Referral for Outpatients Urological Services: Poor Conformity and Pre-referral Evaluation in Western Kenya

Background: This study was aimed at establishing the degree of conformity with the referral system, level of pre-referral investigative evaluations and degree of diagnosis concordance between the referring centres and the referral hospital in Western region of Kenya.
Methods: This was a hospital based descriptive, prospective, cohort study. The Urology Outpatient clinic of Moi Teaching and Referral Hospital (MTRH), a 750 bed tertiary centre in the Western region of Kenya catering for approximately half of the Kenyan population. Ninety-four first time attendees to the urology clinic seen in the year 2011. The primary outcome measures were conformity with the referral system and the level of investigative evaluation prior to referral. The secondary outcome measure was comparison between peripheral centre diagnosis and the diagnosis made at the referral hospital.
Results: There was a predominance of males attending the urology clinic with the male to female ratio of 14.7: 1.Over a third (36.2%) of the patients were referred with the top three referring facilities being District Hospitals (47%), Private Clinics (26.5%) and Mission Hospitals (11.8%). The factors that correlated with likelihood of being referred were the administrative origin of patient (p <0.001), the centre attended (p <0.001), the diagnosis made (p<0.001) and the age group (p=0.010). On multivariate analysis, the greatest determinants of the need for referral were the centre attended and the diagnosis made (both p<0.001). The diagnosis made was found to be the most powerful predictor of likelihood for referral. The majority (88.2%) of the patients had clearly defined diagnoses from the referring centres but only 7.4% had preliminary investigations prior to referral. There was a 76.7% concordance and 11.5% discrepancy in diagnosis between the referring centre and the referral hospital.
Conclusion: The diagnoses made by the referring centres are correct in about three quarters of the referrals but conformity with the referral system and the level of preliminary investigations prior to referral are appallingly low.