Assessing referral quality among primary care paediatricians within Cyprus’ general health system

Abstract Background Five years after the implementation of the General Healthcare System (GHS) in Cyprus, and as part of its broader quality assurance strategy, the Health Insurance Organization (HIO) introduced quality indicators for Personal Physicians (PPs). High-quality referral practices are essential for timely and appropriate specialist care for children. This study aimed to evaluate the quality of referrals from Personal Physicians for children (PPCs, i.e. paediatricians), to identify gaps, and to support system-level improvements. Methods From September 2023 to July 2024, referrals were audited using two sampling strategies: (1) representative sampling and (2) targeted sampling of PPCs with the highest monthly referral volumes. Referrals were evaluated across three domains: clinical actions prior to referral (max: 23), clarity of referral reason (max: 7), and appropriateness (max: 20). The scoring system allowed a maximum of 50 points with 30 as the threshold for a successful referral. Due to limited relevance to paediatric care, three criteria were excluded from the original scoring system for adult PPs, yielding a modified maximum score of 43 points and a new threshold of 26. Analyses included descriptive statistics, t-tests, and regression models (STATA 18). Results A total of 1,229 referrals from 45 PPCs were evaluated. PPCs in the top-referral group scored significantly lower (mean: 26.3 points) than those in the representative sample (29.8 points; p < 0.05). Older PPC were associated with higher referral quality, while greater visit volume was associated with lower quality. Pre-referral documentation had the lowest domain score, though most referrals met minimum thresholds. Modified scoring showed similar trends. Conclusions Referral quality varied across PPCs, with younger, high-volume providers scoring lower. Findings support enhanced monitoring, revised criteria, and targeted training. Future research should assess its impact on referral quality. Key messages • Age of Personal Physicians for children was positively associated with referral quality score, while visit volume was associated negatively. • Improved referral quality among Personal Physicians for children requires education strategies and enhanced audit policies to promote better clinical documentation and appropriate referral practices.