Patterns and Impact of Consultations to an Endocrinology Unit in a Tertiary Hospital in Southwestern Nigeria.

BACKGROUND: The dearth of endocrinologists in Nigeria, coupled with a paucity of data on patterns of endocrine consultations pose a challenge in evaluating the impact of consultations on patients' management and eventual outcomes. The objectives of this study were to determine the frequency, sources of referrals, the common cases referred, the reasons for consultation requests, and the outcome of patients who benefitted from endocrine consultations.
MATERIALS AND METHODS: This study was carried out in the Endocrinology unit of Babcock University Teaching Hospital, over 9 months. All patients referred to the unit were sampled (total sampling). Their sociodemographic parameters, sources, and reasons for consultations were documented. The patients' case notes were then retrospectively reviewed, to determine the impact of the consultation on their management and outcome.
RESULTS: A total of 108 consults were received throughout the study. Most consultations were requested by the general outpatient clinic (37%) followed by cardiology clinic (12%). The most common reason was to take over management of the patients. Diabetes mellitus accounted for 68.7% of the cases seen. Diagnosis made by the referring physician was confirmed in most cases, new diagnoses or change in diagnosis was reached in 9.3% and 3.7%, respectively. About 39.8% of the patients were lost to follow-up, while 53.8% were in good and fair clinical condition.
CONCLUSION: Most of the cases referred for specialist care were from the general outpatient clinic, had diabetes mellitus, and benefitted from specialist care by the way of advanced investigations and treatments, though about a third were lost to follow-up. It is imperative that a good referral system is maintained among physicians, to ensure that patients get the best care available. Attention must be paid to common causes of patient attrition such as lack of widespread health insurance coverage, to ensure continuity of care.

INTRODUCTION

Endocrine disorders, along with other non-communicable diseases, form an increasing burden of illnesses challenging the developing world, especially with the advances in medical knowledge and technology making it easier to diagnose and manage these illnesses.123 Common endocrine disorders encountered in the Nigerian clinical setting include diabetes mellitus, thyroid disorders, Conn's syndrome, Cushing's syndrome, and Addison's disease.45 Patients with endocrine disorders often have their initial evaluation done by primary care physicians and doctors from other specialties, before eventually ending at the desk of an endocrinologist. Core medical teaching always emphasizes the importance of good communication and referral in medical practice. This has been proven time and again to have tremendous benefits in the management and outcome of patients.6789

Nigeria is a highly populous country of about 190 million people.10 Endocrine disorders such as diabetes mellitus affect up to 5% of the population,11 and contribute up to 10% to medical emergencies in some parts of the country. However, the country only has about 200 endocrine specialists to service this teeming population.12 The implication is that a vast majority of people with endocrine and metabolic disorders are not getting the specialized care that they need. There is a paucity of studies evaluating endocrine consultations in Nigeria, making it difficult to assess the current status, as well as the impact of consultations on patient outcomes.

This study will help highlight the importance of referrals between physicians, in the management of endocrine disorders. Furthermore, this study will help to identify the common endocrine conditions seen by non-endocrinologists and to develop informed strategies to further educate medical practitioners on the immediate management of these illnesses. We anticipate that this study will serve as a baseline from which further research in this area can spring up.

The objectives of this study were to ascertain the frequency of requests for endocrine consultations, to determine the sources of consults, the common cases referred, the reasons behind consultations, and the outcome of patients who benefitted from endocrine consultations.

MATERIALS AND METHODS

This was a retrospective study carried out at the endocrinology, diabetes, and metabolism (EDM) unit of Babcock University Teaching Hospital, a tertiary health institution situated in Ilishan-Remo, Southwest Nigeria. The duration of the study was over a period of 9 months (January–September 2018). The EDM unit as at the time of this study was made up of a consultant endocrinologist, a senior registrar (on rotation), registrars (on rotation), and house officers (on rotation). Patients from different towns and cities across the Southwest region of Nigeria are referred to the unit. Medical emergencies are seen in the emergency room and sent to the medical wards after appropriate triage and resuscitation. Non-emergencies are seen at the endocrinology outpatient clinic following referral from the general outpatient clinic, specialist clinics, or other surrounding health facilities. All final decisions regarding patient management are made by the consultant endocrinologist.

Patients referred to the endocrinology unit during the study were included and followed up throughout the study. Parameters of interest in this study included sociodemographic parameters, location/point of referrals, common reasons for referral, patients' outcomes, and impact of consultation on management. Case notes of the patients were reviewed retrospectively to determine the outcomes of consultations, following management by the endocrinology unit.

Definitions

The impact on diagnosis was defined as:

New endocrine diagnosis made – makes a novel endocrine diagnosis where no previous diagnosis existed

Incorrect diagnosis changed – endocrine consultation leads to a change in an incorrect diagnosis made by the referring physician

Current diagnosis confirmed – diagnosis made by the endocrine unit is congruent with that of the referring physician.

While the impact on the management was defined as:

Adds to management (including requesting relevant investigations and treatment)

No addition to management.

Clinical outcomes:

Good clinical condition – when significant clinical improvement was documented

Fair clinical condition – when some clinical improvement was documented, though not yet optimal

Poor clinical condition – when no clinical improvement or deterioration in clinical condition was documented, or optimum care was hindered by comorbidities, complications, or financial constraints

Dead

Lost to follow-up – In this category, improvement, deterioration, or deaths were not reported, as patients had not returned for follow-up.

The above definitions were developed following review and modification of definitions from similar studies.1314

Ethical approval was granted by the Babcock University Health Research Ethics Committee (BUHREC), with reference number BUHREC653/18.

Data collected were entered and analyzed using IBM Statistical Package for Social Sciences (SPSS) for Windows, Version 21.0, Armonk, NY, and descriptive statistics, generated.

RESULTS

A total of 108 referrals were received throughout the study, averaging about three consults per week. The mean age of the patients reviewed was 53.0 ± 18.0 years; the range was between 17 and 87 years, and majority of the participants were male (50.9%; 55/108).

Most consultations were requested by the general outpatient department (37%; 40/108) followed by cardiology clinic (12%; 13/108), other units accounted for the remaining 51% [Table 1]. There were more outpatient (69.4%; 75/108) than inpatient (17.6%; 19/108) requests, the rest were emergency and external referrals (13.0%; 14/108).

Table 1

Sources of referrals

Source	Frequency (%)
Outpatient
General outpatient clinic	40 (37.0)
Cardiology clinic	13 (12.0)
Neurology clinic	7 (6.5)
General surgery clinic	5 (4.6)
Nephrology clinic	2 (1.9)
Otolaryngology clinic	2 (1.9)
Hematology clinic	2 (1.9)
Gastroenterology clinic	1 (0.9)
Gynaecology clinic	1 (0.9)
Ophthalmology clinic	1 (0.9)
Orthopedics clinic	1 (0.9)
Inpatient
Nephrology unit	6 (5.6)
Cardiology unit	5 (4.6)
Neurology unit	4 (3.7)
Gastroenterology unit	3 (2.8)
Orthopedics unit	1 (0.9)
Accident and emergency	8 (7.4)
External referrals	6 (5.6)
Total	108 (100)

The most prevalent reason for referral was for takeover of management (65.7%), whereas the other reason for referral was for co-management (34.3%) with the referring units.

A final diagnosis of diabetes mellitus accounted for (68.7%; 74/108) of the cases for which consultations were requested. Other diagnoses made are shown in Table 2.

Table 2

Spectrum of endocrine disorders diagnosed after consultation

Case	Frequency (%)
Type 2 Diabetes mellitus	70 (65.0)
Type 1 Diabetes mellitus	4 (3.7)
Diabetes insipidus	3 (2.8)
Distal symmetrical polyneuropathy	1 (0.9)
Galactorrhea	2 (1.9)
Hyperglycemia secondary to chronic pancreatitis	1 (0.9)
Hyperlipidemia	1 (0.9)
Hyperprolactinemia	3 (2.8)
Hypertension secondary to Conn’s syndrome	1 (0.9)
Hyperthyroidism	9 (8.3)
Hypogonadotropic hypogonadism	1 (0.9)
Primary hypothyroidism	2 (1.9)
Metabolic syndrome	2 (1.9)
Pheochromocytoma	1 (0.9)
Postmenopausal syndrome	3 (2.8)
Primary hypogonadism	1 (0.9)
Recurrent hypoglycemia	2 (1.9)
Thyroid storm	1 (0.9)
Total	108 (100)

Assessing the impact of consultations, the diagnosis of the referring physician was confirmed in 86.1% (93/108) of the cases, new diagnosis that was not previously made was reached in 9.3% (10/108) of the cases, incorrect diagnosis was changed in 3.7% (4/108) of the cases, and only in 0.9% (1/108) of cases was a diagnosis not reached, because the patient had features suggestive of postmenopausal syndrome, and still undergoing evaluation.

Of the 108 patients, 43 (39.8%) were lost to follow-up, 31 (28.7%), 27 (25.05), and 3 (2.8%) were in good, fair, and poor clinical conditions, respectively. During the study, 4 (3.7%) mortalities were recorded.

DISCUSSION

This study was an attempt to describe the pattern and outcome of endocrine referrals in a tertiary health-care center in South-west Nigeria. For the first time, to the best of our knowledge, we established a spectrum of clinical cases in Southwest Nigeria, unlike other studies that focused on specific diagnoses such as diabetes and thyroid disorders, or the pattern of endocrine admissions in the emergency department alone.41516 The other studies on the spectrum of endocrine disorders are studies done in the pediatric population.1718

The general outpatient clinic was the source of most referrals to the endocrinology unit, which is also in tandem with the observation that most of the referrals were for outpatients. This is so because of the structure of health services in Nigeria, where most uncomplicated cases are handled by the general practitioners/family physicians, who then refer cases which seem to require more specialized care. This highlights the importance of the outpatient department in any hospital and the health system as a whole.19 The second highest referrals came from the cardiology unit; this too is not surprising as cardiovascular risk factors are shared with some endocrine disorders such as diabetes mellitus.

The identification of epidemiological trends in hospital admissions and the influence of this on a specific clinical unit are essential for health-care planning and resource allocation.4 Most of our patients were male (50.9%), though the difference in sex distribution is only minimal. This finding is however in variance with other studies done among patients with diabetes2021 but similar to a study by Anyawu et al. and Olamoyegun et al., who looked at endocrine-related disorders presenting to the Emergency in Lagos, Nigeria, and dyslipidemia in Nigerians, respectively.422 The higher percentage of patients with diabetes in our study (68.7%) is in keeping with other studies. We are in agreement with other workers that suggest that diabetes (especially Type 2) is the most common endocrine disorder presenting to most endocrinology clinics. Again, a previous study put the prevalence of endocrine presentation at the emergency to be about 10.2%, similar to the 7.4% observed in our center4 [Figure 1].

Figure 1

Bar chart showing the source of referrals to endocrinology unit (expressed in percentages)

One of the major impacts of referrals to our unit was confirmation of the diagnosis made by the referring physician. This is in variance with what was observed by a study done by Linedale et al., who studied the pattern of referral to a gastroenterology clinic from a primary health center (PHC). They noted in their study, 61% of patients did not have a diagnosis before referral from the PHC.23 The reason for this difference may be explained as follows; our study was done in a tertiary hospital where specialists and consultants would have reviewed before referral thus, it is only in few cases that there will be a diagnostic dilemma. Perhaps, similar findings may be observed in our PHCs; however, this was not the focus of this present study. About 13% of patients either had a new or a change in their diagnosis. It is important that physicians seek expert opinion from other specialists to improve diagnostic efficiency and patient satisfaction.

A significant population of our patients were lost to follow-up. This is a pattern that has been worrisome not only to endocrinologists but also other specialties as well.4131516 The reasons for these are numerous, and some studies have identified a few. These include low insurance coverage of health care, as most patients in this part of the world still pay for health care from their pockets.24 Our center being a private institution however still had attrition rates similar to studies done in government hospitals. Another reason could be patient dissatisfaction. Linedale et al. in their study reported that only 22% of patients were satisfied with health care.23 Patient expectations are important when dealing with illnesses, as this goes a long way in understanding why they will be satisfied with the treatments offered.

Mortality was lower in our study (n = 4, 3.7%) compared to a study done by Anyawu et al. (n = 29, 22%).4 The reason for this is not farfetched. Most of our cases came from the clinics and hence were presumed to be stable. In Anyanwu et al.'s study, the workers focused on endocrine patients presenting to the emergency room. The common causes of death in that study were hyperglycemic emergencies, sepsis, thyroid, and hypoglycemic crisis.4

CONCLUSION

Most of the cases referred for specialist care were from the general outpatient clinic, had diabetes mellitus, and benefitted from specialist care by way of advanced investigations and treatments, though about a third was lost to follow-up. We hereby submit that endocrine disorders remain common in medical practice, and often require referral for specialist care. We hereby advocate that a good referral system within and outside the tertiary centers are key to proper diagnosis and providing quality health care to patients. Finally, patient attrition is common in developing countries, and stakeholders need to be more proactive in identifying and solving reasons for this phenomenon, so as to reduce the morbidity and mortality from diverse clinical conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.