Identification and Ranking of the Reasons for not Referring Patients from Level 1 to Level 2 through Electronic Referral System of Golestan Province in 2019

Background: The public sector of the health care system provides justice and access for all people who need more specialized services through the referral system. If the challenges of the referral system are not identified and addressed promptly, the system will not be efficient and effective. The purpose of this study was to rank the reasons for non-referral of outpatient level 1 to level 2 in the electronic referral system of Golestan province in 2019. Methods: In this descriptive and cross-sectional study, 431 outpatients participated from the pilot hospitals of the e-referral system in Golestan province, who did not refer to the level 2 specialist despite that an appointment was set by the system. The participants were selected using a stratified random sampling method. Data were collected using a questionnaire and analyzed by descriptive statistics and Friedman test in SPSS 23 software. Results: The most important reasons for patients who were not referred from level 1 to level 2 in the electronic referral system included the presence of a trusted and familiar physician, inability to pay the visit of a specialist, and high cost of transportation from home to the designated specialist, respectively. The gender of the specialist physician and lack of guidance on referral to the specialist physician were indicated by the referral center. Patients ranked the reasons of not referring to the specialist differently (P < 0.001). Conclusions: The current status can be improved by increasing the public confidence in specialized physicians working in the electronic referral system and making the specialized services free for the poor patients. Furthermore, raising the patientchr('39')s awareness about using Level 2 specialized services through the mass media can help patients to benefit from these services.