Do referral rates vary widely between practices and does supply of services affect demand? A study in Milton Keynes and the Oxford region.

Two commonly held beliefs about referral rates were investigated in this study: first that demand for services is determined by supply and secondly that there is wide variation between general practices in their referral rates. All referrals to specialist outpatient clinics were recorded during two 11-week periods by general practitioners in eight practices in the new town of Milton Keynes and in 17 practices elsewhere in the Oxford region. During the first period, only a limited outpatient service was available in the new town; for many specialist services, people had to be referred to hospitals outside the district. Referral rates from Milton Keynes were very similar to those from the rest of the region. By the second period the range of specialist facilities available locally had expanded considerably with the opening of the new district general hospital and during this period there was a statistically significant but rather small increase in referral rates from Milton Keynes. Variation in referral rates between general practices within each geographical group was greater than that between the two groups. Overall, there was about a three-fold variation between general practices in outpatient referral rates which is considerably less than that commonly thought to exist.     

Does the North Staffordshire slot system control demand of orthopaedic referrals from primary care?: A population-based survey in general practice

BACKGROUND: Attempts to manage general practice demand for orthopaedic outpatient consultations have been made in several areas of the NHS, with little robust evidence on whether or not they work. AIM: To evaluate the effect of the North Staffordshire 'orthopaedic slot system' on the demand for general practice referrals to orthopaedic outpatients. METHOD: A prospective study of 12 general practices in the slot system, 24 controls, and the 63 other general practices in North Staffordshire. Comparison periods were the baseline year (0); the first calendar year (1); and the first half of the second calendar year (2). A multifactor linear regression model was used. RESULTS: Mean referral rate decreased 22% in the slot group in period 1, and was maintained in period 2 (9.40, 7.29, 7.31 referrals per 10,000 population per month for periods 0, 1 and 2, respectively). The control and other groups showed a small decrease in period 1, but in period 2 higher referral rates were observed. The reduction in referrals of 20-40% in participating practices compared to other practices equates to 2-4 referrals per 10,000 patients per month. CONCLUSIONS: Our study suggests that practices willing and able to take up an offer of a slot system for managing their orthopaedic referrals will be able to significantly reduce referral rates for their patients when compared to similar practices who do not. Further research on the generalisability, effectiveness and cost-effectiveness of such systems is warranted.     

Musculoskeletal clinic in general practice: study of one year''s referrals.

BACKGROUND. A musculoskeletal clinic, staffed by a general practitioner trained in osteopathy, medical acupuncture and intralesional injections, was set up in an inner London general practice in 1987. AIM. A retrospective study was undertaken of one year's referrals to the clinic in 1989-90 to determine how general practitioners were using the clinic in terms of problems referred; consultation patterns of patients attending the clinic and 12 months after initially being seen; and how access to the clinic influenced referrals to relevant hospital departments. METHOD. Day sheets were studied which recorded information on demographic characteristics of patients referred to the clinic and their problems, diagnoses made, duration of symptoms, number and range of treatments given, and recurrence of problems. Use of secondary referral sources was also examined. RESULTS. During the study year 154 of 3264 practice patients were referred to the musculoskeletal clinic, and attended a mean of 3.5 times each. Of all the attenders 64% were women and 52% were 30-54 years old. Eighty one patients (53%) presented with neck, back or sciatic pain. A specific traumatic, inflammatory or other pathological process could be ascribed to only 19% of patients. Regarding treatment, 88% of patients received osteopathic manual treatment or acupuncture, or a combination of these treatments and 4% received intralesional injections. Nine patients from the clinic (6%) were referred to an orthopaedic specialist during the year, two with acute back pain. Referrals to orthopaedic specialists by the practice as a whole were not significantly lower than the national average, although the practice made fewer referrals to physiotherapy and rheumatology departments than national figures would have predicted. Seventeen patients (11%) returned to the clinic with a recurrence of their main complaint within a year of their initial appointment; second courses of treatment were usually brief. CONCLUSION. The clinic encouraged a relatively low referral rate to musculoskeletal specialists outside the practice. However, a need was identified for better communication about the potential of the approaches used in order that referrals to secondary specialists, particularly orthopaedic specialists, could be further reduced.     

Unravelling referrals to medical outpatients

Little is known about the process of referral to Irish hospital outpatient medical clinics. We analysed pre-referral management, information quality and communication to a general medical outpatient clinic. 100 consecutive attendee referral letters were prospectively assessed for information, appropriateness, legibility and pre-referral management. Patients underwent a questionnaire. We documented the final diagnosis and management patterns. 16% of letters were largely illegible, Only 47% of letters gave examination findings and of those, 40% omitted significant details. Appropriate pre-referral investigations were performed in 55%. Where performed, results were not enclosed in 32%. In 61% of cases therapy could have been instituted prior to referral, of these treatment was not started in 36%. 16% of patients did not understand the reason for referral. 10% of referrals were inappropriate. In this limited study there were substantial communication deficiencies in patient referral. If standard criteria were set (e.g. by proforma) before a referral is accepted perhaps the quality of patient care might improve especially if treatment could be initiated earlier by referring doctors.     

Effect of information about waiting lists on referral patterns of general practitioners.

In a two year trial general practitioners in the West Midlands were provided with extended waiting time information for hospital consultation and treatment in general surgery. Selected general practitioners were sent monthly bulletins on comparative times to wait for both outpatient appointment and inpatient treatment throughout the region. Their referrals to consultant general surgeons were monitored, alongside those of a matched control group not receiving such information. Differences were found between the two groups which indicate the willingness of general practitioners to change their referral practice when adequate information is available. In addition, patients referred to their local hospital had longer waiting times than patients matched for clinical condition and district of origin who were sent to hospitals where it was indicated that a shorter wait might be expected.     

Measuring general practitioner referrals: patient, workload and list size effects

Individual general practitioners are known to vary widely in the number of patients they refer to hospital outpatient departments; indeed there is increasing concern that the 'high' referrers use a disproportionate quantity of National Health Service resources. Data from a one-week survey of referrals by 122 general practitioners in one health district showed that a different age-sex mix of patients consulting individual general practitioners might account for about one quarter of his or her referrals. The results also showed that different referral rates, calculated by using either workload or list size denominators, identified markedly different groups of high referrers. These different methods of measurement are discussed, and on practical grounds a referral rate based on actual referrals divided by mean practice list size is suggested for future comparisons.     

Home visiting by a geriatric department

The practice of home visiting by the geriatrician in an inner city area is described. Visiting was of two kinds: domiciliary consultations made at the request of the general practitioner, and visits made with the consent of the general practitioner to see whether hospital admission was essential. Since 1962, 4,000 visits have been made, and in a sample of 100 visits made in 1977, 45 were domiciliary consultations and 55 followed requests for admission. Fifty-six patients were admitted at once and five following a subsequent outpatient appointment. The patients were referred by 51 general practitioners. At none of the consultations was the geriatrician accompanied by the general practitioner. Referral information given by the general practitioners was analysed. Information about acute physical disease and social conditions was commonly given but reference to psychological state, chronic disabilities, and drug therapy was much less common. Drugs were mentioned in only 27 referrals. More complete referrals would have been valuable to the geriatrician and to the general practitioner in deciding their courses of action. More accompanied visits and reference to a check-list consisting of acute physical disease, psychological state, social conditions, chronic disabilities, and drug therapy is suggested to improve communication and the quality of referrals.     

General practice based physiotherapy: its use and effect on referrals to hospital orthopaedics and rheumatology outpatient departments.

BACKGROUND. In November 1992, a pilot scheme was established in Doncaster to provide an on-site physiotherapy service in six non-fundholding general practices covering a population of approximately 44,000 people. AIM. The aim of the pilot scheme was to transfer a hospital-based physiotherapy service, to which general practitioners had direct access, to a primary care setting and to reduce referrals to an orthopaedics outpatient department. METHOD. Use of physiotherapy services and referrals to orthopaedics and rheumatology before and during the first year of the scheme were monitored. Comparisons were made with data over the same time periods for general practices that were not in the scheme. The location of management of patients referred to physiotherapy was monitored for an eight-month period during the scheme. RESULTS. In the first year the scheme had a utilization rate of 31 per 1000 patients in the participating practices, representing a 164% increase over the hospital-based physiotherapy utilization rate for the year prior to the scheme. Eight per cent of physiotherapy patients received hospital-based treatment during the scheme. Changes in hospital outpatient referral rates attributable to the scheme were reductions of 8% to the orthopaedics department and 17% to the rheumatology department. CONCLUSION. The increase in the use of the physiotherapy service was possibly caused, in part, by general practitioners sending patients to on-site physiotherapy who previously would have been referred to orthopaedics and, largely, by an increase in the treatment of patients who previously would not have been referred to hospital. Physiotherapy based in general practice can be a substitute for hospital-based physiotherapy and can contribute to a reduction in referrals to orthopaedics and rheumatology outpatient departments. However, it can result in an increase in use of physiotherapy services.     

Does providing more accessible primary care psychology services lower the clinical threshold for referrals?

BACKGROUND: The growing number of specialist services being provided within primary care has lead to the argument that this will reduce the clinical threshold for referrals to these clinics. AIM: The possibility that increasing the accessibility of primary care psychology services will reduce the threshold for referral was examined by comparing levels of psychological disturbance among patients seen by practice-based clinical psychologists with those attending outpatient clinics. METHOD: Psychological symptoms, distress, disruption in daily life and satisfaction with life were assessed using a questionnaire-based methodology. A consecutive series of 177 patients, assessed in a local general practice or an outpatient department across a wide range of urban locations, was studied over a fixed period. RESULTS: The study revealed equivalent levels of psychopathology within both specialist and primary care clinics. Of the overall sample, 79% were likely to merit a formal psychiatric diagnosis, relating primarily to mood disorder. Levels of subjective distress and life satisfaction were also equivalent at both service locations. CONCLUSION: The lack of evidence for a reduction in clinical threshold for referral within the primary care sample suggests that general practitioners' referral rates are similar regardless of whether practice-based clinical psychology services are available. This has implications for primary-care-led commissioning of mental health services.     

A prospective analysis of inpatient consultations to a gastroenterology service

The provision of a formal consultation service for inpatients between subspecialists is little studied. We prospectively surveyed the pattern of inpatient consultations from hospital-based generalists and surgeons to the gastroenterology (GI) service for inpatients in a large urban teaching hospital over a 5 month period. There are two GI consultants/attendings and five GI registrars/fellows on the service. A formal consultation is made by the requesting team to the GI service using the hospital computer network. All referrals over a 5 month period were prospectively analysed. 242 consecutive inpatient referrals were sent to the GI service over 5 months. Average age was 56 years, 48.8% males. 32 consultants/attendings from other disciplines sent referrals. Most patients were seen within one working day. Urgent referrals were seen without delay. The commonest reasons for referral were abdominal pain (15.8%), percutaneous endoscopic gastrostomy (PEG) tube insertion (13.6%), diarrhoea (12.8%), abnormal liver blood tests (10%), nausea and vomiting (8.2%), anaemia (6.2%), and melaena (4.9%). Iatrogenic diseases accounted for 6.2% of consultations. Ongoing patient care was assumed by the GI team in 9.5% of referrals. 15.3% required a second consultation visit before discharge. 22.7% of referrals were followed in the GI outpatients' clinic after discharge. 51.2% underwent an endoscopic procedure. 13.6% of referrals were for PEG tube insertion. A quarter of these were considered unsuitable for immediate PEG tube insertion. Subspecialty consultation provides an expert opinion, encourages discussion and learning, and improves patient care. In our experience, the provision of specialist advice and reassurance often speeded up a patient's work-up and expedited discharge. However, evaluating referral patients and subsequently providing ongoing inpatient and outpatient care and provision of endoscopy for these referrals contributes significantly to the workload of the GI service.     

General practitioner referral rates to district psychiatry and psychology services.

The number of referrals made to a district psychiatry service by each of the local general practitioners over a five year period was counted and a large variation in general practitioner referral rate was found. Ten referral letters from each of the general practitioners were independently assessed for the amount of detail included and a mean score for each general practitioner obtained. A significant negative correlation was found between referral rate and amount of detail in referral letters, that is low referrers wrote very detailed letters. The procedure was repeated over an 18 month period including referrals to the district psychology service. Referral rate to the psychologists was positively correlated with detailed referral letters, that is those who referred many patients to the psychologists wrote detailed letters. This study has indicated a wide variation in the use of the psychiatry and psychology services by general practitioners which cannot be explained solely on the basis of a general referral tendency. It is likely that constructive liaison between psychiatrists and general practitioners, especially those who refer a large number of patients, could enhance the care of patients with psychiatric disorder in general practice.     

Investigation of benefits and costs of an ophthalmic outreach clinic in general practice.

BACKGROUND: With the advent of general practitioner fundholding, there has been growth in outreach clinics covering many specialties. The benefits and costs of this model of service provision are unclear. AIM: A pilot study aimed to evaluate an outreach model of ophthalmic care in terms of its impact on general practitioners, their use of secondary ophthalmology services, patients' views, and costs. METHOD: A prospective study, from April 1992 to March 1993, of the introduction of an ophthalmic outreach service in 17 general practices in London was undertaken. An ophthalmic outreach team, comprising an ophthalmic medical practitioner and an ophthalmic nurse, held clinics in the practices once a month. Referral rates to Edgware General Hospital ophthalmology outpatient department over one year from the study practices were compared with those from 17 control practices. General practitioners' assessments of the scheme and its impact on their knowledge and practice of ophthalmology were sought through a postal survey of all partners and interviews with one partner in each practice. Patient surveys were conducted using self-administered structured questionnaires. A costings exercise compared the outreach model with the conventional hospital ophthalmology outpatient clinic. RESULTS: Of 1309 patients seen by the outreach team in the study practices, 480 (37%) were referred to the ophthalmology outpatient department. The annual referral rate to this department from control practices was 9.5 per 10,000 registered patients compared with 3.8 per 10,000 registered patients from study practices. A total of 1187 patients were referred to the outpatient department from control practices. An increase in knowledge of ophthalmology was reported by 18 of 47 general practitioners (38%). Nineteen (40%) of 47 general practitioners took advantage of the opportunity for inservice training with the outreach team; they were more likely to change their routine practice for ophthalmic care or referral criteria for patients with cataracts or diabetes than those who did not attend for inservice training. The outreach scheme was popular with patients, for whom ease of access and familiarity of surroundings were major advantages. The cost per patient seen in the outreach clinics (48.09 pounds) was about three times the cost per patient seen in the outpatient department (15.71 pounds). CONCLUSION: The model of ophthalmic outreach care in this pilot study was popular with patients and general practitioners and appeared to act as an effective filter of demand for care in the hospital setting. However, the educational impact of the scheme was limited. Although the unit costs (per patient) of the outreach scheme compared unfavourably with those of conventional outpatient treatment, potential health gains from this more accessible model of care require further exploration.     

Case-control study of GP attendance rates by suicide cases with or without a psychiatric history.

BACKGROUND: Targets for reduction in suicide deaths have been set against a background of an increasing number of people committing suicide. It is often assumed that a reduction can be effected by increasing the detection in primary care of patients at risk. This presupposes that there are indicators that enable suicide risk to be detected reliably. AIM: To compare the characteristics of those who commit suicide with an age- and sex-matched control group in terms of level of general practitioner attendance, diagnosis and pharmacological treatment of mental illness, and to compare those suicides with and without a psychiatric history in terms of general practitioner attendance and history of pharmacological treatment. METHOD: From a total of 48 deaths attributed to suicide and undetermined causes in the Forth Valley in 1993, general practice case notes were located for 41. Live controls were matched to index cases by age, sex and practice. Information on consultations, referrals to secondary care, medication and diagnoses in the previous 10 years was extracted from general practice and, for suicides, psychiatric case notes. RESULTS: Over the 10-year period, suicide patients attended their general practitioner at a higher level than control subjects. However, the number of suicide patients who attended their general practitioner in the month before their death did not differ in comparison with control subjects over a similar period. Suicide cases, in comparison with control subjects, were more likely to have received a psychiatric diagnosis from their general practitioner, been prescribed psychotropic medication and received referral to specialist mental health services. Those suicide patients with a psychiatric history had a significantly higher number of general practitioner consultations than those without a psychiatric history in four out of the five years preceding death. Those suicide patients without a psychiatric history did not differ significantly from control subjects on any of the variables assessed. CONCLUSION: For those people committing suicide who do not have a psychiatric history and whose consultation patterns do not differ from the norm, it is difficult to suggest how general practitioners might improve their detection of relevant suicidal risk factors. For those patients with a psychiatric history who commit suicide, until we have more detailed information regarding the specific content of general practitioner's consultations before death and how these differed from other consultations of the deceased, then it is premature to assume that general practitioners are failing to identify indicators of impending suicide.     

Patients with suspected myocardial infarction: effect of mode of referral on admission time to a coronary care unit.

The aim of this prospective study was to determine the delay between the onset of symptoms and arrival in the coronary care unit of patients with suspected acute myocardial infarction, and the relative contribution to the total delay of patient delay, method of referral (self referral or general practitioner referral) and delay in the hospital before reaching the coronary care unit. All patients admitted with chest pain to the coronary care unit at Dudley Road Hospital, Birmingham, over the six month period April-September 1989 were included in the study. Ninety five patients were referred by their general practitioner and 107 patients attended the accident and emergency department directly or arrived by ambulance without contacting their general practitioner. The proportion of self referred and general practitioner referred patients with acute myocardial infarction, angina and non-cardiac chest pain were not significantly different. The total delay was significantly longer for patients who had been referred by their general practitioner (median 5.3 hours) than for self referrals (3.2 hours, P less than 0.001), with a significantly higher proportion of self referrals arriving at the coronary care unit within six hours of the onset of symptoms (77% versus 54%, P less than 0.01). Among general practitioner referrals, initial patient delay accounted for a median of 2.5 hours and the general practitioner's response time for a median of 1.1 hours. The delay in hospital was similar for both groups of patients. In inner city areas, self referral may result in considerably less delay than general practitioner referral allowing a greater proportion of patients to receive effective thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Referring patients to geriatric hospitals: a survey of general practitioners' opinions

Many geriatric day hospitals are under-utilized. A survey of general practitioners' opinions on referral systems to day hospitals in east Surrey produced an 85% response rate. Of the 80 general practitioners who responded 58% referred occasionally, 39% frequently and 4% never. When asked about referring patients directly to the day hospital via the coordinator instead of via the consultant geriatrician, 58% of general practitioners said they would like to have direct access, and 87% were in favour of other health workers involved with the elderly initiating referrals with the general practitioner's consent. Rehabilitation was mentioned as the main reason for referral by 76% of general practitioners, medical assessment by 56% and social care by 48%. Comments received suggested that the hospital day was too long and that early rising associated with attendance caused stress in the elderly attenders. It is concluded that the present system of referral via the consultant is not always satisfactory and that a referral card system which permits general practitioners to refer directly to the geriatric day hospital may increase utilization.     

Community psychiatric nursing: a survey of patients and problems

The work of a community psychiatric nursing service for acute psychiatric conditions was reviewed for the period 1980-82. Five community psychiatric nurses operated in 10 health centres. General practitioners were the most frequent users of the service and a wide range of psychiatric problems were encountered. The age structure of all referrals was found to be significantly related to sex, with the proportion of females in all age groups at least twice that for males. The most frequent reason for referral was mood/affect disturbance; female patients referred for the first time were predominant. Over half of all problems resolved within three months of referral and a limited number of patients were sent for further psychiatric investigation.     

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care.

BACKGROUND: Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates. AIMS: To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints. DESIGN OF STUDY: Randomised controlled trial. SETTING: Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months. METHOD: The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial. RESULTS: One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024). CONCLUSION: Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.     

Comparing the quality of referrals of general practitioners with high and average referral rates: an independent panel review.

The quality of referrals of four general practitioners, two with high and two with average rates of referral to the department of internal medicine, was judged by an independent expert panel. The panel, consisting of two general practitioners and one specialist, reviewed a set of information about the referrals blindly and in random sequence. The same distribution of quality of referrals was found among the referrals of the two high referring general practitioners (n = 192) as among those of the general practitioners with average rates (n = 88); that is, 57% and 55% respectively, of the cases had clear medical indications for referral, while the data did not permit a conclusion in 15% and 10%, respectively, of the cases. Controlling for sex, age and status of the referral (first or repeat referral) did not alter the results. We conclude that using referral rates to judge referral quality is misleading. However, a blind and randomly performed panel review of referrals is a time consuming but feasible method of quality assessment.