Virtual Interconsultations for Primary Care Referrals to Rheumatology: Real-World Implementation and Societal Cost-Avoidance Analysis in a Public Health System

Aznar, Antonio; Hernández-Díaz, Marta; Ferraz-Amaro, Iván; Flores-Rodríguez, Miguel; Viotti, Jose María; Hernández-Hernández, María Vanesa; Delgado-Frias, Esmeralda; García-Dorta, Alicia; Bethencourt Baute, Juan José; Sánchez-Pérez, Hiurma; Trujillo, Elisa; García-González, María; Gonzalez-Dávila, Enrique; Díaz-González, Federico

Virtual Interconsultations for Primary Care Referrals to Rheumatology: Real-World Implementation and Societal Cost-Avoidance Analysis in a Public Health System

Articles in Press

Document Type : Original Article

Authors

Antonio Aznar ¹

Marta Hernández-Díaz ¹

Iván Ferraz-Amaro ¹^{, 2}

Miguel Flores-Rodríguez ¹

Jose María Viotti ¹

María Vanesa Hernández-Hernández ¹

Esmeralda Delgado-Frias ¹

Alicia García-Dorta ¹

Juan José Bethencourt Baute ¹

Hiurma Sánchez-Pérez ¹

Elisa Trujillo ¹^{, 2}

María García-González ¹

Enrique Gonzalez-Dávila ³

Federico Díaz-González ¹^{, 2}

¹ Servicio de Reumatología, Hospital Universitario de Canarias, La Laguna, Spain

² Departamento de Medicina Interna, Dermatología y Psiquiatría de la Universidad de La Laguna, La Laguna, Spain

³ Departamento de Matemáticas, Estadística eInvestigación Operativa, IMAULL, Universidad de La Laguna, La Laguna, Spain

Abstract

Background
Rising demand for rheumatology care strains referral pathways between primary care and specialist services. We evaluated whether a virtual interconsultation (VIC) program, an asynchronous e-consult system integrated into the electronic health record (EHR), improved referral efficiency for new patients and generated net societal cost savings in a public health system.

Methods
We conducted a retrospective study of 12 213 VICs (10 181 patients) submitted from primary care to a tertiary rheumatology service between January 2021 and June 2022. Extracted EHR data included demographics, referral reason, delay time (submission to specialist response), resolution time (minutes per case), and outcomes (virtual resolution vs. in-person referral). Referral efficiency was assessed by the proportion of referrals resolved without an in-person visit and time to specialist response. Descriptive and comparative analyses used Mann–Whitney U, chi-square, and student’s t tests. The economic evaluation used a cost-avoidance micro costing approach from a societal perspective. Robustness of the economic evaluation was assessed through one-way sensitivity analyses, probabilistic Monte Carlo simulations (>100 000 iterations), and threshold analysis (ie, the minimum virtual resolution rate at which the program achieves breakeven).

Results
Patients were predominantly female (69%), mean age 54.8 years. Median specialist response time was 53.5 hours (interquartile range [IQR]: 20.6–122.3) and median resolution time 3.2 minutes (IQR: 1.6–8.6). Overall, 41.4% of referrals were resolved without an in-person visit. The program generated net societal savings of €206 280 over 18 months in the deterministic base case; the probabilistic analysis yielded a mean of €200 540 (95% credible interval: €142 289–€261 316) and a 100% probability of net savings. Absenteeism was the principal economic driver (highest Spearman correlation with net savings in Monte Carlo simulation, r = 0.92). The breakeven virtual resolution rate was 5.6%.

Conclusion
Integrating VICs into routine rheumatology referral pathways improved referral efficiency and produced substantial societal cost savings. These findings support scaling EHR-integrated VIC programs across publicly funded health systems to optimize specialist resources and enhance access to care.

Keywords

E-Consultation

Rheumatology

Primary Care

Cost-Avoidance

Referral Management

Spain