Figure - uploaded by Siri Malm
Content may be subject to copyright.
Referral pathway. Flow of referral and process of care in the intervention (blue arrows) and control group (red arrows).
Source publication
Background
The referral letter plays a key role both in the communication between primary and secondary care, and in the quality of the health care process. Many studies have attempted to evaluate and improve the quality of these referral letters, but few have assessed the impact of their quality on the health care delivered to each patient.
Metho...
Context in source publication
Similar publications
The referral letter is an important document facilitating the transfer of care from a general practitioner (GP) to secondary care. Hospital doctors have often criticised the quality and content of referral letters, and the effectiveness of improvement efforts remains uncertain.
A cluster randomised trial was conducted using referral templates for p...
Citations
... 18 There is need for the evaluation of the cost-effectiveness of the increased workload in primary care and the community in a resource-limited NHS in the long term. 18 Poor communication between primary and secondary care has been reported for inflammatory bowel disease, 31 cancer, 32 dyspepsia, colonic malignancy, chest pain and chronic obstructive pulmonary disease, 33 and CF was not perceived to increase communication. However, quick electronic advice was associated with CF and is highly valued by GPs, 29 and email communication between primary and secondary care was found to provide quick answers for advice or reassurance and enhance patient benefits such as unnecessary referrals. ...
Objective
Exploring the views of stakeholders to the referral management systems (RMS) used by GP practices in Northumberland, UK to evaluate its perceived effectiveness.
Design
This was an in-depth qualitative semi-structured interview study.
Participants and setting
32 participants (GPs, hospital consultants, referral support, hospital managers, Clinical Commissioning Group manager) in the North East of England, UK.
Method
Interviews using a grounded theory approach and thematic analysis.
Results
The main benefit of RMS mentioned by participants was that it allowed for unnecessary referrals to be vetted by consultants, and helps ensure patients are sent to the correct clinic. Generally, the consultants in our study felt that RMS did not significantly help them reject referrals. Some GPs experienced that RMS undermined GP autonomy and did not help when they had exhausted their abilities to manage a patient in primary care, and it was suggested that in some cases RMS may delay rather than prevent a referral. The main perceived disadvantage of RMS was the additional workload for GPs and consultants, and RMS was felt to be a barrier to commutation between GPs and consultants. Frustration with the system design and lack of knowledge of its cost-effectiveness were articulated.
Conclusion
Although RMS was reported to reduce some unnecessary referrals, the effect of referral delay and rejection is unknown. Although there were some positive attributes described, RMS was mostly received negatively by the stakeholders.
... There are a variety of descriptions related to the working relationships between nurses and physicians and thereby the relationships with patients within the healthcare system, most of which are described in terms of cooperation, 28 collaboration, 29 teamwork, 29 or partnership. 30 Cooperation comes from the Latin verb cooperari and is described as 'the process of working together to the same end'. ...
... 31 In healthcare, cooperation is often used to describe a healthcare process, such as the referral of patients between primary and secondary healthcare. 28 Collaboration, on the other hand, derives from the Latin collaboratio -working together. As such, it describes 'the action of working with someone to produce or create something'. ...
This study aimed to explore how diabetes specialist nurses (DSNs) discursively construct and reconstruct their professional position in their working relationships with physicians and thereby the relation with patients in primary healthcare in Sweden. Twenty-nine DSNs working in diabetes care from 21 primary healthcare centres were included in focus-group interviews. The interviews were analysed using discourse analysis. From a social constructionist perspective, findings showed that the working relationship between the DSNs, physicians and thereby the relation with patients was discursively constructed as a relationship within a gendered discourse. The DSNs constructed their subject position metaphorically as ‘mothers’ in this relationship. The construction of doing gender implies that the DSNs became visible as biological women, but invisible in being perceived as competent, well-educated professionals, because skills such as multitasking and versatility are often associated with female abilities.
... Patients, hospital doctors, and outcome evaluators were blinded to the intervention status of the patient; participating GPs could not be blinded since they actively used the intervention. Further details about the randomization and study methods are described elsewhere [35]. ...
... It was intended that the intervention referrals within the project would be sent to a specific electronic address at UNN Harstad to enable assessment of intervention uptake. The intervention was in use from September 2011 to November 2013 and stopped after the planned period of approximately 2 years [35]. The control group followed normal referral practice. ...
... Patients were recruited from September 2011 until February 2014. Further details about the randomization and recruitment processes are described elsewhere [35]. ...
Background
The assessment of quality of care is an integral part of modern medicine. The referral represents the handing over of care from the general practitioner to the specialist. This study aimed to assess whether an improved referral could lead to improved quality of care. MethodsA cluster randomized trial with the general practitioner surgery as the clustering unit was performed. Fourteen surgeries in the area surrounding the University Hospital of North Norway Harstad were randomized stratified by town versus countryside location. The intervention consisted of implementing referral templates for new referrals in four clinical areas: dyspepsia; suspected colorectal cancer; chest pain; and confirmed or suspected chronic obstructive pulmonary disease. The control group followed standard referral practice. Quality of treatment pathway as assessed by newly developed quality indicators was used as main outcome. Secondary outcomes included subjective quality assessment, positive predictive value of referral and adequacy of prioritization. Assessment of outcomes was done at the individual level. The patients, hospital doctors and outcome assessors were blinded to the intervention status. ResultsA total of 500 patients were included, with 281 in the intervention and 219 in the control arm. From the multilevel regression model the effect of the intervention on the quality indicator score was insignificant at 1.80% (95% CI, −1.46 to 5.06, p = 0.280). No significant differences between the intervention and the control groups were seen in the secondary outcomes. Active use of the referral intervention was low, estimated at approximately 50%. There was also wide variation in outcome scoring between the different assessors. Conclusions
In this study no measurable effect on quality of care or prioritization was revealed after implementation of referral templates at the general practitioner/hospital interface. The results were hindered by a limited uptake of the intervention at GP surgeries and inconsistencies in outcome assessment. Trial registrationThe study was registered under registration number NCT01470963 on September 5th, 2011.
... This article presents the patient experience aspect of a cluster randomised study evaluating the effect of the implementation of referral templates for four diagnostic groupsdyspepsia, suspected colorectal cancer, chest pain and chronic obstructive pulmonary disease (COPD)-in the patient referral pathway. 11 Previously, we have shown that the referral templates led to increased referral quality, 12 publication. This publication aims to assess whether the implementation of a referral template in the transition of care from the general practitioner (GP) to the hospital has affected the patient experience of the care process. ...
... An additional weakness was the lack of a sound analytical plan proposed in the methods paper. 11 To ensure transparency, the analysis presented in this paper is therefore simple and based on single-question assessment. Given the clustered nature of the study, an assessment of clustering is given for a subsection of the questionnaire, but very little effect was seen. ...
Objectives
To evaluate if a referral intervention improves the patient experience of the referral and treatment process.
Setting
Interface between 14 primary care surgeries and a district general hospital.
Participants
The 14 general practitioner (GP) surgeries (7 intervention, 7 control) in the area around the University Hospital of North Norway Harstad were randomised and all completed the study. Consecutive individual patients were recruited at their hospital appointment. A total of 500 patients were recruited with 281 in the intervention and 219 in the control arm.
Interventions
Dissemination of referral templates for 4 diagnostic groups (dyspepsia, suspected colorectal cancer, chest pain and chronic obstructive pulmonary disease) coupled with intermittent surgery visits by study personnel. The control arm continued standard referral practice. The intervention was in use for 2.5 years.
Outcome
The main outcome was a quality indicator score. This paper reports a secondary outcome, the patient experience, as measured by self-report questionnaires. GPs in the intervention group could not be blinded. Patients were blinded to intervention status. Analysis was based on single-question comparison with a questionnaire subscore used to assess the effect of clustering.
Results
On the individual questions, overall satisfaction was very high with minor differences between the intervention and control group. Interestingly, the most negative responses, in both groups concerned questions relating to patient interaction and information. Very little evidence of clustering was found with an estimated intracluster correlations coefficient at 1.21e⁻¹¹.
Conclusions
In total, this indicates no clear effect of the implementation of referral templates on the patient experience, in a setting of generally high patient satisfaction.
Trial registration number
NCT01470963; Results.
... This paper is part of a larger study assessing the effect of a referral intervention on the quality of health care delivered to individual patients. Information about further assessments within the referral project is available in the published methods paper [22]. ...
... However, in some cases the referral letter revealed the intervention status. Further information about study methods are available in detail in the methods paper [22]. ...
... Children (<18 years of age) and patients with reduced capacity to consent were excluded from the project. Further details about the GP surgeries and the recruitment process are published in the methods paper [22]. ...
The referral letter is an important document facilitating the transfer of care from a general practitioner (GP) to secondary care. Hospital doctors have often criticised the quality and content of referral letters, and the effectiveness of improvement efforts remains uncertain.
A cluster randomised trial was conducted using referral templates for patients in four diagnostic groups: dyspepsia, suspected colorectal cancer, chest pain and chronic obstructive pulmonary disease. The GP surgery was the unit of randomisation. Of the 14 surgeries served by the University Hospital of North Norway Harstad, seven were randomised to the intervention group. Intervention GPs used referral templates soliciting core clinical information when initiating a new referral in one of the four clinical areas. Intermittent surgery visits by study personnel were also carried out. A total of 500 patients were included, with 281 in the intervention and 219 in the control arm. Referral quality scoring was performed by three blinded raters. Data were analysed using multi-level regression modelling. All analyses were conducted on intention-to-treat basis.
In the final multilevel model, referrals in the intervention group scored 18 % higher (95 % CI (11 %, 25 %), p < 0.001) on the referral quality score than the control group. The model also showed that board certified GPs and GPs in larger surgeries produced referrals of significantly higher quality.
In this study, the dissemination of referral templates coupled with intermittent surgery visits produced higher quality referrals.
This trial has been registered at ClinicalTrials.gov. The trial registration number is NCT01470963 .
... 48 Deficient interdisciplinary communication across the continuum of care may explain a part of problems experienced with patient referrals and prioritization along with delayed treatments. 49 In 2009, as an attempt to solve this problem and help lift the burden of CNCP, the Quebec Health Ministry designated four Pain Centers of Expertise (PCE) across the province with the mandate of improving the management of chronic pain by implementing an integrated and hierarchical continuum of services. Each PCE includes: 1) one or more tertiary care multidisciplinary pain treatment clinic affiliated with one tertiary care rehabilitation center; 2) designated regional secondary pain clinics; and 3) designated local primary care clinics. ...
Purpose
There is evidence that the management of chronic non-cancer pain (CNCP) in primary care is far from being optimal. A 1-day workshop was held to explore the perceptions of key actors regarding the challenges and priority interventions to improve CNCP management in primary care.
Methods
Using the Chronic Care Model as a conceptual framework, physicians (n=6), pharmacists (n=6), nurses (n=6), physiotherapists (n=6), psychologists (n=6), pain specialists (n=6), patients (n=3), family members (n=3), decision makers and managers (n=4), and pain researchers (n=7) took part in seven focus groups and five nominal groups.
Results
Challenges identified in focus group discussions were related to five dimensions: knowledge gap, “work in silos”, lack of awareness that CNCP represents an important clinical problem, difficulties in access to health professionals and services, and patient empowerment needs. Based on the nominal group discussions, the following priority interventions were identified: interdisciplinary continuing education, interdisciplinary treatment approach, regional expert leadership, creation and definition of care paths, and patient education programs.
Conclusion
Barriers to optimal management of CNCP in primary care are numerous. Improving its management cannot be envisioned without considering multifaceted interventions targeting several dimensions of the Chronic Care Model and focusing on both clinicians and patients.
... Good communication between primary and secondary/tertiary care is essential for the smooth running of any health-care system. [2] Poor communication may result in disruptions in continuity of care, delayed diagnosis, increased costs through duplication of services, iatrogenic complications, [3] erroneous prioritization, [4] erosion of patient confidence and patient dissatisfaction. [2] Studies have shown that a comprehensive referral may help to ensure that the right patients are seen by specialists sooner rather than later. ...
Background: Communication between primary care doctors and specialists/hospital doctors is vital for smooth functioning of a health care system. In many instances referral and reply letters are the sole means of communication between general practitioners and hospital doctors/specialists. Despite the obvious benefits to patient care, answers to referral letters are the exception worldwide. In Sri Lanka hand written conventional letters are used to refer patients and replies are scarce. Materials and Methods: This interventional study was designed to assess if attaching a structured reply form with the referral letter would increase the rate of replies/back-referrals. It was conducted at the Family Medicine Clinic of the Faculty of Medicine, University of Kelaniya. A structured referral letter (form) was designed based on guide lines and literature and it was used for referral of patients for a period of six months. Similarly a structured reply form was also designed and both the referral letter and the reply letter were printed on A4 papers side by side and these were used for the next six months for referrals. Both letters had headings and space underneath to write details pertaining to the patient. A register was maintained to document the number of referrals and replies received during both phases. Patents were asked to return the reply letters if specialists/hospital doctors obliged to reply. Results: Total of 90 patients were referred using the structured referral form during 1st phase. 80 letters (with reply form attached) were issued during the next six months. Patients were referred to eight different specialties. Not a single reply during the 1 st phase and there were six 6 (7.5%) replies during the 2 nd phase. Discussion: This was an attempt to improve communication between specialists/hospital doctors and primary care doctors. Even though there was some improvement it was not satisfactory. A multicenter island wide study should be conducted to assess the acceptability of the format to primary care doctors and specialists and its impact on reply rate.
Background:
The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.
Methods:
A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.
Results:
A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.
Conclusions:
Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
Background:
Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources.
Objectives:
To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting.
Search methods:
We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies.
Selection criteria:
We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD.
Data collection and analysis:
Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations.
Main results:
We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes.
Authors' conclusions:
The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.
