Characterizing barriers to closing cross-institutional referral loops: Workflow and information flow analysis.

The specialty referral process consists of primary care clinicians referring patients to specialty consultants. This care transition requires effective care coordination and health information exchange between care teams; however, breakdowns in workflow and information flow impede "closing the referral loop" and delay or prevent referrers from receiving the consultant's "visit notes," particularly in cross-institutional referrals. This study aimed to describe and map the referral process as it occurs in clinics and identify and characterize work system barriers affecting its performance.

Consultants' and referrers' perceived barriers to closing the cross-institutional referral loop, and perceived impact on clinical care.

Background: Cross-institutional (external) referrals are prone to communication breakdowns, increasing patient safety risks, clinician burnout, and healthcare costs. To close these external referral loops, referring primary care physicians (PCPs) need to receive patient information from consultants at different healthcare institutions. Although existing studies investigated the early phases of external referral loops, we lack sufficient knowledge about the closing phases of these loops.

Drs. Walkup and Cottingham Reply.

Thank you to the authors for taking the time to read our editorial "Antipsychotic Induced Weight Gain and Metformin" in JAACAP and send in a letter to the editor with comments.

A randomized, double-blind, placebo-controlled trial of metformin treatment of weight gain associated with initiation of atypical antipsychotic therapy in children and adolescents.

Objective: Second-generation, or atypical, antipsychotics effectively treat psychiatric illness in children and adolescents. However, weight gain and abnormalities in insulin sensitivity, including diabetes, complicate this therapy.

Method: A 16-week double-blind, placebo-controlled trial was conducted to evaluate the effectiveness of metformin in managing weight gain in 39 subjects, ages 10-17, whose weight had increased by more than 10% during less than 1 year of olanzapine, risperidone, or quetiapine therapy.

Metformin for weight loss in pediatric patients taking psychotropic drugs.

Objective: Metformin was assessed as a treatment for weight gain in children taking olanzapine, risperidone, quetiapine, or valproate.

Method: The subjects were 19 patients aged 10-18 years; 15 were white and four were black, and there were 12 boys and seven girls. In a 12-week open-label study, each patient received metformin, 500 mg t.