Pediatric outpatient referrals to a tertiary centre in Singapore: a 10-year review of referral characteristics and attendance patterns

Abstract

Singapore, a high-income country with declining birth rates, operates a primary care–led referral system for pediatric specialist services. Understanding referral characteristics, waiting times and attendance rates are important for service planning and the efficient use of healthcare resources. We conducted a retrospective clinical audit of all consecutive referrals to the General Pediatrics Specialist Outpatient Clinic (SOC) at KK Women’s and Children’s Hospital between 1 January 2015 and 31 December 2024. Descriptive analyses were performed to characterize referral volume, referral source, referral-to-appointment time and attendance status. Multivariable logistic regression was used to identify factors associated with clinic non-attendance. Receiver operating characteristic (ROC) analysis was performed as an exploratory assessment of referral-to-appointment time. A total of 156,161 referrals were recorded over the 10-year period. The median age of referred children was 4.2 years (IQR 1.2–9.5). Referrals originated predominantly from public healthcare polyclinics (43.9%) and the children’s emergency department (32.8%). The median referral-to-appointment time was 21 days (IQR 7–38), and overall clinic attendance was 63.0%. Longer referral-to-appointment time was independently associated with non-attendance (adjusted odds ratio [aOR] 1.018 per day; 95% CI 1.017–1.019; p < 0.001), equivalent to approximately 70% higher odds of non-attendance for every 30-day increase in waiting time. Subsidized referrals (aOR 2.007, 95% CI 1.929–2.087; p < 0.001) and emergency department referrals (aOR 2.070, 95% CI 2.018–2.214; p < 0.001) were associated with higher non-attendance, while self-initiated referrals were associated with lower non-attendance (aOR 0.304, 95% CI 0.287–0.322; p < 0.001). ROC analysis demonstrated modest discriminatory performance (AUC 0.669, 95% CI 0.666–0.672). An exploratory referral-to-appointment threshold of 27.5 days yielded a sensitivity of 58.3% and a specificity of 71.3% for identifying clinic non-attendance. This study describes referral characteristics and attendance patterns among children referred to a general pediatric specialist outpatient service over a 10-year period. Longer referral-to-appointment time, subsidized referral status, and referral source were independently associated with clinic non-attendance. Recognition of these factors may help guide targeted interventions to reduce non-attendance and improve access to specialist outpatient care.

The authors' abstract, as published at the source. BMC Pediatrics, 2026 · DOI ↗