This phenomenon is well understood in health where specific targets, for example referral-to-treatment times in selected conditions or A&E waiting times, suck up resources so things get worse elsewhere.
For example, referral to a sexologist or psychologist may be necessary in case of relationship problems or sexual abuse [ 44].
Interestingly, there were no significant differences between the cases (mean 1.2, SD 2.8) and the controls (mean 0.7, SD 1.8) p=0.515 regarding callers' requests for service, for example, referral to a doctor.
Local variation in practice, for example referral rates to secondary care or procedures for avoiding inpatient admissions, can greatly influence the cost of providing an intervention.
Example 3: Patient referrals to tertiary care, frequently occurring in the Netherlands, may cause differences.
For example, this included referrals to substance misuse services or psychiatric support for active symptoms of psychosis.
For example, earlier referral to PC services has been shown to reduce ED presentations amongst both adult and paediatric patients when compared to usual care [20,38].
16 This is even lower than reported in our study, but these patients were recruited by general practitioners, and thus may have subsequently received dietary therapy later on in the care trajectory for example, after referral to an orthopaedic surgeon.
For example, a referral to dermatology about a fast-growing keratising skin lesion that does not include body mass index or blood pressure in the letter may still have sufficient essential information.
In order to exclude the potential impact of centre-specific variations in healthcare practice, for example referrals for revascularization, we conducted a sensitivity analysis using a composite endpoint restricted to cardiovascular mortality, non-fatal myocardial infarction and non-fatal stroke.
