method, and 2) systematic random sampling. The rst, 429 patients were selected. These patients were referred by a rural family physician (FP) to a specialist in the district hospital, but despite appointment made for them by the relevant FP, they had not visited specialists. Then, data was collected using a self-made questionnaire whose validity and reliability were conrmed (α = 0.90). Descriptive statistical methods were used to describe the data and analytical methods, i.e. Spearman, Mann-Whitney and Croscal Wallis correlation tests were also conducted. Data analysis was performed using SPSS 16 at a signicant level of 0.05.

visiting a physician, patients take into account a variety of structural, process, and outcome factorsofhealth care providers.
Various studies conducted by many researchers show that variables such as family income and service costs, distance between patients' residence place and that of service providers and quality of services are important determinants in the selection of health care providers [19]. The present study aims at guring out why outpatients referred by family physicians to level 2 do not visit specialists within the framework of eReferral system.It is also aimed at making it transparent for administrators and health care planners and also explaining executive interventions in line with improving the existing situation.

Research Design
The present descriptive analytical cross-sectional study was conducted in Golestan province in northern Iran in the calendar year started on 21 March 2019. The population under study included all patients who were referred by a family physician at level 1 to a specialist at level 2 within the framework of electronic health referral system, but they did not visit the designated specialist to receive services. The study was conducted in the cities of Bandar-e-Turkman, AqQala and Aliabad-e-Katoul, located in the west of Golestan province in northern Iran,wherein the electronic health referral system for outpatient services in these three cities was launched as a national pilot plan.

Recruitment
Of the 15,053 individuals who had been referred to the second level of services in the rst six months of 1397 AH (21 March 2018 -22 September 2018), but had not followed up the process after referral; 5,103,5,895 and 4,355 persons were from Bandar-e-Turkman, AqQalaand Ali Abadaktol, respectively. By using Morgan's table and taking into account the 10% drop in the samples, 431 people were calculated as sample size. The samples were selected by strati ed random sampling method with allocation proportionate to the number of referred patients. Therefore, the number of samples considered for Bandar-e-Turkman city, AqQala and Aliabad was 146, 169,116, respectively.

Data Collection
Records of the patients referred to hospitals in the cities of Bandar-e-Turkman city, AqQala and Aliabad were rst reviewed. It came out that some patients who had been referred by a family physician in rural health centers to a specialist in the district hospital in the past month, had not visited the appointed specialist to receive outpatient services. Since the receipt of appointment from the family physician, i.e. in maximum 30 days, the referred patients could visit a specialist. The sampling was done in two phases: 1) proportionate strati ed sampling method, and 2) systematic random sampling. By using a proportionate strati ed sampling method in the rst phase, 429 patients were selected. These patients were selected according to the referral code registered in the health information software system. In this way, from the list of patients' names, rst the starting point for this regular process was selected and then a suitable interval was selected and the names were selected at equal intervals in the list.
A self-made questionnaire was used to collect the data. To design the questionnaire, rst of all the questions were extracted from scienti c sources and previously-conducted studies [20][21][22][23][24] and the views of the scienti c experts and executives were taken into account. The questionnaire focused on ve dimensions and consisted of 34 items, of which 11 items dealt with the designated specialist, 6 items dealt with the admission and queuing system, 10 items related to the clinic conditions, 2 items related to the recommendation and suggestions of others, and 5 items related to the conditions and side expenditures. The responses were scored as a ve point Likert scale: "I Strongly disagree" with a score of 1, "I disagree" with a score of 2, "I have no idea" with a score of 3, "I agree" with a score of 4 and "I strongly agree" with a score of 5. At the end of the questionnaire, in an open-ended question, patients were asked to state other reasons for not visiting a specialist, if there were any.
Qualitative and quantitative methods were used to determine the content validity. To assess the qualitative validity, 15 experts and elites in the eld of the subject were asked to review the questions and to apply their corrective opinion on grammar and sentence structure; and put phrases in appropriate order. To quantitatively validate content validity, Content Validity Ratio (CVR) was used, and a team of experts was asked to review each question based on a three-part spectrum of "essential, useful but not essential, not necessary." Since the acceptable range depends on the number of experts, based on the judgment of 11 experts in this study, the number was considered to be 0.59, which was nally con rmed based on the answers of the content validity for all questions. Cronbach's alpha coe cient was also used to determine the internal consistency and reliability of the questionnaire. Given the total sample size of the study required for calculating Cronbach's alpha (more than 10% of the total sample size), the minimum sample size was 50. In this study, the overall value of Cronbach's alpha coe cient was calculated to be 0.9 and for the dimensions of the questionnaire were as the following:the designated specialist (a = 0.81), the admission and queuing system(a = 0.74), the clinic conditions(a = 0.80), the recommendation and suggestions of others(a = 0.70), the conditions and side expenditures (a = 0.75); which indicates the high internal consistency of the questionnaire items. The questionnaire was lled in through telephone conversations and by a trained interviewer, and the information on 429 people was collected completely (response rate of 99%).

Ethics
The research project was approved by the Research Committee on Ethics in Golestan University of Medical Sciences (IR.GOUMS.REC.1398.048). At the time of data collection, respondents were assured that their information would remain con dential; nevertheless, the questionnaire was lled in anonymously.

Data Analysis
Descriptive statistics methods (tables, frequency, percentage for qualitative data and mean, standard deviation (SD) for quantitative data) were used and given the abnormality of data distribution according to Clemogrov Smirnov's test (p < 0.001),Mann-Whitney and Kruskal-Wallis tests were used to analyze the data. Data were analyzed using SPSS 16. The signi cance level of all tests was considered to be 0.05.

Descriptive ndings
Most of the participants in the study were female (54.7%), in the age group of 30-60 years (43.4%), married (81.6%), holding a high school diploma (26.4%), housewives (47.2%), covered by AqQala city (35.2%), resident of the villages (81.6%) and held health insurance (91.6%). In general, 28 patients (6.5%) declared that they were sponsored by support organizations, of which 70.6% were supported by the Imam Khomeini Relief Foundation )Komite Emdada charity body) and 29.4% were sponsored by the welfare organization. Of these patients 65% visited other specialists (other than the one designated by the referral system) and 35% did not visit any specialists at all. Majority of the patients who did not visit the designated specialist, visited some other specialists in private clinics (49.2%) not under the e-referral system to complete the treatment process. Table 1 shows the frequency distribution of patients in terms of demographic and clinical variables and referral pattern.  Table 2 shows the dimensions of the reasons why patients did not visit a specialist. The mean and standard deviations for the items in each dimension are presented in Table 3. The following items related to each dimension accounted for the highest scores: in the dimension of introducing the specialist, the item of existence of a trusted physician whom the patient always visits (2.79 ± 1.14), in the dimension of the admission and queuing system, the item of not providing necessary guidance to patients by the referral center ( In the dimensions of the introduced specialist (p < 0.001), admission and queuing system (p = 0.009), clinic conditions (p = 0.004) and conditions and side expenditures (p = 0.040), there was a signi cant difference given the respondents' profession, but this difference was not signi cant in terms of the others' advice and suggestions (p = 0.217). Also, a signi cant difference was observed in all dimensions taking into account the place of residence (p < 0.001). In terms of admission and queuing system (p = 0.010), clinic conditions (p < 0.001), others' advice and suggestions (p = 0.002) and conditions and side expenditures (p = 0.001), there was a statistically signi cant difference depending on the type of health insurance. However, this difference was not signi cant in the case of a specialist (p = 0.051). Table 4 shows the relationship between demographic variables and the reasons why patients did not visit specialists in level 2.

Discussion
According to the ndings of the present study, among the determined dimensions, the clinic conditions accounted for the highest score. This dimension includes items such as physical inability to go to the clinic, the distance between the clinic and the patient's place of residence, the crowdedness and disorder in the designated clinic, and long waiting time to visit specialist. Lux et al. are of the opinion that the level of hospital access is an important factor in choosing a treatment center [25]. The results of a study conducted by Taylor et al., alsoindicated that 32% of patients believed that the distance between the hospital and their home was one of the important factors in choosing a hospital [26]. Mossadeq Rad and Jooya's study showed that 17.3% of patients said that the proximity to their place of residence was the reason for visiting a specialist [27]. The study conducted by Allahyariet al. showed that the location of the hospital was of particular importance to 66.7% of the patients [28]. In a study conducted in the United States, they looked at the waiting time for a doctor's appointment to assess the average waiting time for new patients to visit their own physician. The study was conducted in 15 megacities with the highest physician-population ratios in the United States, and concluded that despite the large number of physicians in each megacity, a large number of patients had to wait 14 days or more to see their physician [20][21]. Williamson et al. have also stated that one of the main reasons for not visiting a specialist wasthe large distance between medical centers and patients' place of residence [29].
The dimension of the conditions and side expenditures also accounted for a high score in the patients' views. This dimension included itemssuch as not being able to afford paying for a visit to a specialist and the high cost of commuting. Findings of Behboudi study indicated that 89.3% of patients mentioned economic factors as the reason for choosing a medical center [23]. The results of a study by Kraaijvanger et al. also showed that nancial considerations were among the reasons for patients' self-referral [22]. According to the ndings, the third dimension that affected the issue was admission and queuing system.
Due to the coincidence of their working hours in the morning with the time of providing level 2 services, people were not able to visit specialist and receive relevant services. Providing services in the afternoon can be a solution to this problem. This was one of the reasons why people turned to the private sector, which was in line with Martin's study [30].
Despite the fact that in this study the dimensions of introduced specialist and others' advice and suggestions were in the lower ranks why they did not visit a specialist, but in this regard, the results of the study conducted by Kraaijvanger et al. in 2016 showed that lack of trust in the physician was among patients' self-referral reasons [22].
In other studies, high knowledge and competence were introduced as the rst and most important factor in choosing a physician [31][32][33][34]. The results of 60 meta-analysis on patients' satisfaction showed that positive verbal behavior and participatory structure during consultation, providing information by physicians, adequate time allocation, good medical skills and providing the required information play an effective role in enhancing satisfaction level [35][36]. The results of Mossadegh Rad and Jooya's study also showed that 11% of the patients visited physicians based on their friends and acquaintances recommendations, and 5.8% of them said they visited the physician because of having a friend or acquaintance working in the o ce of the specialist [27]. In other studies,it has been stressed that people visited a physician on the advice of others [22][23]27]. In another study, forgetting the date of the appointment was also identi ed as a reason for not visiting the designated specialist [37]. A reminder system, could help remind patients on their appointments sending them messages via their mobile phones, homes' phone, email, etc.
O cials and physicians need to understand the differences in the expectations of different groups of patients and provide them with their services in a way that meets different patients' needs. According to the ndings, there was a relationship between reasons why patients did not visit a specialist and age and education variables. Usually, older people and more educated people pay more attention to the referred