Specialist LINK Data Year End Report April 2019

Linking Calgary area physicians and clinician

together to improve patient care.

1 May 21, 2019

Specialist LINK

Specialist LINK Data Year End Report, April 2019 (Fiscal Year March to April)

Table of Contents INTRODUCTION ........................................................................................................................................................... 4

I. History Health System Support Specialty Integration ...................................................................................... 4

II. Historical HSS Timelines Overview .................................................................................................................... 5

III. History Specialist LINK ................................................................................................................................... 5

IV. Specialist LINK Activities For 2018-2019 ........................................................................................................ 6

V. Method ............................................................................................................................................................... 7

SPECIALIST LINK PHONE CALL VOLUME ...................................................................................................................... 7

SPECIALIST LINK WEBSITE METRICS HISTORY ............................................................................................................. 8

I. Web based connection ...................................................................................................................................... 8

II. Website Traffic ................................................................................................................................................... 9

III. Access and Enhanced Pathway Downloads by Specialty .............................................................................. 9

1. Access Pathway .......................................................................................................................................... 9

2. Enhanced Primary Care Pathways ........................................................................................................... 10

IV. Resources Downloads by Specialty ............................................................................................................. 11

V. Other Resources Downloads/Consultation ..................................................................................................... 12

1. Physician Resources (data collection since January 2019) ...................................................................... 12

2. News Items (data collection since August 2017) ..................................................................................... 12

VI. Testimonials (data collection since January 15, 2019) ................................................................................. 13

SPECIALIST LINK SURVEYS ......................................................................................................................................... 13

Calgary Zone PCN Physician Survey Results ............................................................................................................. 14

I. Physicians Demographics ............................................................................................................................. 14

II. Awareness of Specialist LINK telephone advice request service and utilization ....................................... 15

III. Satisfaction with telephone advice request service ............................................................................... 15

1. Specialist LINK telephone Advice Request impact on patients care (n=80) ........................................... 15

2. Overall satisfaction with Specialist LINK telephone Advice Request (n=210) ....................................... 15

IV. Enhanced primary care pathways ........................................................................................................... 16

1. Utilization (n=329) .................................................................................................................................... 16

2. Most helpful pathways to family physicians’ practice ........................................................................... 16

2 May 21, 2019

Specialist LINK

3. Specialist LINK Primary Care Pathways impact on patients care (n=131) .............................................. 17

Fall PCN Physician Survey Results ............................................................................................................................. 17

I. Specialist LINK telephone advice request service utilization ..................................................................... 17

II. Reasons for call ............................................................................................................................................ 17

III. Outcome of calls ....................................................................................................................................... 18

IV. Patient presence during the call .............................................................................................................. 18

V. Feedback on Pathways................................................................................................................................. 19

SPECIALIST SURVEY RESULTS .................................................................................................................................... 19

I. Caller’s information.......................................................................................................................................... 20

1. Caller’s type (up to March 2019 n=974) ....................................................................................................... 20

2. Caller’s unique identification (up to March 2019) ....................................................................................... 20

II. Call information ................................................................................................................................................ 20

III. Patients information .................................................................................................................................... 21

IV. Reasons for call ............................................................................................................................................ 21

V. Specialist Recommendation ............................................................................................................................ 22

VI. Outcome of calls ........................................................................................................................................... 23

VII. Appropriate use of Specialist LINK .............................................................................................................. 24

VIII. Service feedback .......................................................................................................................................... 24

1. Feedback about the experience of providing advice .................................................................................. 24

2. Call support .................................................................................................................................................. 25

IX. Diagnosis & Theme of Call ........................................................................................................................... 25

SPECIALIST LINK COST ANALYSIS .............................................................................................................................. 27

I. Analysis based on Survey Results .................................................................................................................... 27

1. Direct Cost .................................................................................................................................................... 27

2. Direct Savings ............................................................................................................................................... 28

3. Call Survey Analysis ...................................................................................................................................... 28

II. Analysis based on Call Volume ........................................................................................................................ 29

1. Direct Cost .................................................................................................................................................... 29

2. Direct Savings ............................................................................................................................................... 29

III. Extrapolated Savings .................................................................................................................................... 31

IV. Indirect Savings and Other Direct Savings................................................................................................... 31

APPENDIX .................................................................................................................................................................. 32

3 May 21, 2019

Specialist LINK

I. Tables ................................................................................................................................................................ 32

Table 1. Specialties included in Specialist LINK ....................................................................................................... 32

Table 2. Specialist LINK Call Volume by specialty ................................................................................................... 32

Table 3. Physicians requesting telephone advice through the website by specialty ............................................ 33

Table 4. Access Pathways included in Specialist LINK website .............................................................................. 33

Table 5. Enhanced Primary Care Pathways included in Specialist LINK website ................................................... 33

Table 6. Resources included in Specialist LINK website.......................................................................................... 34

Table 7. Length of call by specialty .......................................................................................................................... 34

Table 8. Patients’ age by specialty........................................................................................................................... 35

Table 9. Call reasons by specialty ............................................................................................................................ 35

Table 10. Specialist recommendation by specialty ................................................................................................. 36

Table 11. Outcome of calls by specialty .................................................................................................................. 37

Table 12. Specialist LINK diagnosis themes by specialty ........................................................................................ 38

Table 13. Specialist initial face-to-face consultation fee by specialty .................................................................... 41

Table 14. Emergency Visits and Diagnostic Testing ................................................................................................ 42

Table 15. Average cost and savings per survey by year.......................................................................................... 42

Table 16. Call Savings Per Specialty ......................................................................................................................... 42

II. Figures .............................................................................................................................................................. 43

Figure 1. Historical Website Traffic ......................................................................................................................... 43

Figure 2. How many times have family physicians used Specialist LINK ............................................................... 44

Figure 3. Reasons to not having used Specialist LINK ............................................................................................. 44

III. Specialist survey verbatim answers for open-ended questions ................................................................. 44

1. Specialist Recommendation ........................................................................................................................ 44

2. Outcome of calls ........................................................................................................................................... 47

3. Appropriate use of Specialist Link ............................................................................................................... 47

4. Service feedback .......................................................................................................................................... 48

5. Diagnosis & Theme of Call ........................................................................................................................... 49

REFERENCES .............................................................................................................................................................. 55

Tech talk: Connecting primary and specialty care in Calgary ................................................................................. 55

4 May 21, 2019

Specialist LINK

INTRODUCTION Calgary Area Primary Care Networks and Alberta Health Services stakeholders partnered to develop the Health Systems Support (HSS) specialty Integration Task Group. Family doctors working closely together with specialist to improve patient care. Empowering the Patient’s Medical Home to provide care for patients through co-created access and enhanced primary care pathways, supported by specialist support through a dedicated telephone advice and website “Specialist LINK”. Specialist LINK provides real time telephone non-urgent advice that improves efficiency and enhances the coordination of patient care delivery while strengthening the relationships between primary and specialty care. The telephone advice line operates Monday to Friday from 8 am to 5 pm (except Chronic pain service until 4 pm).

Family physicians can either visit the Specialist LINK website and click on the preferred specialty or phone a

centralized number and select a specialty from the automated list and leave their name and a direct call-back

number. Through an automated phone system, specialists are connected and return the call within 1 hour.

Specialist LINK phone advice and website have been instrumental for the HSS specialty integration work.

I. History Health System Support Specialty Integration

Since early 2006 partnerships between specialty care, AHS and specific primary care networks were established. Supporting patients’ needs within each PCN boundary. These innovative projects provided great learnings and informed some of the Calgary Zone solutions.

In 2012, seven Calgary Area Primary Care Networks and Alberta Health Services stakeholders partnered and

developed a Calgary Zone Primary Care Action Plan (CZPCAP), to increase the pace of primary care development

by focusing efforts on those areas common to all eight partners for a more coordinated and sustainable effort.

(CZPCAP,2012)

In the same year, the Primary Care Council and Secretariat identified a priority to enhance the relationship between primary care and acute care to address issues of access, comprehensive and coordinated care delivery, informational continuity, communication and provide health care value to patients, providers, system & funder. The Calgary Zone HSS Specialty Integration task group was created in 2013. Family doctors working closely

together with specialists to improve patient care. Starting with specialty groups that provided the biggest

concerns regarding access and coordinated care for patients. Specialist LINK was piloted, and access and

enhanced primary care pathways were co-created. (HSS,2016)

The rapid growth of Specialist LINK over the past years highlights the continued progress made by the Calgary

Zone Health System Supports task group. This group continues to work with a variety of specialty groups to

improve access and care for their patients. Adding specialties to the tele-advice line, as well as develop clinical

pathways for conditions commonly seen in primary care.

5 May 21, 2019

Specialist LINK

II. Historical HSS Timelines Overview

III. History Specialist LINK

Since 2014, Specialist LINK telephone advice line has been providing timely clinical collaboration between over 1,700 family physicians and specialists physicians in the Calgary Zone. Since 2016 the Specialist LINK website has become a central communication platform that links primary and specialty care. Supporting family physicians and specialists with patient care solutions through pathways on enhanced primary care, simplified access to specialty care, news items on quality improvement projects and direct connection to the Specialist LINK phone advice line.

Specialist LINK now includes a total of 16 specialty services.

HSS Calgary Zone HSS specialty Integration working with specialty care

2013

Specialist LINK Phone Advice Line

2014

Enhanced Primary Care pathways

2014

Specialist LINK website

2015

Access Pathways & improvement projects

2016

eReferral Advice Request (local and provincial)

2017

Specialist LINK & eReferral advice request partnership with CFHI

2017

Alberta Referral Directory Specialist LINK & eReferral partnership

2017

Patient engagement

2018

Specialist LINK website and phone line redesign

2019

RAAPID partnership

2019

6 May 21, 2019

Specialist LINK

IV. Specialist LINK Activities For 2018-2019

In the last fiscal year, through the Canadian Foundation Health Improvement (CFHI) grant we worked closely with

eReferral Advice Request to offer two unique complementary modalities for non-urgent advice that provide

physicians with a choice to receive specialty advice depending on their practice style and patient needs. Specialist

LINK provides advice within 1 hour and eReferral Advice Request within 5 calendar days through eReferral

platform. The two modalities combined provide family physicians access to advice from a total of 26 specialties.

(Tech Talk,2018)

Through the CFHI partnership we updated our phone line and redesigned our Specialist LINK website, providing a

new service that permits to doctors and support staff to request a tele-advice online via a desktop computer,

laptop, tablet, cell phone or other mobile devices. The new version of the website includes now physicians’

resources, updates, patients and physicians’ testimonials and specialist resource tab. (Specialist LINK,2019)

The Specialist LINK family physician annual survey was completed in June 2018. 343 family physicians completed

the survey with representation from each of the Calgary Zone PCN’s. 3/7 PCNs embedded questions into their

annual surveys, 4/7 sent out a separate link for the survey. Due to the different data collection dates there was

wide range of dates in which the survey was completed. Highlights of the results are noted in this report.

(Specialist LINK,2018)

In July 2018 AHS completed independent Specialist LINK evaluation, to measure Specialist LINK awareness among family physicians in Calgary and Area Primary Care Networks, Alberta. Results indicated that the awareness and utilization of Specialist LINK is very high among family physicians. 89% of family physicians are aware of Specialist LINK, 72% use it in their practice, 73% said using Specialist LINK changed their patient management, 55% are aware of the clinical pathways of those, 74% are accessing and following pathways in their practice, 78% of users said the pathways have changed their clinical practice. (Alberta Health Services, 2018) In September 2018, Calgary Foothills PCN embedded Specialist LINK family physician survey questions 165 family physicians completed the survey. Highlights of the results are noted in this report. (CFPCN, 2018)

Calgary Zone Health Systems Support (HSS) Specialty Integration task group focused on patient engagement

framework with the result of having patient advisors present in our working groups.

In the fall of 2018 Specialist LINK cost savings analysis showed that we surpassed $1 million savings. (Specialist

LINK, 2019)

Through the success of Specialist LINK in the Calgary Zone there has been high interest from other regions in

Alberta and other provinces. A Specialist LINK toolbox was created to support spread and scale of the Specialist

LINK advice line in other regions. To understand the area of coverage serving Calgary Zone a spot check was

performed. Results showed that from 2001 calls made between October 1st, 2018 and January 22nd, 2019, 1986

phone numbers could be identified and 99.4% of these calls were from Alberta, Calgary 81.3%. However, 13 calls

were from outside the province (Saskatchewan, Ontario, New Brunswick and Nova Scotia). (Area of coverage,

2019)

7 May 21, 2019

Specialist LINK

V. Method

Specialist LINK report provides cumulative data being tracked by Specialist LINK. Data is derived from phone

system, physician surveys, Google analytics and other physician reported resources. Both quantitative and

qualitative data is collected. Fiscal year noted is from April to March. Since launching in December 2014,

specialist groups joined at different intervals. Specialists are requested to submit a feedback survey at the end of

each call in the first 9 to 12 months after joining the service. Family physicians are surveyed once a year,

additional long-term metrics are still being identified and defined for this program.

SPECIALIST LINK PHONE CALL VOLUME Specialist LINK now includes a total of 16 specialty services (Table 1). In the last fiscal year 4 new specialties joined and 75% increase of call volume. Since 2014, over 11,777 advice calls have been received.

*See Table 2. Specialist LINK Call Volume by specialty for more details.

67 335

1,264

3,670

6,441

FY 14-15 FY 15-16 FY 16-17 FY 17-18 FY 18-19

Total Calls received by Fiscal Year

2704

532

19851801

1497

622

1097

298 29254

517

88 121 24 65 80

Call Volume by Specialty* FY18-19

FY17-18

FY16-17

FY15-16

FY14-15

Total

8 May 21, 2019

Specialist LINK

SPECIALIST LINK WEBSITE METRICS HISTORY

I. Web based connection

In January 2019, a redesigned version of the website was launched, providing a new service that permits to

doctors and support staff to make a web-based connection by sending a text through the website to the specialty

of choice.

Since the launch of the web-based connection to Specialist LINK telephone advice line, overall, 890 (45%)

requests have been made through the website, in contrast to 1,102 (55%) requests through the phone

connection.

Access to the service through the website has been significantly increasing from 22% in January to 58% in March.

During the last 2 and a half months, 262 physicians (including 1 rheumatologist) and 1 nurse practitioner have

requested the service through the website at least once (Table 3).

* See Table 3. Physicians requesting telephone advice through the website by specialty for more details.

22%

49%

58%78%

51% 42%

56

206254

01/2019 02/2019 03/2019

Web-based and Phone Connections Comparison (Jan 15 to Mar 31, 2019)

Web-based Connection Phone Connection Physicians using the service

162

47

2411

4 3 2 3 0 2 1 0 1 0 0 1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

No

. of

Ph

ysic

ian

s

Times of telephone advice requests to Specialist Link

Number of times telephone advice requested by unique physicians*

9 May 21, 2019

Specialist LINK

II. Website Traffic

Compared to last fiscal year, the total visits to the Specialist LINK website increased by 71%. The average duration visitors spent on the website decreased from 1.92 min in FY 17-18 to 1.57 min in this fiscal year. 11% of Specialist LINK visitors used a mobile device. Graph below shows a summary of the website traffic, refer to Figure 1 for further details.

III. Access and Enhanced Pathway Downloads by Specialty

Working closely with family physicians, specialists, specialty central access and triage, specialty care initiated

several access improvement projects to streamline and simplify access. One-page simplified guideline(s) were

developed to support family physicians accessing specialty care and enhanced care pathways to support family

physicians with the care of their patients.

1. Access Pathway

This fiscal year, 3 new access pathways were posted on Specialist LINK website. Total of 6 access pathways are

now available on the website (Table 4).

*2018/2019 pathways: Respirology (October), Palliative Care (December) and Urology (January).

FY 17-18

FY 18-19

583

476

401

213

389

242

8093

144

Access Pathway Downloads

Endocrinology Neurology Rheumatology Respirology* Palliative Care* Urology*

2,288

10,120 17,402

4,964

21,458

46,364

5,746 9,608

FY 16-17 FY 17-18 FY 18-19

Website Traffic Metrics by Fiscal Year

Total Visits Total page views Downloads

10 May 21, 2019

Specialist LINK

2. Enhanced Primary Care Pathways

This fiscal year, 5 new enhanced primary care pathways were posted on Specialist LINK website. Total of 17

enhanced primary care pathways are now available on the website (Table 5). Top 3 enhanced pathways that

were downloaded were NAFL, IBS and gout pathway.

*GI specific pathway data available since September 2017, prior pathways were accessed through GI website (GI pathway)

Specific Enhanced Primary Care Pathway Downloads (data collection since April 2017)

FY 17-18

FY 18-19

935

2458

52713741055 1695

6471201

420 189

Enhanced Primary Care Pathway Downloads by Specialty

Gastroenterology * Hepatology Neurology Rheumatology Endocrinology Respirology

92

317

144

156

107

119

0

0

678

419

518

287

343

213

GI Pathway

IBS

GERD

Dyspepsia

H. Pylori

Constipation

Chronic Diarrhea

GastroenterologyFY 18-19

FY 17-18

New

257

291

346

89

72

0

203

302

378

55

183

574

Parkinsons Disease

Tremor

Vertigo

Vertigo Algorithm

Diabetic peripheral

Migraine

NeurologyFY 18-19

FY 17-18

New

11 May 21, 2019

Specialist LINK

IV. Resources Downloads by Specialty

Total for this Fiscal year 16 new resources were posted on Specialist LINK website (Table 6).

* Data collection since April 2018

Specific Resources Downloads (data collection since April 2018)

314

122

211

0

554

71

213

363

Gout

Gout Algorithm

Radiograph for p.arth

PeripheralArthritis

RheumatologyFY 18-19

FY 17-18

0123

Uncomplicatedobstructive sleep

apnea

RespirologyFY 18-19FY 17-18

FY 18-19

184163

15

Resources Downloads by Specialty*

Gastroenterology Neurology Rheumatology Respirology Opioid use disorder

184CZ gastroenterology referral

Quick reference

Gastroenterology

0

83

14

66

Canadian Thoracic Society (CTS)Respiratory Guidelines

Calgary Zone Pulmonary ReferralQuick Reference

Calgary Zone Sleep CentreReferral Quick Reference

Pulmonary

Respirology

1280

103

527

0

NAFLD

Liver requisition

HepatologyFY 18-19

FY 17-18

New

New

ew

New

12 May 21, 2019

Specialist LINK

V. Other Resources

Downloads/Consultation

1. Physician Resources (data collection since January 2019)

The new version of the website includes “Support Services at a Glance”, a page that allows family physicians in

the Calgary area seeking specialist support to now choose from six great options: 911, RAAPID, Community

Paramedics, Specialist LINK, eReferral Advice Request and Regular referrals.

The collected data show cases only the hits to more information to the specific service.

2. News Items (data collection since August 2017)

One ‘By the Numbers’ newsletter form FY 18-19 and two from the previous year as well as one quarterly report

FY 18-19 and one from the previous year were published on the website.

Main Page Hits to more information

194

848

Support Services at a glance activity ARD

eReferral AdviceNetcareSpecilaist LINK

Community ParamedicsReferralRAAPID website

911 website

67

154

23

203

SL newsletter

By the numbers

Updates/Reports FY 18-19

FY 17-18

0

5

3

1

1

2

2

1

0

Opioid use disorder telephone consultation service

Opioid Framework (w team)

Opioid Framework (w/o team)

Opioid Describing Framework (w team)

Opioid Describing Framework (w/o team)

Billing codes

Suboxone prescribtion

Poster

Health team integration video

Opioid Use Disorder

13 May 21, 2019

Specialist LINK

VI. Testimonials (data collection since January 15, 2019)

The new version of the website includes two additional tabs: “patients’ stories” and “for specialists”, these tabs

contain respectively patients’ perspectives and physicians’ testimonials concerning their experience with

Specialist LINK.

* Physician testimonials data collection started in March 2019

SPECIALIST LINK SURVEYS

Specialists are requested to submit a feedback survey at the end of each call in the first 9 to 12 months after joining the service. As of September 2017 HSS, specialty integration task group mutual agreed that family physician feedback would be captured through an annual survey collected by all 7 PCN, this was completed in June 2018.

Additionally, the Calgary Foothills Primary Care Network’s 2018 annual physician survey included a section about Specialist LINK that included specific questions that were not captured through the Calgary zone survey. In 2018/2019 fiscal year 343 family physician (all 7 PCN annual survey), 165 family physicians (PCN specific annual physician survey) and 270 Specialist surveys were received. 4 Specialty services completed data collection. The analysis includes 2018-19 fiscal year results and when applicable a comparison to previous fiscal years and overall results.

Please note that all open-ended questions were coded for themes and direct quotations were used in all verbatim quotations, please refer to the Appendix FY 18/19 for a complete list of responses. Previous fiscal year appendix is available on request.

FY 18-19

50238

Testimonials

Physicians Testimonials* Patients Perspectives

14 May 21, 2019

Specialist LINK

Calgary Zone PCN Physician Survey Results

Calgary Zone Family Physician survey was completed between September 2017 and June 2018. Standardized

questions were developed while the distribution of the surveys varied by PCN. 3 out of 7 PCNs embedded

questions into their annual surveys, 4 out of 7 sent out a separate link for the survey. Due to the different data

collection dates, there was a wide range of dates in which the survey was completed. Highlights of the results are

noted below, and full report is available on request. (Specialist LINK, 2018)

I. Physicians Demographics

343 family physicians completed the survey with representation from each of the Calgary Zone PCN’s.

174

102

19 19 13 9 5 2

CalgaryFoothills

South Calgary Highland Mosaic Bow Valley Calgary WestCentral

Calgary Rural Not a memberof a PCN

# o

f R

esp

on

den

ts

Respondents by PCN

89

50

3343 44

82

0-5 6-10 11-15 16-20 21-25 25+

# o

f R

esp

on

den

ts

Years in practice

Years in Practice

15 May 21, 2019

Specialist LINK

II. Awareness of Specialist LINK telephone advice request service and utilization

Family physicians were asked whether they were aware of the service or not and if they were aware of it,

whether they have ever used it. 93% of the family physicians are aware of Specialist LINK telephone advice

request service and 77% of the them have used it at least once, see Figure 2 for more details. 98 family

physicians have reported not using the service for reasons related to personal choice, time, patients’ needs and

applicability (Figure 3).

III. Satisfaction with telephone advice request service

Family physicians who have used Specialist LINK at least once were asked to rate the service.

1. Specialist LINK telephone Advice Request impact on patients care (n=80)

2. Overall satisfaction with Specialist LINK telephone Advice Request (n=210)

20%

34%

60%

59%

18%

6%

1%

1%

1%

I now feel more confident, or better equipped, tosupport a patient in my practice.

I have confidence that Specialist LINK will equipme to support patient care in the future.

Specialist LINK telephone Advice Request Impact on Patients' Care

Strongly agree Agree Neutral Disagree Strongly disagree

54%

35%

10%

0% 2%

Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied

% o

f R

esp

on

den

ts

Satisfaction with Specialist LINK Telephone Advice Requests

93%

77%

7%

23%

Awareness (n=342)

Utilization (n=308)

Awarness and Utilization of the service

Yes No

Dissatisfaction Reasons (Themes):

- Call back took too long

- Call did not provide me with more information than I already had

- Access/navigation can be difficult

16 May 21, 2019

Specialist LINK

Physicians were asked to explain their rating of the service (n=160). Overall, physicians’ comments were all

positive about Specialist LINK telephone advice request.

Verbatim comments examples:

“Prompt advice and very pleasant and collegial interactions. Often saves patient a trip for a consult or furthers

investigation or management while waiting for referral”.

“Rapid, friendly and informative service. reduces burden on system as a whole”

“Extremely useful for non-typical scenarios that just require a chat when I am uncertain what to do and can't find

advice by reading.”

“Exceptional resource” wish that there were more specialties available. Must be saving the healthcare system

money and prevents many unnecessary consults, improves patient care as I am able to start them on appropriate

treatment immediately even if they still need to go and see the specialist”

IV. Enhanced primary care pathways

1. Utilization (n=329)

2. Most helpful pathways to family physicians’ practice

Yes, 40% No, 60%

Have you referred to the enhanced primary care pathways?

78

60

41

38

38

36

32

29

28

27

27

22

17

GERD

Dyspepsia

Chronic constipation

IBS

Helicobacter Pylori

Headache

Access to Rheumatology

Access to Endocrinology

Access to Neurology

Suspected essential tremor

Enhanced vertigo/simplified vertigo

Gout

Suspected parkinson's disease

Most Helpful Pathways to the Practice

Haven’t referred because (n=181):

- Not aware of pathways available (n=139)

- Not needed for patients in my panel (n=42)

17 May 21, 2019

Specialist LINK

3. Specialist LINK Primary Care Pathways impact on patients care (n=131)

*Full Report is available on request, survey included questions on future direction for HSS specialty integration

group.

Fall PCN Physician Survey Results

165 Calgary Foothills PCN Family Physician completed Specialist LINK section within annual survey in September 2018. Capturing questions that were not included in the Calgary Zone survey. This data has been compared with the overall data received from Calgary Zone family physicians last fiscal year.

I. Specialist LINK telephone advice request service utilization

II. Reasons for call

Physicians who reported having used the Specialist LINK telephone advice service in the past 12 months were

asked about the reasons of their call.

31%

51%

56%

44%

11%

5%

2%

1%

1%

I now feel more confident, or better equipped, to supportthat type of patient in my practice.

I have confidence that Specialist LINK will continue toequip me to support patient care in the future.

Impact of the Referral to Primary Care Pathways on Patients' Care

Strongly Agree Agree Neutral Disagree Strongly disagree

Yes, 75% No, 25%Fall 2018

Have you used the Specialist LINK telephone advice service in the past 12 months?

4%

28%

99%

6%

11%

30%

87%

Needed advice for a closed referral

Had a question on a care pathway

Needed advice while waiting forreferral

Needed advice for patient care plan

Reasons to call Specialist LINK

2018 Fall PCN Physican Survey (n=125) 17-18 Physican Survey (n=106)

18 May 21, 2019

Specialist LINK

III. Outcome of calls

Physicians who responded to whether they were contemplating a specialist referral before using the telephone

advice service were asked to specify which outcomes resulted.

Of the physicians who were contemplating a specialist referral before calling the service, 60% of the respondents

to the 17-18 physician survey reported still needing the referral, while 43% of the respondents to the 2018 Fall

PCN physician survey reported still needing the referral.

IV. Patient presence during the call

Physicians who used the Specialist LINK telephone advice service were asked to think about all the calls they have

made to Specialist LINK over the past year and answer the questions around circumstance of the call (n=123).

82% of the physicians reported that patients were aware of the advice call and overall, 41% of them reported

that patients were either in the room or waiting at the clinic.

Yes, 83% Yes, 80%No, 17% No, 20%

2018 Fall PCN Physican Survey (n=123)

17-18 Physican Survey (n=100)

Were you contemplating a specialist referral before calling the telephone-advice service?

Outcomes to 'YES' (n=102):

1% did not specify outcomes

56% No longer need the referral

43% Still need the referral

Outcomes to 'No' (n=21):

5% did not specify outcomes

86% Still do not need a referral

10% Now need a referral

Outcomes to 'YES' (n=80):

3% did not specify outcomes

40% No longer need the referral

60% Still need the referral

Outcomes to 'No' (n=20):

70% Still do not need a referral

30% Now need a referral

7%

4%

72%

34%

14%

20%

60%

82%

8%

Was your patient waiting at your clinic when youmade the call with the specialist?

Was your patient present in the room when youmade the call with the specialist?

Was your patient aware of the advice call?

Yes, always Yes, sometimes No

19 May 21, 2019

Specialist LINK

V. Feedback on Pathways

SPECIALIST SURVEY RESULTS

Specialists submitted their feedback surveys after calls via fax or an online survey link. Data collection process is

considered complete when the number of surveys exceeded the target sample size, calculated based on their

annual call volume. In 18-19 fiscal year, 269 surveys were completed adding up to a total of 1121 surveys since

February 2015.

54% 39% 7%

Have you used the enhanced primary care pathway, onwww.specialistlink.ca, for supporting patient care

planning? (n=165)

Yes No Not aware of this resource

90% 7%

2%

1%Having used this (these) pathway(s), I now feel moreconfident, or better equipped, to support that type of

patient in my practice. (n=87)

Strongly agree/Agree Neither agree nor disagree Disagree/Strongly disagree Not applicable

26 23

4

21

97

131

49

11

16

1

196

57

85

47

79

8

1

37

90

32

4

35

21

23

17

6

3

1

Rheumatology (254, 22.7%)

Endocrinology (244, 21.8%)

Neurology (216, 19.3%)

Gastroenterology (98, 8.7%)

Hepatology (90, 8.0%)

Chronic Pain (83, 7.4%)

Psychiatry (35, 3.1%)

Nephrology (29, 2.6%)

Vascular surgery (23, 2.1%)

Respirology (20, 1.8%)

Palliative Care (17, 1.5%)

Sport Medicine (6, 0.5%)

podiatric surgery (3, 0.3%)

Unknown (2, 0.2%)

Urology (1, 0.1%)

Pediatricians

CHF

Number of surveys received by Specialty (total =1121)

FY14-15 FY15-16 FY16-17 FY17-18 FY 18-19

20 May 21, 2019

Specialist LINK

I. Caller’s information

1. Caller’s type (up to March 2019 n=974)

2. Caller’s unique identification (up to March 2019)

867 surveys included the caller’s name, 844 (97%) were family physicians, 6 (0.7%) were nurse practitioners and

17 (2%) were specialists.

A total of 530 unique family physicians have been identified by specialty using Specialist LINK from 1 to 13 times.

Out of the 98 callers that requested advice in FY 18-19, 79 were new (not reported previously).

II. Call information

Since 2015, information around the length of call was reported in 929 surveys. The average length of call is

between 6 – 10 minutes.

Specialties to which the telephone advice required over 15 minutes in average are Chronic Pain (average of 25.5

min in 77 calls) and Palliative care Pain (average of 16.9 min in 17 calls), see Table 7 for more details.

Family physicians, 945 (97%)

Specialists, 23 (2%)Nurse Practitioners, 6

(1%)

382 (72%)

87 (16%)

24 (5%)11 (2%)

10 (2%)6 (1%) 2 5 (1%) 1 1 0 0 1

1 2 3 4 5 6 7 8 9 10 11 12 13

No

. of

Ph

ysic

ian

s

Times of surveys completed to Specialist Link

Times unique family physicians have used Specialist LINK (up to March 2019)

Specialties using Specialist LINK

telephone advice: Dentist, Geriatric,

Nephrology, Palliative Care, Pharmacist,

Psychiatry and Rheumatology.

21 May 21, 2019

Specialist LINK

III. Patients information

The overall average patients’ age is 52 years old (3 to 96 years). Palliative Care is the specialty that included the

highest overall patients’ age (78 years old) while Psychiatry included the lowest overall patients’ age (42 years

old), see Table 8 for more details.

IV. Reasons for call

The reason of call question was included in the specialist survey starting February 2016. Specialists were asked to

select one or more reasons for the call. Overall, 88% of the respondents reported that the reason of the call is a

27%

47%

14%

7%3% 2%

29%

45%

18%

8%

0% 0%

1-5 6-10 11-15 16-25 26-35 >35

Length of Call in minutes

Up to Mar 2019 (n=929)

FY 18-19 (n=229)

0.3% 0.3%

7%

15%

18% 17%

19%

24%

0.5% 1%

6%

13% 14%17%

21%

28%

Under 5 6 to 15 16 to 25 26 to 35 36 to 45 46 to 55 56 to 65 Over 65

Patients age

up to March 2019 (n=864)

FY 18-19 (n=218)

22 May 21, 2019

Specialist LINK

routine advice on management (73%), diagnostic testing (53%) and therapeutic (27%). See Table 9 for

V. Specialist Recommendation

Specialist recommendation question was included in the specialist survey starting February 2016. Specialists

were asked to select one or more recommendations. For more details about specialist recommendations by

specialty see Table 10.

Specialists who specified ‘Advice provided’ as one of their recommendations were asked to specify and their responses were themed, please refer to the appendix for the complete list of verbatim responses.

Routine, 88%

Urgent, 12%

Emergency, 0%

Referral Status at Central Triage, 4% Other, 2%

Advice on Primary are Pathway(s), 2%

Reasons for call from Physicians (n=1065)

Routine advice on (n=936): 73% management 53% Diagnostic testing 27% Therapeutics

41%

39%

32%

29%

26%

5%

5%

2%

2%

40%

47%

34%

17%

20%

6%

2%

2%

Advice provided

Reassurance of physician's care plan

Medication recommendation

Additional diagnostic testing

Specialist follow-up required and referred

Advice on primary care pathways

Other

Referred to ER

More info needed

Specialist Recommendation up to March 2019 (n=971)

FY 18-19 (n=220)

23 May 21, 2019

Specialist LINK

Advice Medication Referral Advice Other testing

Up to March 2019 (n=186) 101 (54%) 21 (11%) 51 (27%) 13 (7%)

FY 2018-2019 (n=70) 28 (40%) 13 (19%) 18 (26%) 11 (16%)

VI. Outcome of calls

Specialists were asked to specify if a consult, an ER visit, a diagnostic test and/or lab test were avoided after the

telephone advice. Overall, 46% of the respondents reported that the call avoided a consult, 34% an ER visit, 12%

a diagnostic test and 8% a lab test. For more details about outcome of calls by specialty see Table 11.

* Note that the top 3 specialties that reported having avoided ER visits were Vascular Surgery, Rheumatology and

Psychiatry & Hepatology, while the top 3 higher number of surveys completed by specialties that were collecting

data in FY 18-19 were Psychiatry, Hepatology and Nephrology. Table 11.

Specialists who answered ‘other diagnostic tests and/or lab tests’ were asked to specify their answer, please refer to the appendix for the complete list of verbatim responses.

46%

34%

12%8%

48%

20%

12%5%

A consult An ER visit* Diagnostic Test(s) Lab Test(s)

In your opinion, did the phone conversation AVOID:

Up to March 2019 (n=1035)

FY 18-19 (n=247)

37%

24%

12%

6%3% 2% 2% 2%

40%

25%

45%

15%

30%

MRI CT X-ray ECG Barium HBT PFT DEXA Other

Diagnostic tests avoided: Up to March 2019 (n=83)

FY 18-19 (n=20)

24 May 21, 2019

Specialist LINK

VII. Appropriate use of Specialist LINK

Specialists who answered ‘No’ were asked to specify their answer, please refer to the appendix for the complete list of FY 18-19 verbatim responses.

Not Appropriate (12/13, 92% responses) Urgent nature (1/13, 8% responses)

“referred to private endocrinologist already but seeking

advice for same reason before the other endo sees”

“urgent referral, not "routine phone advice"

VIII. Service feedback

1. Feedback about the experience of providing advice

Specialists were asked to explain their answer (“Positive” n=42, “Negative” n=4 and “Other” n=6, FY18-19), please refer to the appendix for the complete list of verbatim responses.

Yes, 93%

Yes, 94%

No, 7%

No, 6%

Up to March 2019 (n=978)

FY 18-19 (n=230)

Was this an appropriate use of Specialist LINK?

97%

98%

2%

2%

2%

Up to March 2019 (n=732)

FY 18-19 (n=186)

The Experience in providng Advice was:

positive negative other

25 May 21, 2019

Specialist LINK

2. Call support Specialists were asked to select one or more areas that the call supported. Overall, 81% of the respondents

reported that the call supported mutual collegial support, 76% advice and education, and 72% enhanced patient

care.

Specialists who answered “other” were asked to explain their answer (n=3, FY18-19), please refer to the appendix for the complete list of verbatim responses.

IX. Diagnosis & Theme of Call

1065 archived and recent (Feb 2015 to March 2019) surveys completed by specialists were reviewed. In order to

find out the most common reasons of calls to the Specialist LINK telephone advice service, we explored the

theme of calls (241) and diagnosis (218), as well as in some cases a combination with the comments when the

other fields were incomplete or hard to read. Subsequently, 250 call reasons were themed.

The following table displays the list of top 3 themes (pathologies) by specialty. Note that the percentages might

exceed 100% as in some cases more than one pathology was discussed with the specialist, therefore, each

pathology was counted as a separate theme. See Table 12 for more details.

The top three pathologies that were more frequently reported in FY 18-19 were depression, NAFLD and

hormonal disorder.

Verbatim responses are included in the appendix.

Up to March 2019 (n=250) FY 18-19 (n=152)

Chronic Pain

MSK pain 7 Chronic pain 1

Osteoarthritis 6

Chronic pain 3

Endocrinology

Hormonal disorder 7 Hormonal disorder 7

Diabetes 4 Diabetes 4

Thyroid nodule 3 Thyroid nodule 3

Gastroenterology Gout 2

72%81%

76%

2%

62%

77% 80%

1%

Enhanced patient care Mutual collegial support Advice/Education Other

Did the call support any of the following: Up to March 2019 (n=824)

FY 18-19 (n=225)

26 May 21, 2019

Specialist LINK

Iron deficiency 2

Hepatology

NAFLD 9 NAFLD 9

Hepatitis C/B 7 Hepatitis B 4

Liver enzymes disorder 3 Liver enzymes disorder 3

Nephrology

Chronic Kidney Disease (CKD) 8 Chronic Kidney Disease (CKD) 6

Hematuria 5 Hematuria 5

Acute kidney injury 4 Acute kidney injury 3

Neurology

Abnormal EEG results 1

Brain Injury 1

Results interpretation 1

Palliative Care

Cancer - Lung 4 Cancer - Lung 4

Dementia 4 Dementia 4

Podiatric Surgery

Fracture 1 Fracture 1

MSK injury 1 MSK injury 1

Vascular malformation 1 Vascular malformation 1

Psychiatry

Depression 15 Depression 15

Alcohol abuse 5 Alcohol abuse 5

Bipolar disorder 5 Bipolar disorder 5

Rheumatology

MSK pain 7 MSK pain 1

Gout 5

Rheumatoid Arthritis 5

Sport Medicine

AC joint separation 1 AC joint separation 1

Achilles tendon rupture 1 Achilles tendon rupture 1

Ankle sprain 1 Ankle sprain 1

Back strain 1 Back strain 1

Grade 1 spondylolisthesis 1 Grade 1 spondylolisthesis 1

TFCC injury 1 TFCC injury 1

Urology Renal stone 1 Renal stone 1

Vascular Surgery

Abdominal Aortic Aneurysm (AAA) 4 Abdominal Aortic Aneurysm (AAA) 4

Carotid artery stenosis 3 Carotid artery stenosis 3

27 May 21, 2019

Specialist LINK

SPECIALIST LINK COST ANALYSIS

Estimation of net potential savings is based on a simple cost analysis factoring in direct costs for Specialist face to face consult request, Emergency (ER) visits and when applicable certain diagnostic tests avoided through Specialist LINK Program.

Cost and Savings variables per call are calculated based on the following inherent assumptions: ➢ Direct Cost: Both the Family Physicians and the Specialist billed for the tele-advice services. ➢ Direct Savings: All the recommendations from the specialist on avoiding ER consult, specialist consult and

or further diagnostic testing were followed by the family physician, relevant direct variable costs were avoided.

I. Analysis based on Survey Results

1. Direct Cost

Both family physicians and the specialists billed for the tele-advice services. Family physicians billed $32 for each

call and specialists $76, except for Podiatric Surgery specialists who billed $66.87 per call (Alberta Medical

Association Fee Navigator). Chronic Pain line is managed by nurse practitioners, both family physicians and

specialists were unable to bill therefore Chronic Pain cost was not included in the cost factor at this time, (83X

$108 = $8,964) has been deducted from total.

Cost by number of surveys received:

Specialty 14-15 15-16 16-17 17-18 18-19 Total per specialty

Gastroenterology 26 23 49 - - 98

Respirology 4 16 - - 20

Neurology 131 85 - 216

Endocrinology 97 57 90 244

Rheumatology 21 196 37 254

Hepatology 11 47 32 90

Pediatricians - - 0

Chronic pain 79 4 83

Nephrology 8 21 29

Podiatric Surgery 3 3

Psychiatry 35 35

Congestive Heart Failure 0 0

Vascular Surgery 23 23

Palliative Care 17 17

Sport Medicine 6 6

Urology 1 1

Unknown 2 - - 2

Total Surveys received 26 27 327 472 269 1,121

28 May 21, 2019

Specialist LINK

Cost (FP fee $32 + Specialist phone

consultation fee $76- except for podiatric surgery $66.87)

$ 2,808 $ 2,916 $ 35,316 $ 42,444 $ 28,593 Total Cost $ 112,077

2. Direct Savings

Direct savings were calculated based on the cost of ER visits, specialist consults and or further diagnostic testing

avoided as a result of the call. See Table 13 and Table 14 for more details about specialists’ consultation fees, ER

visits fees and major diagnostic testing fees.

Saving by number of avoidances reported in surveys received:

Avoided (% of total surveys received) 14-15 15-16 16-17* 17-18 18-19 Total per avoidance

Face to Face consult 11 (42%) 15 (56%) 142 (43%) 186 (39%) 122 (45%) 476 (42%)

ER visit 16 (62%) 15 (56%) 103 (31%) 172 (36%) 49 (18%) 356 (32%)

MRI 0 0 20 (6.1%) 6 (1.3%) 5 (1.9%) 31 (3%)

CT Scan 0 0 8 (2.4%) 3 (0.6%) 9 (3.3%) 20 (2%)

X-ray 0 0 5 (1.5%) 2 (0.4%) 2 (0.7%) 9 (1%)

Savings (consult $93.15 to $207 + ER $350 to $

386.1 + MRI $658.81 + CT $623.33 + X-ray $130) $7,712 $8,190 $82,725 $97,976 $49,968 Total Savings

$246,571

*Survey expanded in Feb 2016 to include diagnostic testing

Overall Percent of Avoidance across the years:

Avoidance types and numbers varied according to specialties with different patients’ needs and forms of care.

3. Call Survey Analysis

Average cost and savings were calculated based on the specialists surveys completed every fiscal year as well as

across the fiscal years, see Table 15 for average cost and saving per survey by year.

Consults avoided42%

ER visits avoided32%

Diagnostics avoided (MRI, CT, Xray)

5%

29 May 21, 2019

Specialist LINK

Savings based on all surveys: (1,121 surveys 2014-2019)

II. Analysis based on Call Volume

Analysis on call volume was based on the assumption that data follows similar pattern from survey data

calculation.

1. Direct Cost

Direct cost of the total of 11,777 calls was calculated based on the estimated cost and savings per survey across

the years (Table 15).

14-15 15-16 16-17 17-18 18-19 Across the years

Average Cost per Survey $108 $108 $108 $90 $106

Number of Calls 67 335 1264 3,670 6,441 11,777

Total Cost $7,236 $36,180 $136,512 $330,300 $682,746 $1,192,974

2. Direct Savings

Direct savings of the total of 11,777 calls were calculated based on the assumption that data follows similar

pattern of ER visits and specialist consults avoidance from survey data calculation.

No. of avoidance: 14-15 15-16 16-17 17-18 18-19 Total estimated

Consults 28 186 549 1446 2898 5,107

ER visits 41 186 398 1337 1159 3,121

Average savings of calls per specialty were estimated and results indicated that the top three specialties that had

the highest average savings per call were Vascular Surgery, Sport Medicine and Rheumatology. See Table 16 for

more details about cost savings by specialties.

Avoided Consults = 5,107 patients Avoided ER visits =

3,121 patients

Total Cost

$112,077

Total Savings

$246,571

TOTAL NET SAVINGS = $134,494 An average savings of $120 per call,

plus other direct or indirect costs saved

30 May 21, 2019

Specialist LINK

Direct savings by number of calls received:

Specialty 14-15 15-16 16-17 17-18 18-19 Total

Gastroenterology 67 327 542 786 982 2,704

Respirology

8 91 155 278 532

Neurology

276 746 963 1,985

Endocrinology

219 587 995 1,801

Rheumatology

103 603 791 1,497

Hepatology

33 222 367 622

Pediatricians

410 687 1,097

Chronic pain

123 175 298

Nephrology

24 268 292

Podiatric Surgery

4 50 54

Psychiatry

10 507 517

Congestive Heart Failure

88 88

Vascular Surgery 121 121

Palliative Care

24 24

Sport Medicine

65 65

Urology

80 80

Total of Calls received 67 335 1,264 3,670 6,441 11,777

Average Savings per Survey $ 297 $ 303 $ 253 $ 208 $ 186

Total Savings (no. of calls X average savings per survey for each FY)

$ 19,899 $ 101,505 $ 319,792 $ 763,360 $ 1,198,026 $ 2,402,582

Overall savings based on all calls received: (11,777 calls 2014-2019)

Total Cost

$1,192,974

Total Projected Savings

$2,402,582

TOTAL PROJECTED NET SAVINGS

= $1,209,608 (+74% of savings since last fiscal

year)

31 May 21, 2019

Specialist LINK

III. Extrapolated Savings

Prospective cumulative savings to the end of FY 2020 based on trend and current service delivery were plotted in

the figure below. Based on these trends, a total projected net savings of 2 million could be reached in Q4 of fiscal

year 2019-20.

IV. Indirect Savings and Other Direct Savings

Greater saving is expected once we account for other cost such as indirect patient savings through avoided travel and lost wages, decreased productivity for attending visits, health outcomes associated with shorter waiting times.

Patient Physicians & Specialist Other Direct Savings

Wait time Appointment time

Travel time & parking Travel cost Lost wages

Time off work/ loss of productivity Translation

caregiver time/ lost wages

Wait time Direct physician’s office time

Admin cost no show cost

Physician burnout consequences

Diagnostic tests Lab tests

Pharmaceutical interventions Travel & parking for Lab/DI tests

Medical equipment/supplies

$12,663 $77,988

$261,268

$694,328

$1,209,608

R² = 0.9979

$-

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

$2,000,000

$2,200,000

Cu

mm

ula

tive

To

tal S

avin

gs

32 May 21, 2019

Specialist LINK

APPENDIX

I. Tables

Table 1. Specialties included in Specialist LINK

Fiscal Year Specialty Service

FY 14-15 Gastroenterology (December)

FY 15-16 Respirology (February)

FY 16-17 Neurology (July)

Endocrinology (October)

Rheumatology (December)

Hepatology (March)

FY 17-18 Pediatricians (April)

Chronic Pain (July)

Nephrology (February)

Podiatric Surgery (March)

Psychiatry (March)

Congestive Heart Failure (March)

FY 18-19 Vascular Surgery (March 2018)

Palliative Care (September 2018)

Sport Medicine (November 2018)

Urology (January 2019)

Table 2. Specialist LINK Call Volume by specialty

Specialty 14-15 15-16 16-17 17-18 18-19 Total per specialty

Gastroenterology 67 327 542 786 982 2,704

Respirology

8 91 155 278 532

Neurology

276 746 963 1,985

Endocrinology

219 587 995 1,801

Rheumatology

103 603 791 1,497

Hepatology

33 222 367 622

Pediatricians

410 687 1,097

Chronic pain

123 175 298

Nephrology

24 268 292

Podiatric Surgery

4 50 54

Psychiatry

10 507 517

Congestive Heart Failure

0 88 88

Vascular Surgery 121 121

Palliative Care

24 24

Sport Medicine

65 65

Urology

80 80

Total of all 67 335 1,264 3,670 6,441 11,777

33 May 21, 2019

Specialist LINK

* Volume of calls are extracted from the phone record, unsuccessful connections and repeat calls from same call identifier

matching same return id within 3 hours of first call have not been included in the total volume reporting

Table 3. Physicians requesting telephone advice through the website by specialty

Specialty Number of Callers’ ID Number of Unique Callers’ ID

Chronic Pain 16 15

Congestive Heart Failure 16 10

Endocrinology 68 57

Gastroenterology 58 44

Hepatology 30 27

Nephrology 20 17

Neurology 84 67

Palliative Care 4 4

Pediatricians 50 42

Psychiatry 34 29

Respirology 20 16

Rheumatology 57 48

Sports Medicine 19 15

Urology 35 29

Vascular Surgery 16 13

Table 4. Access Pathways included in Specialist LINK website

Fiscal Year Access Pathway Posted Date Specialty Area

FY 16-17 Neurology Access Pathway January 2017 Neurology

FY 17-18 Endocrinology Access Pathway May 2017 Endocrinology

Rheumatology Access Pathway June 2017 Rheumatology

FY 18-19 Respirology Access Pathway October 2018 Respirology

Palliative Care Access Pathway December 2018 Palliative Care

Urology Access Pathway January 2019 Urology

Table 5. Enhanced Primary Care Pathways included in Specialist LINK website

Fiscal Year Name of Primary Care Pathway Posted Date Specialty Area FY 15-16

IBS June 2015 (GI website first) Gastroenterology

GERD June 2015 (GI website first) Gastroenterology

Dyspepsia June 2015 (GI website first) Gastroenterology

H. Pylori March 2016 (GI website first) Gastroenterology

FY 16-17

Launch Specialist LINK Website June 2016

Constipation Sept 2016 Gastroenterology

Parkinson’s Disease Dec 2016 Gastroenterology

Essential Tremor Feb 2017 Neurology

FY 17-18 Dizziness / Vertigo Enhanced/ simplified pathway May 2017 Neurology

34 May 21, 2019

Specialist LINK

Gout Enhanced/simplified pathway Sept 2017 Rheumatology

Radiographs for peripheral Arthritis Dec 2017 Rheumatology

Non-Alcoholic Fatty Liver Disease (NAFLD) Jan 2018 Hepatology

Diabetic Peripheral Neuropathy Jan 2018 Neurology

FY 18-19

Headache and Migraine May 2018 Neurology

Thyroid Nodule May 2018 Endocrinology

Peripheral Arthritis May 2018 Rheumatology

Chronic Diarrhea Oct 2018 Gastroenterology

Uncomplicated Obstructive Sleep Apnea Nov 2018 Respirology

Table 6. Resources included in Specialist LINK website

Year Specialty Area Name of Resource Posted Date

FY 18-19

Gastroenterology

Calgary Zone Gastroenterology Referral Quick Reference

June 2015

Neurology

Department of Clinical Neurosciences/ Program and Clinics July 2016

Headache App- treatment strategies for a primary headache May 2017

Respirology

Canadian Thoracic Society (CTS) Respirology Guidelines Calgary Zone Pulmonary Referral Quick Reference

Feb 2016

Calgary Zone Sleep Centre Referral Quick Reference Oct 2018

Calgary Zone Pulmonary Referral Quick Reference Oct 2018

Opioid use disorder

Opioid use disorder telephone consultation service February 2019

Opioid Framework (w team) February 2019

Opioid Framework (w/o team) February 2019

Opioid Describing Framework (w team) March 2019

Opioid Describing Framework (w/o team) March 2019

Billing codes March 2019

Suboxone prescription March 2019

Poster March 2019

Health team integration video March 2019

Table 7. Length of call by specialty

No. of surveys

Range Mean 2-5 min 6-10 min 11-15 min 16-25 min 26-35 min >35 min

Gastroenterology 69 2 - 25 10.0 min 9 (13%) 48 (70%) 9 (13%) 3 (4%)

Respirology 17 5 - 15 8.8 min 3 (18%) 12 (71%) 2 (12%)

Neurology 194 2 - 20 7.9 min 67 (35%) 103 (53%) 20 (10%) 4 (2%)

Endocrinology 217 3 - 30 9.6 min 71 (33%) 90 (41%) 39 (18%) 16 (7%) 1 (1%)

Rheumatology 171 2 - 41 9.7 min 37 (22%) 95 (56%) 26 (15%) 10 (6%) 1 (1%) 2 (1%)

Hepatology 73 2 - 20 7.2 min 41 (56%) 24 (34%) 6 (8%) 1 (1%)

Chronic Pain* 77 5 - 60 25.5 min 2 (3%) 10 (13%) 7 (9%) 22 (29%) 24 (31%) 12 (16%)

Nephrology 28 3 - 20 8.3 min 12 (43%) 13 (46%) 2 (7%) 1 (4%)

Podiatric Surgery 2 3 - 7 5.0 min 1 (50%) 1 (50%)

Psychiatry 35 5 - 1 8 10.9 min 5 (14%) 17 (49%) 11 (31%) 2 (6%)

35 May 21, 2019

Specialist LINK

Vascular Surgery 20 1 - 15 10.0 min 1 (5%) 13 (65%) 5 (25%)

Palliative Care 17 5 - 25 16.9 min 1 (6%) 1 (6%) 6 (35%) 9 (53%)

Sport Medicine 6 6 - 10 7.2 min 1 (17%) 5 (83%)

Urology 1 5 - 5 5.0 min 1 (100%)

*Note: Chronic Pain service is managed by nurse practitioners

Table 8. Patients’ age by specialty

Number of surveys Range (years) Mean (years)

Gastroenterology 79 18 - 96 55.5

Respirology 11 26 - 85 60.5

Neurology 175 12 - 92 47.8

Endocrinology 199 16 - 94 48.4

Rheumatology 183 3 - 91 51.9

Hepatology 71 5 - 85 50.6

Chronic Pain 70 20-85 53.5

Nephrology 23 19-84 61.1

Podiatric Surgery 2 63 - 68 65.5

Psychiatry 35 14 - 81 42.3

Vascular Surgery 21 55 - 94 72.5

Palliative Care 16 60 - 92 78.4

Sport Medicine 5 16 - 70 46.4

Urology 1 74 74

Table 9. Call reasons by specialty

Routine Advice

Routine Advice on Urgent Emergency Referral Status at Central Triage

Advice on Primary Care Pathway(s)

Other

Management Diagnostic testing

Therapeutics

Gastroenterology n=94

78 (83%) 49 (64%) 42 (32%) 17 (22%) 17 (18%)

2 (2%) 4 (4%) 1 (1%) 8 (9%)

Respirology n=20

18 (90%) 15 (83%) 11 (61%) 1 (6%) 1 (5%) 1 (5%) 0 0 0

Neurology n=208

178 (86%)

127 (77%) 98 (60%) 44 (27%) 34 (16%)

0 11 (5%) 4 (2%) 0

Endocrinology n=241

232 (96%)

126 (62%) 119 (59%) 37 (18%) 13 (5%) 0 5 (3%) 4 (3%) 0

Rheumatology n=229

193 (84%)

121 (81%) 96 (64%) 60 (40%) 33 (14%)

0 19 (8%) 6 (3%) 6 (3%)

Hepatology n=85

70 (82%) 28 (44%) 41 (65%) 2 (3%) 14 (16%)

0 3 (4%) 1 (1%)

Chronic Pain n=81

77 (96%) 47 (94%) 2 (4%) 20 (40%) 0 0 0 0 3 (4%)

Nephrology n=27

23 (85%) 20 (91%) 11 (50%) 5 (23%) 5 (19%) 0 1 (4%) 1 (4%) 1 (4%)

36 May 21, 2019

Specialist LINK

Podiatric Surgery n =3

3 (100%) 3 (100%) 0 0 0 0 0 0 0

Psychiatry n= 33

24 (73%) 19 (83%) 0 16 (70%) 9 (27%) 1 (3%) 1 (3%) 0 2 (6%)

Vascular Surgery n=21

20 (95%) 17 (89%) 9 (47%) 5 (26%) 3 (14%) 1 (5%) 0 0 0

Palliative Care n=16

13 (81%) 11 (85%) 3 (23%) 7 (54%) 1 (6%) 0 0 0 2 (13%)

Sport Medicine n=5

4 (80%) 4 (100%) 1 (25%) 1 (25%) 2 (40%) 0 0 0 1 (20%)

Urology n=1

1 (100%) 1 (100%) 1 (100%) 0 0 0 0 0 1 (100%)

Table 10. Specialist recommendation by specialty

Advice provided

Additional diagnostic testing

Specialist follow-up required and referred

Reassurance of physician’s care plan

Medication recommendation

Referred to ER

More info needed

Other Advice on primary care pathways

Gastroenterology (n=92)

41 (45%) 32

(35%)

34

(37%)

25

(27%)

17

(18%)

8

(9%)

3

(3%)

9 (10%)

0

Respirology

(n=18)

9

(50%)

12

(67%)

6

(33%)

0 5

(28%)

1

(6%)

0 1 (6%) 0

Neurology

(n=194)

77 (40%) 68

(35%)

71

(37%)

43

(22%)

43

(22%)

7

(4%)

2

(1%)

10 (5%)

3

(2%)

Endocrinology

(n=237)

96 (41%) 66

(28%)

47

(20%)

91

(38%)

49

(21%)

1

(0.4%)

10 (4%) 4 (2%) 12

(5%)

Rheumatology

(n=113)

82 (37%) 73

(33%)

52

(23%)

114

(51%)

109

(49%)

0 3

(1%)

0 23

(10%)

Hepatology

(n=84)

30 (36%) 16

(19%)

25

(30%)

24

(29%)

3

(4%)

1

(1%)

0 8 (10%)

3

(4%)

Chronic Pain

(n=56)

16 (29%) 2

(4%)

0 22

(39%)

42

(75%)

1

(2%)

0 0 0

Nephrology

(n=29)

7

(24%)

5

(17%)

2

(7%)

16

(55%)

5

(17%)

2

(7%)

1

(3%)

0 1

(3%)

Podiatric Surgery

(n=3)

2

(67%)

1

(33%)

1

(33%)

0 0 0 0 0 0

Psychiatry

(n=36)

10 (28%) 1

(3%)

4

(11%)

23

(64%)

25

(69%)

1

(3%)

0 0 2

(6%)

Vascular Surgery

(n=23)

13 (57%) 3

(13%)

7

(30%)

14

(61%)

4

(17%)

0 0 0 1

(4%)

Palliative Care

(n=17)

11 (65%) 1

(6%)

0 5

(29%)

13

(76%)

0 0 0 3

(18%)

Sport Medicine

(n=6)

5

(83%)

0 1

(17%)

3

(50%)

1

(17%)

0 0 0 1

(17%)

Urology 1 (100%) 0 0 1 0 1 (100%) 0 0 0

37 May 21, 2019

Specialist LINK

(n=1) (100%)

Table 11. Outcome of calls by specialty

Consult avoided

ER visit avoided

Diagnostic Test (s) avoided

MRI CT X-ray ECG Barium HBT PFT DEXA other

Gastroenterology n=85

35 (41%) 48 (56%) 0 1 2 0 0 0 0 0 0

Respirology

n=20

5 (25%) 6 (30%) 0 0 0 0 0 0 0 0 0

Neurology

n=207

78 (38%) 62 (30%) 17 6 1 0 0 0 0 0 0

Endocrinology n=236 130 (55%) 48 (20%) 4 1 0 0 0 0 0 0 1

Rheumatology n=232 105 (45%) 129 (56%) 5 3 4 2 2 2 2 2 0

Hepatology

n=78

39 (50%) 18 (23%) 0 0 0 0 0 0 0 0 1

Chronic Pain n=62 25 (40%) 13 (21%) 0 0 1 3 0 0 0 0 0

Nephrology

n=29

15 (52%) 2

(7%)

0 0 0 0 0 0 0 0 1

Podiatric Surgery n=3 0 1

(33%)

0 0 0 0 0 0 0 0 0

Psychiatry

n=35

15 (43%) 5

(14%)

0 0 0 0 0 0 0 0 0

Vascular Surgery n=22

11 (50%) 17 (74%) 3 9 1 0 0 0 0 0 0

Palliative Care n=17 9

(53%)

3

(18%)

0 0 1 0 0 0 0 0 0

Sport Medicine n=6 4

(67%)

4

(67%)

2 0 0 0 0 0 0 0 0

Urology

n=1

0 0 0 0 0 0 0 0 0 0 0

Unknown*

n=2

2 (100%) 0 0 0 0 0 0 0 0 0 0

*unknown – surveys completed with no information on specialty

38 May 21, 2019

Specialist LINK

Table 12. Specialist LINK diagnosis themes by specialty

Specialty Diagnosis themes (n=248, Feb 2015 to Mar 2019) Count

Chronic Pain (n=29)

MSK pain /Injury 7

Osteoarthritis 6

Chronic pain 3

Arthritis 2

Degenerative disc disease 2

Fibromyalgia 2

Opioid Medication 2

Polytrauma/Post-traumatic pain 2

Peripheral Neuropathy 2

Spinal Stenosis 1

Neuropathic pain 1

Post herpetic neuralgia 1

Psoriatic arthritis 1

Rheumatoid Arthritis 1

Vascular necrosis 1

Endocrinology (n=28)

Hormonal disorder 7

Diabetes 4

Thyroid nodule 3

Cortisol 2

Bone fragilization 1

Cancer- Ovary 1

Constipation 1

Gender transition 1

Hyperkalemia 1

Hyperthyroidism 1

Mucco-edema with optic nerve compression 1

Pancreatic cyst 1

Pituitary 1

T3 toxicosis 1

Vitamin D 1

Weight gain 1

Gastroenterology (n=9)

Gout 2

Iron deficiency 2

Cognitive impairment 1

Helicobacter 1

Investigation/Testing 1

Pain 1

39 May 21, 2019

Specialist LINK

Ulcerative colitis 1

Hepatology (n=24)

NAFLD 9

Hepatitis C/B 7

Liver enzymes disorder 3

Autoimmune Hepatitis (AIH) 1

Hemangioma 1

Hepatic abscess 1

Hepatocellular Carcinoma/Diarrhea 1

Wilson's disease 1

Nephrology (n=27)

Chronic Kidney Disease (CKD) 8

Acute kidney injury 4

Hyperkalemia 3

Proteinuria 3

Diabetic nephropathy 2

Hyponatremia 2

Nephrectomy 1

Hematuria (synpharyngitic hematuria, acute kidney injury, Medullary Sponge Kidney) 5

Hypokalemia 1

Potassium 1

Neurology (n=3)

Abnormal EEG results 1

Brain Injury 1

Results interpretation 1

Palliative Care (n=16)

Cancer - Lung 4

Dementia 4

Cancer - Colon 2

Cancer - Prostate 2

Pain 2

Cancer 1

Cancer - Bone 1

Cancer - Breast 1

Cancer - Liver 1

Cancer - Ovary 1

COPD 1

Chronic Heart Failure 1

PSNP 1

Podiatric Surgery (n=3)

Fracture 1

MSK injury 1

Vascular malformation 1

Psychiatry Depression 15

40 May 21, 2019

Specialist LINK

(n=35)

Alcohol abuse 5

Bipolar disorder 5

Anxiety 3

Drug abuse 3

Psychosis 3

ADHD 1

Fetal Alcohol Spectrum Disorders (FASD) 1

Insomnia 1

Mania 1

OCD 1

Panic disorder 1

Paranoia 1

Paranoid personality disorder 1

Personality Disorder 1

Rumination syndrome 1

Schizoaffective Disorder 1

Rheumatology (n=52)

MSK pain 7

Gout 5

Rheumatoid Arthritis 5

Autoimmune disease 3

Inflammatory arthritis 3

Polyarthralgia 3

Osteoarthritis 2

AMS (morning stiffness) 1

Arthralgias 1

Arthritis 1

Chronic pain 1

Crystal Arthropathy 1

Diffuse idiopathic skeletal hyperostosis (DISH) 1

DM/HTN 1

Hidradenitis suppurative 1

Hypermobility syndrome 1

IBD 1

Inflammatory pain 1

Investigation/Testing 1

Osteoporosis 1

Painful Metatarsophalangeal Nodules (MTPS) 1

Polymyalgia rheumatica (PMR) 1

Psoriasis 1

41 May 21, 2019

Specialist LINK

Reiter's syndrome/celiac disease arthralgia 1

Results interpretation 1

Sarcoidosis 1

Scleroderma 1

Sjogren syndrome 1

Skin Bruising 1

SLE 1

Tendinopathy 1

Transient arthritis 1

Sport Medicine (n=5)

AC joint separation 1

Achilles tendon rupture 1

Ankle sprain 1

Back strain 1

Grade 1 spondylolisthesis 1

TFCC injury 1

Urology (n=1)

Renal stone 1

Vascular Surgery (n=22)

Abdominal Aortic Aneurysm (AAA) 4

Carotid artery stenosis 3

Claudication 2

Foot ulcer 2

Peripheral Vascular Disease (PVD) 2

Aortic Atherosclerosis 1

Carotid Tortuosity 1

Celiac Astesy Compression Syndrome 1

Chronic pain 1

Cyanotic toes 1

Groin pain 1

PAD 1

Raynaud's Syndrome 1

Vertebral Art Dissection 1

Table 13. Specialist initial face-to-face consultation fee by specialty

Specialty Face-to-face consultation fee*

Gastroenterology $192

Respirology $207

Neurology $198

Endocrinology $195.12

Rheumatology $198

42 May 21, 2019

Specialist LINK

Hepatology $186.95

Pediatrics $200.30

Chronic Pain n/a

Podiatric Surgery $93.15

Nephrology $199.63

Psychiatry $187.88

Vascular Surgery $160.56

Congestive Heart Failure $175.00

Palliative Care $175.00

Sport Medicine $122.84

Urology $93.38

Anesthesiology $104.12

*Source: Alberta Health Care Insurance Plan Schedule of Medical Benefits, effective April 1, 2018

Table 14. Emergency Visits and Diagnostic Testing

Saving Variables 14-15 15-16 16-17 17-18 18-19

ER visit* $350 $350 $350 $350 $386.1

MRI** n/a n/a $658.81 $658.81 $658.81

CT scan** n/a n/a $623.33 $623.33 $623.33

X-ray** n/a n/a $130 $130 $130

** Source: Canadian MIS Database (CMDB), CIHI, FY 2015/16 provided by the Canadian Institute for Health Information for Average ED cost

per visit for all hospitals in Alberta which include direct expenses only. And average ER cost in Alberta: Trends in Hospital Expenditure, 2005–

2006 to 2017–2018 — Data Tables — Series B: Hospital Expenditure by Functional Area

***Source: information from Interactive Health Data Application, Govt of AB FY 2016-17 (MRI, CT Scan, X-ray (range of X-ray cost from $106

to $154)

Table 15. Average cost and savings per survey by year

14-15 15-16 16-17 17-18 18-19 Across the years

Average Cost per Survey $108 $108 $108 $90 $106 $100

Average Savings per Survey $297 $303 $253 $208 $186 $220

Average NET savings per survey $189 $195 $145 $118 $80 $120

Table 16. Call Savings Per Specialty

Total no. of calls

Total no. of surveys

No. of calls avoided SP consults

% avoided SP Consult per SP

No. of calls avoided ED visits

% ED avoided per SP

No. of calls avoided an MRI

% MRI avoided per SP

No. of calls avoided a CT scan

% CT Scan avoided per SP

No. of calls avoided an X-ray

% X-Ray avoided per SP

Average cost avoidance per call

Average savings per call (subtract FP & SP call fees)

Gastroenterology 2704 98 35 36% 48 49% 0 0% 1 1% 2 2% $ 267 $ 159

Respirology 532 20 5 25% 6 30% 0 0% 0 0% 0 0% $ 168 $ 60

Neurology 1985 216 78 36% 62 29% 17 8% 6 3% 1 0% $ 252 $ 144

Endocrinology 1801 244 130 53% 48 20% 4 2% 1 0% 0 0% $ 193 $ 85

Rheumatology 1497 254 105 41% 129 51% 5 2% 3 1% 4 2% $ 300 $ 192

43 May 21, 2019

Specialist LINK

Hepatology 622 90 42 47% 18 20% 0 0% 0 0% 0 0% $ 164 $ 56

Pediatrics 1097 0

Chronic Pain 298 83 25 30% 13 16% 0 0% 0 0% 1 1% $ 62 $46

Nephrology 292 29 15 52% 2 7% 0 0% 0 0% 0 0% $ 130 $ 22

Podiatric Surgery 54 3 0 0% 1 33% 0 0% 0 0% 0 0% $ 129 $ 30

Psychiatry 517 35 15 43% 5 14% 0 0% 0 0% 0 0% $ 136 $ 28

Congestive Heart Failure

88 0

Vascular Surgery 121 23 11 48% 17 74% 3 13% 9 39% 0 0% $ 692 $ 584

Palliative Care 24 17 9 53% 3 18% 0 0% 0 0% 1 6% $ 168 $ 60

Sport Medicine 65 6 4 67% 4 67% 2 33% 0 0% 0 0% $ 559 $ 451

Urology 80 1 0 0% 0 0% 0 0% 0 0% 0 0%

Unknown - 2 2 100% 0 0% 0 0% 0 0% 0 0% $ 199 $ 91

Total 11777 1121 476 42% 356 32% 30 3% 20 2% 9 1%

*Chronic Pain service is managed by nurse practitioners, both NP and FP do not bill separately for phone consultation. Indirect costs/ other direct costs were not included in the cost analysis due to an absence of data for these variables.

II. Figures

Figure 1. Historical Website Traffic

0

1000

2000

3000

4000

5000

6000

06

/20

16

07

/20

16

08

/20

16

09

/20

16

10

/20

16

11

/20

16

12

/20

16

01

/20

17

02

/20

17

03

/20

17

04

/20

17

05

/20

17

06

/20

17

07

/20

17

08

/20

17

09

/20

17

10

/20

17

11

/20

17

12

/20

17

01

/20

18

02

/20

18

03

/20

18

04

/20

18

05

/20

18

06

/20

18

07

/20

18

08

/20

18

09

/20

18

10

/20

18

11

/20

18

12

/20

18

01

/20

19

02

/20

19

03

/20

19

Historical Website Traffic (data since Nov 2016)

Downloads Page Views Total Visits

44 May 21, 2019

Specialist LINK

Figure 2. How many times have family physicians used Specialist LINK

Figure 3. Reasons to not having used Specialist LINK

III. Specialist survey verbatim answers for open-ended questions

1. Specialist Recommendation Specialists who specified ‘Advice provided’ as one of their recommendations: (n=70) Response themes by Specialty: (Advice, Medication, Referral, Other testing)

Endocrinology n=29 Advice 11/29, 38% responses

• Asked a colleague for bone question- provided advice by email

• Out of my scope of expertise, will consult with a colleague about case and get back to by email

10%

57%

21%12%

1 2-5 6-10 10+

# o

f R

esp

on

den

ts

Times used

How many times have you used Specialist LINK (n=239)

36

19

18

12

11

1

1

Time constraint for making phone calls betweenappointments

Have heard about the service but don't know thedetails of it

Patients' needs met by current system

Not needed for patients in my panel

Patient hasn't met the profile for use

I'm not interested in a telephone advice requestservice

Other: Patient usually wants to 'see' a specialist

Reasons respondents have not used Specialist LINK (n=98)

45 May 21, 2019

Specialist LINK

• FNA-can be done by EFW

• desiccated thyroid contra-indicated in pregnancy

• call patient to see if symptomatic

• check if patient using biotin--& gt; stop it--& gt; repeat thyroid levels in 2 weeks at OFC 's if still abnormal (high T4, high T3, high TSH) refer to endo CAT

• Advised diet may have A, Advised lower Cartus to 20 u qhs and r/a

• Treat hypothyroidism + recheck PRL

• Advised that hypothyroidism unilateral

• Recommended checking for lyses + bicarb to 100 h for DKA. If +DKA --> ER. I f - DKA -->urgent referral

• Consider referral depending on response to current treatment and monitoring Medication 6/21, 17% responses

• Decrease testosterone dose and monitor hct

• stop raloxifene

• Kenalog not a substitution for emergency dose of IM hydro cortisol when ill.

• I recommended starting bisphosphonate. concerned about nonadherence: if IV Aclost possible. I responded that it is usually given if po not tolerated and typically with assessment through op clinic

• Advised to lower to 800-2000/d then r/a --> F/u Dr

• Recommended dividing injection into 2 and considering Lantus for longer coverage Referral 7/29, 24% responses

• refer to osteo clinic

• start tapazole, refer to endo as urgent

• FT4, MRI sella refer to endo

• FT4, MRI sella refer to endo

• work up for pcos but minus the ultrasound refer to peds endo esp re weight management

• Referred to care pathway

• Suggested referral- eval with FCY, cytes, PRL, IUFI--> already on pred 15 mg/d for PmRL. Cautioned re: taper and need to evaluate for AI

Other 5/29, 17% responses

• MRI sella

• MRI sella

• check 8AM serum cortisol

• Cortisol 238 probably needs out AI

• Recommend repeating fasting am PRL, avoiding stimulation

Hepatology n=1 Advice 1/1, 100% responses

• risk of hbv reactivation reviewed

Nephrology n=2 Advice 1/2, 50% responses

• Repeat labs in about 3 months

Medication 1/2, 50% responses

• Re hydrate pin. Topic/step steroids. Higher dose of spirendolone. Check urine lytes/ ismes + continue replacement with KCl

Palliative Care n=5 Advice 1/5, 20% responses

• try medication again, request community consult for ongoing care needs Treatment 1/5, 20% responses

• opioid titration

46 May 21, 2019

Specialist LINK

Referral 3/5, 60% responses

• call TBCC nurse and request P&SM clinic referral

• refer to home care, titrate opioid

• use hemostat dressing. LTC most appropriate place for EOL for dementia pt

Podiatric Surgery n=2 Advice 1/2, 50% responses

• NWB/ cast/ crutches Referral 1/2, 50% responses

• call a shoulder specialist as podiatry is a specialty limited to foot and ankle

Psychiatry n=10 Advice 2/10, 20% responses

• Agreed that Certification was more likely harm than good Medication 4/10, 40% responses

• discussed possible personality disorder, role of antipsychotics and options

• discussed options of lamotrigine vs lithium

• suggested betablocker while awaiting Geriatric Psych intake

• first choice is to stop Aripiprazole, but probably not high risk

Referral 4/10, 40% responses

• Suggested a couple names

• To call Admission Coordinator at Claresholm Care Ctr

• Referral to Community Extension Team for interim

• encouraged routine referral through Access Mental Health Other 1/10, 10% responses

• Screen for abuse/trauma, further diagnostic clarification

Rheumatology n=4 Advice 1/4, 25% responses

• will update c. triage Referral 1/4, 25% responses

• consider wound clinic referral Other 2/4, 50% responses

• repeat x-ray at EFW if report is consistent with erosive OA, focus on pain optimization with Tylenol, NSAIDS, (oral/topical) if she wants a rheum opinion ok to refer but rx for erosive OA is limited, need for rheum assessment now

• recheck ENA in mitogen (lupus panel), in the absence of systemic sx start with a dermatology assessment, periorbital rash from lupus is very unusual, no need for rheum referral now

Sport Medicine n=4 Advice 3/4, 75% responses

• Symptomatic management and MRI arthrogram of wrist

• Continue PT and symptomatic management

• management, bracing, progression of RTW

Referral 1/4, 25% responses

• Contact given to discuss with foot/ankle orthopedic surgeon

Urology n=1

47 May 21, 2019

Specialist LINK

Other 1/1, 100% responses

• perform to u B

Vascular Surgery n=12 Advice 8/12, 67% responses

• No further testing

• ulcer care strategy

• Conservative management

• No vascular Pathology

• u/s to f/o pseudo-areaways

• No further w/u

• Send to ER

• no need CTA Medication 1/12, 8% responses

• ASA, Statins Referral 1/12, 8% responses

• send consult < link Referral 2/12, 17% responses

• confirm patency with ultrasound (2)

2. Outcome of calls Specialists who specified ‘Other’ for Diagnostic tests and Lab tests avoided:

Other Diagnostic tests avoided: (n=6)

Endocrinology (n=3)

• Doc was wondering about TSHoma which is unlikely

• U/S

• ANS: yes

Nephrology (n=1)

• U/S

Rheumatology (n=1)

• Aspiration

Vascular Surgery (n=1)

• CTA

Lab tests avoided: (n=6)

Endocrinology (n=2)

• TRAB

• T3 levels-not helpful, don't check

Hepatology (n=2)

• Liver biopsy

• Liver biopsy

Sport Medicine (n=1)

• Error- no lab tests needed

Vascular Surgery (n=1)

• blood work

3. Appropriate use of Specialist Link

6% (14/234) of specialists answered ‘No’ to whether the call was an appropriate use of Specialist Link

Specialists who answered ‘no’ explained: (n=13)

Not Appropriate (12/13, 92% of responses)

• wrong specialist interrupted

• Not a nephrology issue

• already referred to fertility clinic

• referred to private endocrinologist already but seeking advice for same reason before the other endo sees

• Calming anxiety

• it was the patient's wife calling for advice

48 May 21, 2019

Specialist LINK

• Patient is on both list patient of specialist anyway

• Patient has a nephrologist and family doctor should have directed concerns there.

• I don't think it was intended that we (specialist link) update central triage i.e. status of patient

• Needs referral

• referral was declined by central triage as pt thought to have OA, GP and patient want specialist appt to reassure not missing other problem due to young age, poly articular involvement, & family history

• Already managed by a nephrologist.

Urgent nature (1/13, 8%)

• urgent referral, not "routine phone advice""

4. Service feedback

Specialists commented on experience in providing feedback (n=52):

Positive, comments n=42

• better if peds endo would do phone consult

• family physician needed reassurance

• great to provide education and speak to family MD colleague

• I was able to help her understand the appropriate channels to find help.

• Always good to help a colleague in an area they are not familiar/comfortable with - they know for next time.

• Happy to help

• Good to help a colleague who is not familiar with opioid titration. Next time he will know how to do it.

• WAs able to help support a GP

• The FP was uncertain in an area where I have had experience. Happy to help.

• Clarified that Certification and transfer to ER required

• Quick double check about medication advice

• able to encourage rereferral with appropriate terminology

• helped with referral language to assist correct management by central referral

• Difficult clinical situation - really needs something other than primary care, but what?

• Great interaction with GP

• Tough case, good to share options for future

• GP was expressing gratefulness that psych was on specialty link

• Therapeutic option which GP had not experience with: moclobemide

• Unlikely that patient would accept referral, so best to work with relationship in Primary Care

• Challenging - sudden worsening of probable longer-term illness

• Collaborative - did take extra time and return call to look up risks

• Difficult situation - however I did not have the dose of drug handy, so had to look it up

• Shared responsibility for VERY difficult patient and situation

• able to assist GP during period leading to full consult in clinic (already referred)

• Challenging case - good to discuss

• Extra time to look up risks and called back

• Challenging case, but excellent care in primary care supported by Specialist Link

• Negative, comments

• ? sarcoid arthropathy- telephone advice

• review of result, reassurance for MD & patient re: hand OA

• telephone advice, PMR unlikely, hold off on prednisone and observe

• Easy exchange of info

• referring physician was happy to avoid complex work up

• Easy interaction, guide resolution

• Collaborative care plan arranged

• Shared learning about PAD is octogenarian

• primary care doc wanting to investigate patient complaint efficiently

• Provided reassurance and F/U plan

• Friendly exchange of unique u/s findings

49 May 21, 2019

Specialist LINK

• Good interaction, grateful colleague

• avoided unneeded cost to AHS

• Primary care doc's plan was appropriate, and reassurance was given

Negative, comments (n=4)

• I felt like a middleman and suggested many times that the other nephrologist should be contacted for both patients

• The case was not discussed by the NP caller w/the physician looking after the patient at the care home

• interrupted while performing surgery, ORTHO is not one of the specialties in the program, cannot begin to understand how anyone thought that I should be called for this shoulder injury; should we be using AHS resources for WCB injuries?

• I spent at least 5-10 minutes trying to call back and entering the number different ways. It was a waste of my time. Number provided was not in service - what do we do when this happens?

Other, comments (n=6)

• Today is day 4 since advice given. There is no CT performed and when I called CT booking there is no record of a CT ordered region-wide. I question whether advice acted upon, therefore what's the point?

• Hard to find such consultants

• GP is advocating on patient's behalf

• no lab results available at time of call, CCP+ RF+, I will see next week

• except this is a pediatric patient- recommended paging ped rheum on-call in future if further problems in pts < =18 yr old, ANA not a good screen for pts w/ fatigue, ANA 1:40 is not significant

• Neutral-this is a patient of another urologist already

“Did the call support any of the following…”

Other, comments n=3

• day 7 still no CT results

• Name for court report

• Medico-legal support

5. Diagnosis & Theme of Call

Chronic Pain

Diagnosis (n=1)

• Chronic C, T, L spine pain

Theme of call (n=1)

Management 1/1, 100% responses

• management of increased pain

Endocrinology

Diagnosis (n=4)

• Low BmD off resituate x5 year with low absolute risk of fracture referral to op dime

• Dizzy lightened but Bb measured usually 2h after eating high protein food. Home Bb lowest 9.9-5.9 mmol/l. Hypoglycemia not detected ever

• Called re: intermittently high TSH9.5 c slightly high FT7 that improve. No sx of thyrotoxicosis. No interfering meds/biotin. No FHX of FOH or RTH. Recommended repeating in a few months’ time.

• Borderline Pm, Borderline I cholesterol. Asked re: possible statin. Advised that it should be determined by patient preference+ absolute risk reduction likely very small.

Theme of call (n=29)

Referral 2/29, 7% responses

• 33 F FNA thyroid. Suspicions for follicular neoplasm--> Referral already made

• Overt hyperthyroidism and asked for referral. Clinical 27/29, 93% responses

• Persistent Am low Bg in new LTSC facility testing Cantus 26 u qhs

• Constipation unlikely repeated to PM and domperidone unlikely to help

• high TSH, of 10 and high PRL 45. Advised replace LT7 100-112 mg/ then recheck high SH +PRL in around 2m time

• High weight 9 lbs in 2 weeks (75lbs since May). BMI >40 -->+++stretch marks. query testing is?

• Whipple in Oct for pancreatic cyst (Benin). Admitted c inter abdominal colect---> started on metformin Hbaic 5.6%. Stop metformin shay.

• T3 toxicosis c high manifestations ---> repeat

50 May 21, 2019

Specialist LINK

• Cortisol 238 shay

• Metformin 350 mb bid. Alc 6% GPR 36. Synthroid --->? adherence. YP stop metformin, target ALC < 8-5%

• 4/6 thyroid nodules. 2 inf suspicious. High TPO --> FNA recommended

• Nov 18 HbAc 10.3% --> NSCEMU --> ALC 8.5%. Metformin 500 bid Q: Is Jardiance shay to start offer MI

• 53 F alcoholic with R femur #. High score to L-spine -9. High risk fracture

• 35 M normal bio avail testosterone + fatigue

• 65 M prior hx pit mucco edema resected 20 y ago in USA. MRI sella 10 y ago shows no recurrence. Biochemical testing normal. Addressed no further w/u unless symptoms present Leg down visual fields)

• BSO 2016 for Fotx ovarian CA. D/C on BCP --> stopped last year --->restarted. Has migraines c amra. YP advised HRT already referred to LMC

• Transgender recently F-->M. Edmonton for school. Edmonton ends?

• Mother (24 h K+ high) seen functional med care + desiccated thyroid

• Daughter (high AM cortisol) seen functional med care + desiccated thyroid

• 38 F pregnant 25 weeks GA, TSH 4.65 FC4 12.2 FT3 3.5. No preexistent thyroid.

• High PRL 41 thyroid no SX

• 49 F with vit D of about 70 nmol/l. reaching 50000IU qd

• 19 F pregnant, 10 weeks gestation. TSH < 0.01 FC4 22.9 FT3 6.9 (TFTs ordered with no indication)

• 60 F taking escalating doses on Levemir 60 -->100U qhs over last year with minimum effect. No obvious reason for hyperglycemia. Already seen by DEC and in queue for endo consult.

• 61 F (thin) into DM for years not controlled on oral (metformin) TX, 6LPI agonist, SGLT2i Rx and presented with high BG + ketones in clinic

• 74 F LTC wheelchair with T20m metformin 500 mg bid glagine 30 u qam, 12 u qhs NR 9/6/9 w/h meals. BG on target for breakfast + supper but high BG at lunch

• 54 F, high Tg level. Incidental 1-5 cm, low echoic thyroid lesion --> FNA rec

• 82 F mucco edema with optic nerve compression

• Acne + hair I over body = Pcos metforms spronolectone ? high foot size. Already seen by endocrino and recs already give on netcare.

Hepatology

Diagnosis (n=27)

• NAFLD r/o AIH (x2)

• HBV (x2)

• increase LE

• HBC Ab+ SAg- (x2)

Theme of call (n=21)

Management 2/21, 10% responses

• Management (x2) Clinical 14/21, 67% responses

• r/o AIH (x3)

51 May 21, 2019

Specialist LINK

• HCC and diarrhea (x2)

• High liver enzymes

• High ASMA, N LE

• Giant Hemangioma

• NAFLD

• HBV carrier

• HBcAb positive

• NASH inconclusive SWE but also elevated ALP

• Fatty liver? drug induced

• NAFLD (x2)

• Elevated ALP

• r/o Wilson's disease

• Hepatic Abscess

• elevated LE

• NAFLD - not alpha 1 AT def

• NAFLD/ETOH/Meds

• refused from CAT for high risk NAFLD

• elevated ALP

• ? EtoH Hep

• Monitoring (x2)

• Rule out mass

• safety of A/C

• reassurance

• risk of reactivation with stopping Truvada

• fatty liver

• check cu studies

• risk stratification, pt noncompliant

• advice on wu and pathway Diagnosis & testing 5/21, 24% responses

• further workup

• tests

• workup

• Investigations needed

• Investigations

Nephrology

Diagnosis (n=21)

• U11

• CKD (x5)

• Hematuria

• AKI (x4)

• Amc

• Hyperkalemia (x3)

• hematuria/AKI

• Hyponatremia

• hematuria and proteinuria

• CKD stage 3 a non-proteinuria

• DUI with diminution in K+ secondary to cisplatin

• Potassium

Theme of call (n=16)

Clinical 9/16, 56% responses

• CKD (x4)

• Medullary Sponge Kidney

• Nephrectomy

• consequences of hyponatremia, management plan

• diagnosis

• diminution of K+ (critically low K+) Management 7/16, 44% responses

• Appropriate management

• Management (x4)

• advice on management

• diagnosis/management

Palliative Care

Diagnosis (n=16)

• pain, on Keytruda

• Ovarian cancer, recurrent UTZ's

• Lung cancer, metastases to brain with SOB

• dementia, recurrent breast ca

• Lung Ca (x2)

• Colon Ca/ COPD/ CHF/ Dementia

• bone mets, unknown primary

• Lung Ca and frailty

• Dementia

• Prostate Ca, Dementia

• Prostate Ca

• Colon Cancer

• PSNP

• cervical ca

• Curbasin Liver ca

Theme of call (n=17)

Clinical 8/17, 47% responses

• antibiotics prophylaxis

• Pain control

• Symptom conflict, palliation

• where to access resources e.g. thoracentesis

• Home care referral

• Pain and delirium control, with? EPS from Haldol

• Pain control (x2)

Management 9/17, 53% responses

• secretion management

• Symptom management (x3)

• Help c symptom management

• pain management

• available supports for this patient who lives alone, some symptom management

• management of bleeding and also care placement

52 May 21, 2019

Specialist LINK

• pain management

Podiatric Surgery

Diagnosis (n=3)

• WCB

• fracture

• Vascular malformation

Theme of call (n=3)

Clinical 2/3, 67% responses

• should injury discovered offer pre-amble

• what do I do? Pt weight bearing w/ ---- pain, 4 weeks Management 1/3, 33% responses

• Management

Psychiatry

Diagnosis (n=35)

• Mania

• Insomnia

• Depression - partial response

• Depression

• Alcohol abuse

• Substance Use Disorder

• alcohol use disorder (x2)

• Major Depression in remission

• bipolar disorder - depressed phase

• "Rumination Syndrome"

• Psychosis

• OCD vs anxiety

• Major Depression - treatment resistant

• Major Depression

• unclear - possibly paranoid personality disorder

• possible bipolar depression, past dx borderline pd, narcissistic pd

• Borderline PD and Alcohol Use Disorder / Stimulant Use Disorder (cocaine)

• Major Depressive Disorder and Generalized Anxiety Disorder

• Schizoaffective Disorder

• Panic Disorder

• Depression & anxiety in lactation

• Paranoia secondary to neuro-syphilis

• MDD in remission

• persistent depressive disorder, r/o bipolar 2

• Personality Disorder

• bipolar disorder - mixed state

• Depression with Psychotic Features

• Depression and Alcohol Use Disorder

• Dissociation

• benzodiazepine use disorder

• persistent depressive disorder and major depression

• Anxiety and pregnancy

• Bipolar Depression with Psychosis and ADHD

• FASD with psychosis

• major depression, generalized anxiety disorder, ADHD

Theme of call (n=35)

Referral 6/35, 17% responses

• what is best disposition -? Certify and send to ED?

• Trying to find expert for a court report

• problems with getting services via Access Mental Health

• problems accessing care

• How to refer to Dual Diagnosis in Claresholm Care Centre

• management and referral for further treatment Medication 16/35, 46% responses

• Can patient continue to use sleeping medication

• Medication advice - concern about seizure risk with Ibuprofen with remote childhood history of seizures

• Can MD continue high dose venlafaxine with stable patient new to him

• assistance with Rx selection - first choice side effect limited, already scheduled to see consultant on consult via access

• Medication advice

• Treatment recommendation

• Alternative treatments? ECT

• education re DSM5's approach to medication induced mania, spoke about treatment options

• What drugs are safe in lactation - ? Prozac

• How to maintain antipsychotic treatment

• pt weaned off 30yr diazepam use c/o anxiety. Multiple med dx. Needed help managing request for diazepam

• advice on meds in carded national team athlete on waitlist for services

• safety of aripiprazole in pregnancy (augmenting agent)

• Medication concerns, especially with stimulants in Bipolar patient and longer-term approaches

• medication management

• request assistance with medical management in treatment resistant case with seizure disorder (poss. med related)

Clinical 9/35, 26% responses

• What to do with somebody who GP hasn't seen but is hearing about from wife who is threatening to complete suicide

• difficult patient encounter, difficult marital relationship with unclear pathology

• Treatment resistant due to non-response or side effects - what next?

• Dealing with paranoid patient - difficulty accepting treatment and medication

53 May 21, 2019

Specialist LINK

• Patient well managed on antidepressant but wants to get pregnant and medication is contraindicated - what to do?

• Whether or not to Certify in situation of threats which are not "imminent"

• Dealing with psychosis and depression

• Dissociative episodes in depression and Alcohol Use disorder

• Unusual / rare syndrome diagnosed as psychosomatic, but what to do now?

Management 3/35, 9% responses

• Management

• management of pt seen in ER and struggling

• support and suggestions for future management Other 1/35, 3% responses

• Wasn't able to call the number provided because the number provided was not in service

Rheumatology

Diagnosis (n=0) Theme of call (n=1)

Clinical 1/1, 100% responses

• bilet hand pain

Sport Medicine

Diagnosis (n=6)

• TFCC injury

• AC joint separation

• Achilles tendon rupture

• high ankle sprain

• Back strain with X-ray findings of Grade 1 spondylolisthesis

Theme of call (n=5)

Management 4/5, 80% responses

• Advice on Management

• Management (x2)

• management advice Other 1/5, 20% responses

• Sports medicine

Urology

Diagnosis (n=1)

• Right Renal stone

Theme of call (n=1)

Clinical 1/1, 100% responses

• New problem of stones right side on ultrasound

Vascular Surgery

54 May 21, 2019

Specialist LINK

Diagnosis (n=23)

• PVD Critical ischemia

• Aortic Atherosclerosis

• Carotid artery stenosis

• Carotid Stenosis (x3)

• ischemic legs

• Cyanotic Toes

• Raynaud's Syndrome

• Foot ulcer

• Abdo + chest pain NYD

• PAD

• Groin pain post femoral access for cardiac cath

• AAA (x3)

• Carotid Tortuosity

• Vertebral Art Dissection

• AAA- Symptomatic?

• PVD

• Claudication (x2)

• Celiac Asthesy Compression Syndrome

Theme of call (n=22)

Referral 3/22, 14% responses

• need for referral and/or imaging.

• Should this patient be seen by vascular surgery

• Plan = sent to ER for assessment Diagnosis & testing 4/22, 18% responses

• Review CTA and R/O Vascular Cause for pain

• Investigation and management

• Does pt. need further investigation

• Investigation of the groin pain Medication 4/22, 18% responses

• Treatment f/u

• Type II Endo leack

• Treatment f/u

• medical treatment Management 11/22, 50% responses

• Are investigation and referral necessary?

• management of carotid stenosis (x2)

• management of foot ulcers

• Management of worsening symptoms

• Management of 94 y o with Foot ulcer

• Severe claudication? management

• u/s findings? management

• management (x3)

55 May 21, 2019

Specialist LINK

REFERENCES

Alberta Health Services (2018) Specialist LINK evaluation, Specialist LINK Survey Calgary Zone, Health System

Evaluation and Evidence, Innovation and Research Management

Alberta Health Care Insurance Plan (2018): Schedule of Medical Benefits. https://open.alberta.ca/ publications/somb-2018-11-01

Alberta Medical Association Fee Navigator: https://www.albertadoctors.org/fee-navigator

Area of coverage (2019), Report response on specialty concern receiving calls from outside the Calgary Zone

Calgary Zone Primary Care Action Plan (CZPCAP,2012)

CFPCN (2018), Specialist LINK survey section, Annual Report

HSS (2016), Health System Support Project Charter

Specialist LINK (2018) Calgary Zone Annual Physician Survey, family physician survey completed by AHS

Specialist LINK (2019) Cost Analysis Report

Specialist LINK (2019) Updated website: https://www.specialistlink.ca/

Tech Talk(2018): CFHI :Connecting Primary Care and Specialty Care in Calgary, https://www.cfhi-

fcass.ca/OurImpact/improvement-conversations/connecting-primary-and-specialty-care-in-calgary