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Original Paper
Analysis of the demand of care from Primary Care to Traumatology: Proposals for the improvement of the continuous care
Análisis de la demanda asistencial desde atención primaria a traumatología: propuestas para la mejora del continuo asistencial
H. Fidalgoa, C. da Casaa, R. Bustoa, Á. Vega Suárezb, J.F. Blancoa,c,
Corresponding author
jfblanco@usal.es

Corresponding author.
a Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
b Gerencia de Atención Primaria de Salamanca, Servicio de Salud de Castilla y León (SACYL), Salamanca, Spain
c Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Salamanca, Salamanca, Spain
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is still pending&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In a previous study&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> our group reported great variability in referral rates to TOS between health centres<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> in the Salamanca Health Area&#46; This variability could not be put down to epidemiological reasons&#46; This means that the healthcare capacity&#44; in the case of TOS&#44; may be compromised in situations of high demand or limited resources&#44; as it is one of the specialties that is most in demand&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#8211;8</span></a> This variability may lead to dysfunction resulting in delays in the care of patients referred from PC&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of the present study was to analyse referrals from PC to TOS&#44; with special emphasis on referral rates and referral priority&#44; and to compare them with the referral ratio to other specialist care services&#46; The secondary objective&#44; based on the values of the referral rate spectrum&#44; was to construct 2 referral scenarios as a benchmark to improve the process of continuity of care&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We designed a cross-sectional observational study&#46; For the present study&#44; all referrals from PC to TOS in the Salamanca Health Area during the first semester of 2018&#44; 2019&#44; and 2021 were analysed &#40;<a class="elsevierStyleCrossRef" href="#sec0050">Fig&#46; 1 of the supplementary material</a>&#41;&#44; and the priority of the referral &#40;routine&#44; preferential&#44; or urgent&#41;&#46; The data for the first half of 2020<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> were analysed in a parallel study&#44; given the bias caused by lockdown during the SARS-CoV-2 pandemic&#46; Referrals to TOS from other specialist care and emergency departments were not included in this study&#46; The data were obtained from the register of requests for TOS consultations from all health centres in the Salamanca Health Area&#46; This register shows the centre from which the referral originated&#44; the physician requesting the consultation&#44; the priority &#40;routine&#44; preferential&#44; and urgent&#41; and the clinical reason reflected in the request&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We examined the number of referrals issued by each doctor and each health centre&#46; We grouped the different basic health zones &#40;BHA&#41;&#44; according to the size of the population centre to which they provide health care&#44; into rural &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#44; semi-urban &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#44; and urban &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41; health centres&#46; The Salamanca Health Area primary care management provided the population assigned to each centre and PC practitioner during the periods studied&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Referrals during the first half of 2019 to other specialist care services&#44; such as cardiology&#44; neurology&#44; and general and digestive surgery&#44; were also analysed to establish differences with respect to TOS&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The entire study was conducted in accordance with the Declaration of Helsinki&#44; with the approval of the Ethics Committee for Research involving Medicines &#40;CEIm&#41; of the Salamanca Health Area &#40;reference code&#58; PI 2020 01 415&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">RStudio v&#46; 4&#46;1&#46;1 was used for the statistical analysis&#46; Results are expressed as percentages&#44; or mean and standard deviation&#44; and 99&#46;9&#37; confidence interval &#40;CI&#41;&#46; The monthly referral ratio was calculated using the number of referrals divided by the number of patients assigned per 1000&#44; divided by the number of months in which that physician was recorded as working in that health centre&#46; The <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test was used for the differential analysis of qualitative analysis&#44; adding the Bonferroni correction&#46; The distribution of quantitative variables was assessed using the Kolmogorov&#8211;Smirnov test and these were compared using ANOVA and Student&#39;s <span class="elsevierStyleItalic">t</span>-test or non-parametric tests&#46; Post hoc pairwise comparisons were also made using the Bonferroni method&#46; Wilcoxon&#39;s rank-based test was used for the frequency trend analysis of referrals&#46; In all cases&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#46;05 was considered statistically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">There was a total of 6914 patient referrals to TOS from PC during the first half of 2018&#44; which decreased to 6246 in 2019&#59; in 2021 the total stood at 5664&#46; This translates into an mean monthly patient referral per 1000 inhabitants of each Salamanca Health Area BHA of 3&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;70 in 2018&#44; 3&#46;30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83 in 2019&#44; and 2&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;03 in 2021 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;040&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Regarding the characteristics of the population referred to TOS&#44; the mean age of the patients referred over the 3 periods studied was 52&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;4 years&#44; and 59&#46;4&#37; were women&#46; The priority of the referrals analysed is summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Bonferroni post hoc analysis revealed that the frequency of preferential and routine referrals was significantly higher in 2018 compared to 2019 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and 2021 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The mean monthly referral ratio of patients per 1000 inhabitants was homogeneously distributed among the different types of BHA in 2018 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#44; but not in 2019 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; or 2021 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0050">Table 1 supplementary material</a>&#41;&#46; However&#44; when analysing the mean referral ratio per health centre&#44; regardless of the type of BHA&#44; we found that in 2018 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41; in 2019 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and in 2021 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; there are statistically significant differences that show great variability&#44; as their behaviour is heterogeneous over the 3 years &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">We found that this variability between the different types of BHA is not attributable to epidemiological factors such as sex&#44; age of patients&#44; or reason for referral &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;05 in all cases&#41;&#46; However&#44; we found significant individual variability between referring PC physicians &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; During the study period&#44; referrals to TOS were made by 384 PC physicians in 2018&#44; 378 in 2019&#44; and 379 in 2021&#46; The mean monthly referral ratio per 1000 population per physician was 3&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;69 in 2018&#44; 3&#46;30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83 in 2019&#44; and 2&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;03 in 2021&#46; The distribution of the monthly referral ratio per 1000 inhabitants per physician&#44; distinguishing between the different types of BHA from which they originated&#44; is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; We found that in 2018 the mean referral ratio per 1000 inhabitants of rural BHA was 3&#46;24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;73&#59; in semi-urban BHA it was 3&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;87&#44; and in urban BHA it was 3&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;53 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; In 2019 the mean referral ratio per 1000 inhabitants in rural BHA was 3&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;69&#44; in semi-urban BHA it was 4&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;51&#44; and in urban BHA it was 2&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;32 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Finally&#44; in 2021 the mean referral ratio in rural BHA was 3&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;38&#44; in semi-urban BHA 3&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;09&#44; and in urban BHA 2&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;13 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; The great heterogeneity in the behaviour of referring physicians was maintained through 2021&#58; while 41&#46;0&#37; presented referral ratios below the lower limit of the 99&#46;9&#37; CI of the mean &#40;1&#46;62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;63&#41;&#44; 29&#46;9&#37; showed referral ratios three times as high &#40;4&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;51&#41;&#44; regardless of their type of BHA&#46; If we analyse in depth the trend in the frequency of referral of the physicians above the 90th percentile of the monthly referral ratio&#44; i&#46;e&#46;&#44; the physicians with the highest referral ratio&#44; we find that the PC physicians who refer the most patients per month to TOS are repeated throughout the study &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Given the large number of physicians above the upper limit of the 99&#46;9&#37; CI of the mean referral ratio per 1000 inhabitants &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> blue dashed line&#41;&#44; we considered remodelling the distribution of the referral ratio per physician&#44; adjusting it to values considered reasonable&#44; i&#46;e&#46;&#44; reducing the number of referrals of the physicians who refer the most&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Thus&#44; we constructed scenario 1&#44; in which we adjusted the referral ratio of physicians exceeding the upper limit of the 99&#46;9&#37; CI of the mean to this same interval &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; blue dashed line&#41;&#46; This would mean decreasing the monthly referral rate in 2018 from 69 physicians in rural BHA&#44; 18 in semi-urban BHA&#44; and 40 in urban BHA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#59; in 2019 the monthly referral rate would have been reduced for 72 physicians in rural BHA&#44; for 15 physicians in semi-urban BHA&#44; and for 42 physicians in urban BHA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#59; in 2021 the monthly referral rate would have been reduced for 48 physicians in rural BHA&#44; for 18 physicians in semi-urban BHA&#44; and for 47 physicians in urban BHA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; In this scenario 1 we obtain a new mean referral ratio &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; scenario 1&#41;&#46; Similarly&#44; this scenario 1 would imply a reduction of 168 referrals per month &#40;14&#46;7&#37;&#41; in 2018&#44; 177 referrals per month &#40;16&#46;0&#37;&#41; in 2019&#44; and 162 referrals per month &#40;12&#46;8&#37;&#41; in 2021&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Following this methodology&#44; we propose scenario 2&#44; in which the referral ratio per physician is adjusted to the lower limit of the 99&#46;9&#37; CI of the mean referral ratio per 1000 inhabitants &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; orange dashed line&#41;&#46; This would decrease the monthly referral rate of 145 physicians in rural BHA&#44; 49 physicians in semi-urban BHA&#44; and 67 physicians in urban BHA in 2018&#59; in 2019 the monthly referral rate would have been reduced for 88 physicians in rural BHA&#44; for 18 physicians in semi-urban BHA&#44; and for 61 physicians in urban BHA&#59; and in 2021 the monthly referral rate would have been reduced for 142 physicians in rural BHA&#44; for 47 physicians in semi-urban BHA&#44; and for 94 physicians in urban BHA&#46; We obtain a new mean referral ratio&#44; shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> &#40;scenario 2&#41;&#46; Similarly&#44; this scenario 2 would imply a reduction of 426 referrals per month &#40;37&#46;2&#37;&#41; in 2018&#44; 500 referrals per month &#40;45&#46;2&#37;&#41; in 2019&#44; and 482 referrals per month &#40;38&#46;3&#37;&#41; in 2021&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We also analysed the monthly referral ratio of patients per 1000 inhabitants to other specialties &#40;cardiology&#44; neurology&#44; general and digestive system surgery&#41; in the Salamanca Health Area&#46; We found that&#44; once again&#44; the trend in the frequency of referral per physician does not follow a random pattern&#44; but rather that the physicians who refer the most patients to TOS are also among the physicians who refer the most patients to other specialties &#40;cardiology&#58; &#8745; 32&#46;4&#37; with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#59; neurology&#58; &#8745; 24&#46;3&#37; with p &#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#59; general surgery&#58; &#8745; 35&#46;2&#37; with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; and digestive system&#58; &#8745; 18&#46;9&#37; with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; This confirms the importance of the individual factor in the variability of referrals&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The present study gives an analysis of the origin of a total of 18&#44;824 referrals made from PC to TOS in the Salamanca Health Area during the first half of 2018&#44; 2019&#44; and 2021&#44; which represents more than 5&#37; of the population of the Salamanca Health Area over the study period&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> The year 2020 was excluded from the study due to the exceptional epidemiological situation&#44; although we have included data relating to 2021&#44; when some of the restrictions were maintained&#46; In 2021 &#40;first semester&#41; there was a decrease in the total number of referrals&#44; which we consider to be influenced by the epidemiological situation and the persistence of face-to-face care in the health centres&#46; On 24 May 2021&#44; the return to face-to-face care was ordered and protocols were established for face-to-face consultations in health centres throughout Spain&#59; on 25 May&#44; this decree began to be implemented in all of them&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Throughout the period analysed&#44; we found a great variability in the referral ratio between the different types of BHA&#44; and between the physicians working in them&#44; confirming that there is great heterogeneity&#46; This variability in referrals is not due to epidemiological issues &#40;such as sex&#44; age&#44; or reason&#41;&#44; but to the individual judgement of the physician&#46; Furthermore&#44; although the demand for the TOS service is high&#44; when we analyse referrals to other hospital services&#44; we see that the physicians who refer the most patients to TOS coincide with those who refer the most to other services&#46; Therefore&#44; this referral trend is not random&#44; but will always be conditioned by individual criteria&#44; which is maintained uniformly over time&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Gender variability has also been observed between the general population &#40;around 50&#37; women&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> and the population of patients referred from PC to TOS&#44; possibly because the female gender is more frequently affected<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> by some pathological processes which are the reason for referral&#44; such as osteoarthritis and osteoporosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#8211;15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">From analysis of the priority of the referral to TOS&#44; we deduce that it behaves independently throughout the study period&#46; The number of routine and preferential referrals vary from year to year&#44; while only urgent referrals remain stable over the years&#46; Nevertheless&#44; preferential referrals represent a very high percentage&#44; according to data from the Centre for Analysis and Treatment of Healthcare Information &#40;CATIA&#41; of the SACYL&#58; in the first half of 2021 there were a total of 36&#44;217 routine referrals and 11&#44;139 preferential referrals&#44; of which 15&#46;7&#37; correspond to TOS&#46; This makes us consider the excess demand for preferential consultations which&#44; perhaps&#44; are not due to clinical reasons but potential delay in care provided in TOS&#46; In a previous study&#44; we found that only 7&#46;8&#37; of the 30&#46;7&#37; preferential referrals were for preferential clinical reasons&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">A series of protocols were implemented in 2018 for the referral of patients with low back pain&#44; neck pain&#44; and painful shoulder&#46; Although the data collected cannot accurately establish the direct effects of implementing these protocols&#44; they do not appear to have had a major impact on the health centres making the most referrals&#46; The human and material resources of public health systems are limited&#44; and therefore their efficient use is fundamental to maintaining their sustainability&#46; Thus&#44; improving the criteria for patient referral from PC could lead to a reduction in the number of consultations required to meet this care demand and&#44; in turn&#44; would allow resources to be allocated to other care activities&#44; such as surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> where waiting times distort the quality indicators of the National Health System&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Therefore&#44; we created 2 scenarios of a decrease in the number of referrals and considered the consequences of these scenarios based on the values of the referral rate spectrum&#46; The first scenario takes the mid zone of the referral rate spectrum as a benchmark&#46; In the second scenario&#44; our benchmark is the ideal values that correspond to the lowest recorded referral rates&#46; Both scenarios result in a reduction in the referral ratio&#46; If these models could be achieved&#44; waiting times in consultations could be reduced since&#44; for example&#44; in the first scenario we would have 8 consultations per month to bring forward appointments or we could dedicate those 8 doctors to surgical activity&#46; In the second scenario&#44; which is certainly an ideal scenario&#44; the reduction in waiting times would be very significant &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">In view of these findings&#44; it is essential to introduce tools and objective criteria for assessing referrals&#44; and to instil in the physicians making the most referrals the need to reduce their referral ratio&#44; taking as the benchmark ratios of physicians who make reasonable or even low referrals&#46; This would improve the continuity of care process&#44; not only in the direction of referrals from primary care to TOS but also in the response from the hospital service&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study is not without limitations&#44; however&#46; Firstly&#44; the data we report refer to a specific context in the Salamanca Health Area&#44; therefore studies at national level would be necessary to extrapolate the scenarios presented here&#46; Likewise&#44; we have not analysed the specific context of the health centres&#44; training plans&#44; clinical sessions&#44; or to hospital service accessibility&#44; which could partly explain the variability between centres&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">There is great variability in the referral of patients from PC to TOS&#44; which is largely conditioned by an individual factor or criterion&#46; We find similar findings when we analyse referrals to other hospital services&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The decrease in variability shown in the 2 scenarios considered would imply a decrease in the demand for care that should improve the efficiency of TOS services&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Level of evidence</span><p id="par0130" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">ii</span>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">No specific support from public sector agencies&#44; commercial sector or not-for-profit organisations was received for this research study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interest&#46;</p></span></span>"
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    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyse referrals from Primary Care consultation to Orthopaedic Surgery reference department&#46; As a secondary objective&#44; to establish 2 referral scenarios in order to determine the impact of variability on referral&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional observational study&#44; analyzing referrals from Primary Care to Orthopaedic Surgery during the first half of the years 2018&#44; 2019&#44; and 2021&#46; The number of referrals issued by each doctor and each Primary Care Healthcare Center was examined&#44; according to the classification of the different Basic Healthcare Zones&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There is great variability in the number of referrals&#44; both according to the type of Basic Healthcare Zone and by each Primary Care facultative&#46; The referral ratios behaved uniformly over time &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Due to a large number of referrals&#44; 2 scenarios have been constructed&#58; In the first scenario&#44; the referral ratio would be in the middle of the referral rate spectrum&#46; In the second scenario&#44; the lowest referral ratios recorded have been taken as a reference&#46; The reduction of variability in the 2 scenarios assumed provides a significant reduction in the demand for care&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reducing variability would have a beneficial effect on the capacity of the Orthopaedic Surgery service to provide care&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar las derivaciones dirigidas desde atenci&#243;n primaria a cirug&#237;a ortop&#233;dica y traumatolog&#237;a&#46; Como objetivo secundario&#44; establecer dos escenarios de derivaci&#243;n&#44; con el fin de conocer el impacto de la variabilidad en la derivaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional de car&#225;cter transversal de an&#225;lisis de las derivaciones de atenci&#243;n primaria a cirug&#237;a ortop&#233;dica y traumatolog&#237;a durante el primer semestre de los a&#241;os 2018&#44; 2019 y 2021&#46; Se ha examinado el n&#250;mero de derivaciones que emite cada facultativo y cada centro de salud de atenci&#243;n primaria&#44; atendiendo a la clasificaci&#243;n de las distintas zonas b&#225;sicas de salud&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Existe una gran variabilidad en el n&#250;mero de derivaciones&#44; tanto seg&#250;n el tipo de zona b&#225;sica de salud &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; como por cada facultativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Las ratios de derivaci&#243;n se comportan de forma uniforme en el tiempo &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Debido al alto n&#250;mero de derivaciones&#44; se han construido dos escenarios&#58; en el primero de ellos la ratio de derivaci&#243;n se situar&#237;a en la zona media del espectro de la tasa de derivaci&#243;n&#46; En el segundo escenario se han tomado como referencia las menores ratios de derivaci&#243;n registradas&#46; La reducci&#243;n de la variabilidad en los dos escenarios supuestos proporciona una disminuci&#243;n importante de la demanda asistencial&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La reducci&#243;n de la variabilidad tendr&#237;a un efecto beneficioso sobre la capacidad asistencial del servicio de cirug&#237;a ortop&#233;dica y traumatolog&#237;a&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
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      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0150" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0050"
          ]
        ]
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Box plot representing the monthly referral rate per 1000 inhabitants of each of the health centres in the Salamanca Health Area during the first half of 2018 &#40;A&#41;&#44; 2019 &#40;B&#41;&#44; and 2021 &#40;C&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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            "Tamanyo" => 434690
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Monthly referral ratio per 1000 inhabitants of primary care physicians &#40;standardised frequency histogram&#41;&#44; according to the demographic classification of the basic health area of origin&#44; in the first half of 2018 &#40;A&#41;&#44; 2019 &#40;B&#41;&#44; and 2021 &#40;C&#41;&#46; From left to right&#58; rural BHA &#40;green&#41;&#59; semiurban BHA &#40;orange&#41;&#59; urban BHA &#40;blue&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Workflow&#44; showing the year of study&#44; and the savings in referrals after applying scenario 1 and scenario 2&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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        "mostrarDisplay" => false
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">p</span> &#40;across groups&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6914&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6246&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5662&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Priority of referral n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Routine&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4249 &#40;61&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4232 &#40;67&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3838 &#40;67&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Preferential&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2561 &#40;37&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1926 &#40;30&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1754 &#40;31&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Urgent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">104 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;542&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span> &#40;intra-group&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Priority of referral in the first half of 2018&#44; 2019&#44; and 2021&#44; comparing by year and across years&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Urban BHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ratio x&#175;&#177;&#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;89&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;76&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ratio x&#175;&#177;&#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;77&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;56&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t  " rowspan="3" align="left" valign="\n
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                  \t\t\t\t">Scenario 2</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;59&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ratio x&#175;&#177;&#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#46;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;27&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ratio x&#175;&#177;&#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>&#46;45&nbsp;\t\t\t\t\t\t\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos