Population and data description
Data for analysis were collected from January 2009 to December 2016. The
study base population consisted of 407 patients from each unit. While
407 was the actual number of consecutive patients
evaluated
at the Secondary Unit during the
8-year period, we selected a random sample of 407 from 6,960 consecutive
patients evaluated at the unit of the tertiary center during the same
period. By using online random sampling software
(https://www.randomizer.org/),
randomization was performed for each year of the study to match the
annual number of patients of the secondary hospital unit.
Computerized medical records stored in the information systems of the
hospitals were compiled. Demographic, clinical, and economic data were
analyzed to determine the patient sample and calculate the costs. Data
collected included age, gender, referral sources, time-to diagnosis,
ratio of successive/first visits,
clinical indications for referral,
and final diagnosis. For the study purpose,
indications for referral were
dichotomized into symptoms
suggestive of cancer vs. other
symptoms and final diagnosis was subdivided into malignant vs.
nonmalignant diseases. The study
was carried out in line with the principles of the Declaration of
Helsinki. Approvals were granted by the research ethics committee of the
tertiary university hospital and the network of hospitals to which the
second-level hospital belongs to (Comitè d’Ètica de la Investigació
Clínica [CEIC]-Unió Catalana d’Hospitals). Need for informed consent
was waived due to the retrospective design of this study.