Prevalence and determinants of self referrals to a District-Regional Hospital in KwaZulu Natal, South Africa: a cross sectional study

Introduction Self-referrals to inappropriate levels of care result in an increased patient waiting time, overburdening of higher levels of care, reduced primary healthcare utilisation rate and increasing healthcare costs. Furthermore, self-referral places an additional encumbrance on various levels of care as allocation of resources and infrastructure cannot be accurately planned, based on the facility catchment population. The aim of this study was to determine the prevalence and determinants of patient self-referral at the out-patient department of Stanger Hospital, KwaZulu-Natal between January and June 2017. Methods A cross-sectional study was conducted at the out-patient department in Stanger Hospital, using interviewer administered questionnaires to collect information from 385 patients, through convenience sampling, between January and June 2017. Multivariable regression analysis was used to test for factors associated with self-referral. Results of the 385 patients interviewed 36% (n = 138) were self-referrals. Most of the self-referrals were male (51.5%) and of the African race (57.2%). Five institutional factors namely: care received from healthcare workers (91.3%); waiting times (88.4%); help offered (87%); treatment and attitude of healthcare workers (63%) and availability of medication (55.8%) were considered as the main drivers of self-referral. Multivariable regression analysis established a significant positive association between patient self-referral and age (40 years and below), attitude of healthcare workers, quality of care received form healthcare workers, waiting times and the availability of diagnostic tests. Conclusion This study indicates that most patients attending Stanger Hospital do comply with the prescribed referral pathway, however a significant proportion still bypass the referral system.


Introduction
Guided by the Sustainable Development Goals (SDG) [1], Goal 3 and the National Development Plan (NDP) 2030 [2], the National Department of Health (NDoH) has commenced with the implementation of the National Health Insurance (NHI) as a mechanism to achieve Universal Health Coverage (UHC) [3].
Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship [4]. A wellfunctioning referral system that allows for continuity of care across different tiers of care is central to the delivery of efficient and effective health care and achieving universal health coverage. The Public healthcare system in South Africa is organised in a hierarchical manner with the district health system (DHS) based on the principles of primary health care (PHC) [5] forming the base of the pyramid.

Ward Based Outreach PHC teams and Integrated School Health
Teams offer health education, health promotion and screening at a community level, whilst the District Clinical Specialist team provide mentoring, supervision, clinical supportive and outreach services for PHC clinics [6]. The PHC clinic is the first formal point of contact with the health services. Patients will be able to present at the PHC clinics with any health care requirement (whether for promotive, preventive, curative; rehabilitative, palliative or community-based mental health) and will either receive the care they need based on the defined package of services at this level or will be referred to a hospital if more specialised services are necessary ( Figure 1).
District hospitals form part of the district health system, support primary health care on one hand, and act as a gateway to more specialist care on the other. The district hospital provides level 1 (generalist) services to in-patients and outpatients (ideally on referral from a community health center or clinic) [7]. In some circumstances primary health care services are rendered at the district hospital where there is no alternative source of this care within a reasonable distance [7]. A hierarchical referral relationship between the various levels of hospitals with patients being referred from district hospitals to regional hospitals then to Provincial tertiary hospitals and if required to National Referral Hospitals and Central Hospitals. Specialist, Regional (Level 2), Tertiary (Level 3) and Central (level 4) hospitals provide specialist and sub-specialist services in terms of a defined package of service. A referral system is a comprehensive health care system used to manage client health care needs by referring clients from an initiating facility to an organization, service, or community unit that can better provide the level of care needed. For a referral system to work at its best, all levels of the healthcare delivery system need to be functioning appropriately. Each facility needs to be clear about its role, responsibilities and limitations; have protocols of care for conditions that are specific for that level of service readily available and have suitable means of communication and transport to access support from other levels of care. In 2008, an assessment of the strategic challenges experienced within the South African public health sector revealed numerous systemic problems and concluded that patients were accessing the health system at inappropriate levels and bypassing PHC clinics to attend higher levels of care for their initial visit. This resulted in patients receiving PHC services at regional and tertiary hospitals thus incurring unnecessary costs to the facility [8]. The Kwa-Dukuza municipality services 77% of the district population, but has a low PHC utilisation rate [9]. As Stanger Hospital is the only regional hospital in the Ilembe district and the only hospital in the Kwa-Dukuza Municipality it experiences an influx of patients with medical problems that would be more appropriately managed by the PHC facilities. In 2015, 30,945 patients were self-referred to the hospital [10]. This increased patient load results in increased waiting times for all patients and an increased workload for the affected categories of staff. In the current era of scarce resources, it is important to understand the proportion of patients that are self-referred or inappropriately referred to Stanger Hospital as well as understand the associations between the various factors that affect the referral process. Understanding the referral system and factors associated with compliance are imperative for effective and efficient healthcare planning.

Methods
Study design and setting: a cross-sectional study was conducted at the out-patient department of Stanger Hospital-a 500-bedded regional and district hospital which offers 25 out-patient services. The hospital serves an estimated population of 600 000 from the district. Study population and sampling: a sample size of 385 was calculated using Yamane's formula: n = N/1+N(e)^2 [11]. Using a precision of 5% at the 95% confidence level [12]. Non-probability convenience sampling was used for selecting patients from any of the outpatient departments at Stanger Hospital between January and June 2017. Socio-demographic profile of study population: the mean age of the referred and self-referred patients was 44.7 years (SD: 13.3) and 40 years (SD: 14.9) respectively. More males (51.50%, n = 71) self-referred than females (48.50%, n = 67). Majority of the referrals and self-referrals were Black African (67.60%, 57.20%) and Indian (30.00%, 37.00%) respectively. Only two patients (1.50%) in the self-referred group had no formal education however more patients (15.20%, n = 21) in the self-referred group had a tertiary education compared to (7.70%, n = 19) the referred group. One hundred and thirty two patients (53.40%) in the referred group received a salary/ wage in contrast to 43.50% (n = 60) in the self-referred group.
Similar to the study population, 68.00% (n = 168) of the patients in the referred group and 66.70% (n=92) in the self-referred group; claim to visit their local clinic first if healthcare is required. A small proportion of patients (1.60%) across both groups reported that they had previously been refused hospital care (Table 1).  found to be protective factors (Table 3).

Discussion
The KwaZulu Department of Health has set targets of 7.5% and 6.5% respectively for "new case not referred"; during 2015/16 and 2016/17 in order to improve the operational efficiency of the healthcare delivery system. The findings of the current study (36%) are 3.6 times higher than the current reported rate of 10%, as indicated by the KZN DOH [13]. This is likely attributed to Stanger Hospital being the only regional hospital in the Ilembe district and the only hospital in the This may be accredited to older patients experiencing more difficulty travelling or having stronger ties with local professionals [28]. More males (51.5%; n = 71) self-referred than females (48.5; n = 67). This finding is similar to an Ethiopian study [29] and two US studies that reflected that males who are employed tend to bypass the referral However, these findings are contrary to studies conducted in Brazil and Kenya which showed that a higher percentage of females utilised the A&E department more frequently and inappropriately [33,34]. In addition, local studies have consistently reported a higher proportion of females who self-refer. In a KZN study conducted in the Umuziwabantu sub-district, 77% of females had self-referred to a district hospital [22] whilst a study based in the Greater Tzaneen municipality showed that 68% of self-referrals were female [27]. The higher proportion of female self-referral may be due to females having an increased health-seeking behaviour when compared to males [35] and possibly because of the perception of quality maternal and newborn health services offered particularly during delivery [36].
Some studies have indicated that the difference in perception of health risk between males and females can contribute to the phenomenon of bypassing [37]. This study did not find any significant association between a patients level of education (high school patients with higher levels of education were more likely to selfrefer [38,39] however the inverse was established in middle to lower income countries [18,29]. The findings from a 2015 study, conducted at the Dilokong Hospital, noted that 31.4% of the unemployed patients self-referred as opposed to 24.7% of the employed patients, however this factor was not significant after statistical analysis [40].
Similar findings were observed in other South African studies were over half of the self-referrals were unemployed [22,27]. In addition, US and Dutch study found a trend between patients from higher socio-economic class and self-referral [41,42] [27]. These findings indicate that patient self-referral may be driven by a perception of lack of medication at local clinics. This false perception increases the likelihood to self-refer, resulting in underutilised PHC services.
Study limitations: although due diligence was maintained to ensure the integrity of the study, the findings of the study are influenced by a number of limitations. These included amongst other the reluctance of patients to participate and/or reluctance to disclose all information as they may have felt that it would negatively impact their current/ future healthcare service. In addition the study design provided only a snap shot of the determinants of self-directed referrals among a sample of patients attending Stanger Hospital and the study was conducted over a period of six months.

Conclusion
The majority (64%) of patients seeking medical attention in the study were adherent to the prescribed referral pathway; while only 36% self-referred during the study period. Multivariable regression analysis Furthermore the use of an electronic health record will serve as a tool to assure patients of the continuity of care that will be received even if they are consulted at the nearest PHC facility.
What is known about this topic  A referral system is a comprehensive health care system used to manage client health care needs by referring clients from an initiating facility to an organization, service, or community unit that can better provide the level of care needed;  For a referral system to work at its best, all levels of the

Competing interests
The authors declare no competing interests.