Assessing the referral rate of Family Medicine Program from the first level to the second level using funnel plot in Markazi province (Iran) in 2011

Funnel plot is a graphical tool for investigating publication bias in meta-analysis studies. The aim of this study is to introduce another application of funnel plot that is monitoring one of the Iranian family performance indices and determining the position of each health center of Markazi province in terms of patient referral rates by general practitioners to specialists and to compare it with bar and caterpillar plots. In order to draw the funnel plot، the average monthly percent of referrals for each district of Markazi province in 2011 was computed. In this study، Iranian Ministry of Health and Medical Education standard figure of 10% was considered as the limit of referral to the second level of Iranian health services. The 99% confidence interval of the control limit for each district was computed according to 3 standard deviations of the percent of referrals relative to the total patient visits. Based on funnel plot results، five out of ten districts were in the expected range of referral (Ashtian، Saveh، Tafresh، Khomein، and Komijan). However، in other five districts، the referral rate was greater than the expected rate (Arak، Shazand، Zarandiyeh، Delijan، and Mahallat). Mahallat district had the highest rate of referral. The funnel plot was more informative than the other two plots; thus، it can be viewed as a useful tool in monitoring health programs throughout the country.