Should the Mandatory Health Referral System be Implemented in Türkiye? A Perspective from a Tertiary Pulmonology...

Providing care at the appropriate level is key to cost-effective healthcare. In Türkiye, a mandatory referral system has not yet been implemented. This study aimed to determine the proportion of cases presented to a tertiary outpatient clinic that genuinely required tertiary-level care and to analyze their characteristics compared with those better suited for management at lower levels of care.

This observational study included 692 patients (mean age: 54±15 years; 51% male) who attended two pulmonologists' outpatient clinics. Data on demographics, reasons for application, and all institutions to which individuals applied (primary, secondary, tertiary) for chest conditions within the previous 12 months were collected. After clinical evaluations, the appropriate level of care for each case was assessed.

Overall, 70.2% (n = 486) of cases bypassed primary care. While 10.7% (n = 74) required tertiary-level care, 66.3% (n = 459) required secondary-level care. Emergency departments (30%, n = 208) were visited more frequently than family physicians (29.6%, n = 205). Among cases seen in primary care, 11% were referred to higher-level care. The most common diagnoses were asthma and chronic obstructive pulmonary disease (56.8%; n = 394). While 46% (n = 318) of all cases received prescriptions or follow-up, 18.6% (n = 129) required interventions. Among the cases, 70.1% avoided non-teaching public hospitals, while 15% (n = 104) made more than 10 return visits to the study hospital.

Approximately 70% of cases presenting to a tertiary pulmonology center could have been managed at lower levels of care. Healthcare policymakers should urgently implement sustainable solutions to address the factors that impede the referral chain.