Quality of general practitioner referrals to outpatient departments: assessment by specialists and a general practitioner.

Thirty eight specialists in one district health authority were asked to take part in a questionnaire survey to assess the appropriateness of referral and the quality of the referral letter for 20 consecutive new patients each. A total of 705 new patient referrals to 13 specialties were included in the study. Twelve of the 38 specialists were randomly selected and their 234 new patient referral letters were independently assessed by a general practitioner for the appropriateness of the referral decision. The study revealed errors and omissions in between 5% and 28% of referral letters according to the category of information. Thirteen per cent of the new patient referrals were assessed by specialists to be inappropriate and 4% of patients had been referred to an inappropriate specialty. Significantly more of the referrals to medical specialties were inappropriate (20%) than to surgical specialties (9%) (P < 0.01). There were more than three times the number of errors and omissions in the referral letters of referrals assessed as inappropriate than in the referral letters of referrals assessed as appropriate (P < 0.01). The referral letters of referrals assessed as inappropriate were more than nine times as likely to omit the reasons for or objectives of the referral compared with letters for those referrals assessed as appropriate (P < 0.01). There was a good overall agreement between the specialists and general practitioner in their assessment of the appropriateness of the clinical referrals (kappa = 0.614, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Communication at the interface: do better referral letters produce better consultant replies?

A study of the quality of 637 referral letters from general practitioners (GPs) and corresponding reply letters from medical specialists showed that both types of letters can be improved, and that specific requests by GPs were addressed explicitly by the specialists in only a limited number of cases. Better referral letters resulted only partly in better reply letters. A letter is considered to be of higher quality when a specialist commences a letter with a reference to the specific request by the GP. In conclusion, opportunities for optimal communication should be better used.     

Examining the variation in GPs’ referral practice: a cross-sectional study of GPs’ reasons for referral

Background

There is a large variation in referral rates to secondary care among GPs, which is partly unexplained.

Aim

To explore associations between reasons for referral to secondary care and patient, GP, and healthcare characteristics.

Design and setting

A cross-sectional study in Northern Norway.

Method

Data were derived from 44 (42%) of 104 randomly selected GPs between 2008 and 2010. GPs scored the relevance of nine predefined reasons for 595 referrals from 4350 consecutive consultations on a four-level categorical scale. Associations were examined by multivariable ordered and multivariable multilevel logistic regression analyses.

Results

Medical necessity was assessed as a relevant reason in 93% of the referrals, 43.7% by patient preference, 27.5% to avoid overlooking anything, and 14.6% to reassure the patient. The higher the referral rates, the more frequently the GPs referred to avoid overlooking anything. Female GPs referred to reassure the patient and due to perceived deficient medical knowledge significantly more often than male GPs. However, perceived easy accessibility of specialists was significantly less frequently given as a reason for referral by female GPs compared with male GPs. When the GPs scored the referrals to be of lesser medical necessity, male GPs referred significantly more frequently than female GPs to reassure the patient due to patient preference and perceived deficient medical knowledge.

Conclusion

There are striking differences in reasons for referral between Norwegian male and female GPs and between GPs with high and low referral rates, which reflects difficulties in handling professional uncertainty. Referring to reassure the patients, especially when referrals are less medically necessary, may reflect consideration and acquiescence towards the patients.     

Diagnostic work-up of rectal bleeding in general practice

BACKGROUND: GPs have many patients with gastrointestinal discomfort. Among bowel-related complaints, the sign of rectal bleeding is of particular importance in patients aged 50 years and above, as it can be an early sign for serious bowel diseases such as colon carcinoma. Despite many guidelines offered to GPs for screening and early detection of colorectal carcinomas, there is very little information about the actual diagnostic approach to the sign of rectal bleeding. AIM: The aim of the study was to collect data concerning treatment strategies used by GPs who treat patients presenting with rectal bleeding. DESIGN OF STUDY: Prospective data collection. SETTING: General practices in Germany. METHOD: Over the course of a year, GPs recorded their treatment strategies in patients presenting with rectal bleeding and associated symptoms. Using a digital practice patient file, physicians participating in the study were able to continuously transmit data electronically to the researchers of the study about diagnostics, referrals, hospital admissions, and final diagnoses. RESULTS: During the course of 1 year, 94 participating physicians collected data on 1584 patients. Information about treating rectal bleeding was recorded for 422 patients; 60% of the patients were referred to specialists in internal medicine or gastroenterologists for further diagnostics. A colonoscopy was the most frequently performed diagnostic procedure (46.2%). Twenty-two per cent (n = 93) of the patients--54 of them aged 50 years and above--were exclusively treated by their GP without conducting a colonoscopy or cooperating with specialists. For these patients, GPs diagnosed less severe diseases like haemorrhoids or other proctologic diseases. CONCLUSION: By using a study that allows GPs to transmit electronically their findings and data, it is possible to draw a picture of treatment strategies of GPs in patients presenting with rectal bleeding. The high percentage of patients who received medical treatment in consultation with specialists underscores the significance of the sign of rectal bleeding in general practice. The need for further diagnostic measures in patients who have been treated exclusively by GPs has to be discussed.     

Impact of referral letters on scheduling of hospital appointments: a randomised control trial

Background

Communication is essential for triage, but intervention trials to improve it are scarce. Referral Writer (RW), a referral letter software program, enables documentation of clinical data and extracts relevant patient details from clinical software.

Aim

To evaluate whether specialists are more confident about scheduling appointments when they receive more information in referral letters.

Design and setting

Single-blind, parallel-groups, controlled design with a 1:1 randomisation. Australian GPs watched video vignettes virtually.

Method

GPs wrote referral letters after watching vignettes of patients with cancer symptoms. Letter content was scored against a benchmark. The proportions of referral letters triagable by a specialist with confidence, and in which the specialist was confident the patient had potentially life-limiting pathology were determined. Categorical outcomes were tested with χ² and continuous outcomes with t-tests. A random-effects logistic model assessed the influence of group randomisation (RW versus control), GP demographics, clinical specialty, and specialist referral assessor on specialist confidence in the information provided.

Results

The intervention (RW) group referred more patients and scored significantly higher on information relayed (mean difference 21.6 [95% confidence intervals {CI} = 20.1 to 23.2]). There was no difference in the proportion of letters for which specialists were confident they had sufficient information for appointment scheduling (RW 77.7% versus control 80.6%, P = 0.16). In the logistic model, limited agreement among specialists contributed substantially to the observed differences in appointment scheduling (P = 35% [95% CI 16% to 59%]).

Conclusion

In isolation, referral letter templates are unlikely to improve the scheduling of specialist appointments, even when more information is relayed.     

Midwife-led debriefing after operative birth: four to six year follow-up of a randomised trial [ISRCTN24648614]

Background

As part of the NHS plan it was suggested that all patients receive copies of letters sent to their General Practitioner following outpatient consultations. The former Secretary of State for Health extended this proposal, suggesting that patients have a specific letter to themselves after a hospital consultation.

Methods

The aim of this study was to send cardiorespiratory patients attending Charing Cross Hospital, a copy of the letter sent to their G.P. plus a specific letter to themselves and to assess the usefulness and comprehensibility of each. The letters were analysed for dictation time, Flesch Reading Ease Score, Flesch-Kincaid Grade Level and word count. Eighty-four out of 105 sequential patients (80%) consented and were sent both types of letter after their attendance. Patients returned both letters circling any items they did not understand and stated a preference for the GP letter, patient letter, or both. The patients' GPs were subsequently also asked for their views on each letter.

Results

GP letters took significantly longer to dictate than patient letters. The Flesch Reading Ease Score was significantly higher in the patient letters, indicating that the patient letters were easier to read. The GP letters were significantly longer than the patient letters and patients were significantly more likely to circle more items in the GP letters (p < 0.001). The content of letters is sometimes inaccurate. Thirty-six out of 62 patients (58%) would like to receive both letters, 13/62 (21.6%) would prefer the GP letter and 13/62 (20%) wanted only the patient letter. 45 GPs replied (62.5%), 28/45 (62.5%) wanted the GP letter, 14 GPs (31.1%) wanted both letters and 3/45 (6.7%) wanted the patient letter only. General themes concerned insufficient clinical details and the GPs preferred the structure of the letters written to them.

Conclusion

Patients appreciate copies of the letter being sent to their GP but comprehension is less good than with a shorter letter written especially to the patient. More attention needs to be paid to making letters to GPs simpler to read without losing the structure and detail liked by GPs. A compromise might be to dictate the letter in front of the patient and to provide a speciality-specific glossary to accompany each letter.     

How do patients in a rural setting respond to receiving a copy of their general practitioners letter?

The practice of sending copies of General Practitioners (GPs) letters to patients is not new. As a team in Geriatric and general internal medicine in a rural secondary referral hospital, we asked patients for feedback on how they felt about copies of their GPs letters being sent to them. 126 (96%) of patients were not frightened by the letter. 110(85%) would prefer to continue receiving these letters. Patients in a rural setting want to receive letters about their own medical care.     

General practitioner referral to specialist psychiatric services: a comparison of practices in north- and south-Verona

Specialist psychiatric services run by the Italian National Health Service are mainly hospital-based in North-Verona and community-based in South-Verona. Ninety-two GPs from both areas participated in a one-day survey of their provision of psychiatric care, and this paper focuses on socio-demographic and clinical variables associated with specialist psychiatric referral. The one-day prevalence figure for GP referral to specialist psychiatric services was 7.3% (17.6/10,000): the figures did not differ between the sexes or between the two areas. Whereas in North-Verona 49% of the patients referred were sent to the two local hospital-based public services and 51% to other agencies (mainly to private psychiatrists), in South-Verona 71% of referrals were to the community-based public service. Log-linear analysis showed that past psychiatric history, psychological presenting complaint, social problems and GPs' psychiatric diagnosis exerted positive joint main effects on GP referral to specialist psychiatric services, and that diagnosed organic illness had a negative effect in this regard. In the presence of a psychological complaint, a psychiatric diagnosis proved to be quite unimportant, so that those without a psychiatric diagnosis were just as likely to be referred as those with one. However, in the absence of a psychological complaint a GP diagnosis of depression greatly increased the risk of referral. Though the type of psychiatric service proved not to be an important determinant of GP referral to specialist psychiatric services it influenced the GPs' choice of referral agency.     

Primary care access to computed tomography for chronic headache

Background

The diagnostic yield of neuroimaging in chronic headache is low, but can reduce the use of health services.

Aim

To determine whether primary care access to brain computed tomography (CT) referral for chronic headache reduces referral to secondary care.

Design of study

Prospective observational analysis of GP referrals to an open access CT brain scanning service.

Setting

Primary care, and outpatient radiology and neurology departments.

Method

GPs in Tayside and North East Fife, Scotland were given access to brain CT for patients with chronic headache. All referrals were analysed prospectively over 1 year, and questionnaires were sent to referrers to establish whether imaging had resulted in or stopped a referral to secondary care. The Tayside outpatient clinic database identified scanned patients referred to the neurology clinic for headache from the start of the study period to at least 1 year after their scan.

Results

There were 232 referrals (55.1/100 000/year, 95% confidence interval = 50.4 to 59.9) from GPs in 59 (82%) of 72 primary care practices. CT was performed on 215 patients. Significant abnormalities were noted in 3 (1.4%) patients; there were 22 (10.2%) non-significant findings, and 190 (88.4%) normal scans. Questionnaires of the referring GPs reported that 167 (88%) scans stopped a referral to secondary care. GPs referred 30 (14%) scanned patients to a neurologist because of headache. It is estimated that imaging reduced referrals to secondary care by 86% in the follow-up period.

Conclusion

An open access brain CT service for patients with chronic headache was used by most GP practices in Tayside, and reduced the number of referrals to secondary care.     

Underperforming doctors in general practice: a survey of referrals to UK Deaneries.

BACKGROUND: National Health Service Executive guidelines for rehabilitation of general practitioners (GPs) who require professional support state that these GPs should be advised to contact the Director of Postgraduate General Practice Education in their Deanery. There has been concern about how the needs of these GPs can be met without additional resources. AIM: To monitor and describe the process and outcome of these referrals over a two-year period to assess the size of the problem, to share good practice, and to identify any deficiencies in the system. DESIGN OF STUDY: Quarterly postal questionnaires. SETTING: Deaneries in the United Kingdom, which are geographically-based organisational units for the management of general practice education. METHODS: Three postal questionnaires were devised to cover General Medical Council (GMC) referrals to Deaneries, health authority referrals, and referrals made by Deaneries to the GMC Non-responders were contacted by telephone. RESULTS: Twenty-seven GPs were referred by the GMC, 72 were referred by health authorities, and 18 referrals were made by Deaneries to the GMC. The information provided to Deaneries by the GMC was timely in just over half the cases, and was left to be appropriate in two-thirds of cases. Information provided by health authorities was almost always timely, detailed, and appropriate. The action required by the GMC was felt to be inappropriate in five cases, and not feasible in eight cases. No extra resources were available in the majority of cases. Information about outcome for the GP was either unavailable or unclear in over half the cases. CONCLUSION: This monitoring exercise has revealed several deficiencies in the system for dealing with the educational needs of underperforming GPs. There is a needfor a clear national protocol for referral of GPs to Deaneries and for the support that Deaneries can be expected to provide.     

An analysis of referral patterns for dizziness in the primary care setting.

BACKGROUND: The majority of balance disorders are non life-threatening and symptoms will resolve spontaneously. However, some patients require further investigation and many disorders may benefit from specialist treatment it is unclear whether appropriate identification and referral of this group of patients presently occurs. AIM: To review the management of patients with symptoms of dizziness within primary care. METHOD: A retrospective review of the management of 503 patients who visited their general practitioner (GP) complaining of dizziness between August 1993 and July 1995. Management was then compared with local criteria. RESULTS: On average, 2.2% of patients per year at the practices studied consulted their GP about dizziness, amounting to 0.7% of all consultations. The most common GP diagnosis was of an ear, nose, and throat (ENT) disorder (33.8%). Similarly, many of the 16% referred were directed to ENT (36%) specialists. The proportion of patients referred was significantly higher in those seeing their GP at least twice, those with symptoms lasting a year or more, or where there were additional symptoms associated with the dizziness, indicative of a cardiac, ENT, or neurological disorder. Compared with the local criteria, 17% of management decisions were deemed inappropriate. The major failing was not referring appropriate patients. This group comprised patients with chronic, non-urgent symptoms, and were significantly older than those appropriately referred. CONCLUSION: Patients with chronic symptoms of dizziness, particularly the elderly, are under-referred for specialist consultation and, therefore, do not have access to appropriate treatment regimes. This suggests a need for further training of GPs and evaluation of therapeutic needs of elderly dizzy patients.     

Referral for minor mental illness: a qualitative study.

BACKGROUND: Mild depression and anxiety are common problems in general practice. They can be managed by the general practitioner (GP) alone or referred. Previous quantitative studies have shown a large variation between GPs in terms of referral behaviour. The reasons for this variation are not fully understood. AIM: To describe and analyse GP's decision-making processes when considering who should be treating patients with minor mental illness, using a qualitative method. DESIGN OF STUDY: A qualitative interview study. SETTING: Twenty-three GPs in east London and Essex. METHOD: Subjects were chosen using a purposive sampling strategy and participated in one-to-one semi-structured interviews. A grounded theory approach was used for analysis. RESULTS: Two distinct referral strategies were identified--the 'containment' and the 'conduit' approaches. In addition, referrals were found to be of two types--proactive 'referrals to' and reactive 'referrals away'; for minor mental illness the 'referrals away' were found to predominate. Emotive as well as rational responses informed GP decision making on referral. CONCLUSIONS: Explanations of the variation in referral rates need to recognise the emotive responses of individual GPs to minor mental illness. The contribution of guidelines, which assume consistently rational responses to illness, may therefore be limited.     

GP referral to an eating disorder service: why the wide variation?

BACKGROUND: Early detection and management of patients with eating disorders is thought to improve prognosis, yet little is known about the factors associated with referral of these patients to treatment centres. AIM: To calculate general practitioner (GP) referral rates to a specialist eating disorder service and determine the association between referral rate and general practice and practitioner factors. METHOD: Referral rate was calculated from a database of routine referrals to St George's Hospital Eating Disorder Service from January 1990 to May 1996 and correlated with practice and practitioner details obtained from medical directories and health authority data. RESULTS: There was a wide variation in referral rates. A higher referral rate was found to be associated with practice size, proximity to the clinic, female GPs, GPs having the MRCGP qualification, being United Kingdom qualified, and offering full contraceptive services. Fundholding was associated with lower rates of referral. CONCLUSION: Patients with eating disorders may be at a disadvantage in certain practices. Educational interventions could be targeted towards low referrals.     

Should GPs have direct access to imaging for children with urinary tract infections? An observational study.

BACKGROUND: All children with urinary tract infections (UTIs) should undergo imaging of the urinary tract. The Royal College of Radiologists currently recommends that such children should be referred to a paediatric specialist prior to imaging. AIM: To investigate whether direct referral of such children by general practitioners (GPs) for imaging offers advantages over the traditional approach. METHOD: Information on 100 children with UTIs, who were referred direct for imaging by GPs according to an agreed protocol, was compared with information on 100 children with UTIs referred initially to paediatric specialists. RESULTS: Protocol-guided direct referral resulted in less delay prior to imaging, no evidence of inappropriate referral (as judged by urinalysis and yield from imaging), greater consistency of follow-up arrangements, and a considerable saving in outpatient department (OPD) appointments. There was no increase in the overall number of referrals for imaging. CONCLUSION: Given agreed protocols, there is no basis for current recommendations that GPs should not refer children with UTIs for imaging without a prior paediatric opinion.     

Children referred for specialist care: a nationwide study in Dutch general practice.

BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.     

A qualitative study to investigate why patients accept or decline a copy of their referral letter from their GP

BACKGROUND: Our practice in Northumberland has offered patients copies of their clinical referral letters for almost 3 years. However, many patients declined this offer and this qualitative study was conducted to determine why almost 80% of patients offered a copy of their referral letter opted not to receive one. AIM: To discover why some patients accepted and others declined a copy of the letter written from GP to specialist. DESIGN OF STUDY: A qualitative focus-group study. SETTING: General practice in Northumberland. METHOD: Three focus groups of referred patients were created, and discussions were taped, transcribed and analysed for major themes. RESULTS: The patients chose to accept or decline a copy of their referral letter for diverse reasons. However, most felt that the ability to choose for themselves whether to have a copy or not was essential. CONCLUSIONS: The concept of trust in their GP was a major theme that patients related was often behind their decision to decline a copy of their letter. These results, if transferable, may have implications for the application of this policy.     

Copying referral letters to patients: the views of patients, patient representatives and doctors

To discover the views of patients, patient representatives and doctors on copying referral letters to patients. A three-part study: an analysis of 50 GP referral letters against a standard template; 35 patient interviews using a semi-structured questionnaire in outpatient waiting rooms; 3 focus groups of patients, patient representatives and doctors. There was general agreement that copying referral letters to patients could improve information and decision sharing with patients. Copying referral letters could provide an opportunity for patients to correct mistakes, prepare for their appointments and have a personal record that they could keep and show to others. However, there were concerns about letter content, particularly medical terminology, character judgements and "sensitive" patient information. It was also recognised that providing more information to patients could increase patient anxiety. The style and content of some referral letters may need to change. This is particularly relevant where certain types of information included in referral letters could cause distress for patients or influence the time that patients have to wait for their outpatient appointments.