Facilitators and barriers to improving the quality of referrals for potential oral cancer

Abstract

The quality and content of referral letters are important for prioritisation of patients who may have oral cancer. Referrals letters to the Oral Medicine Clinic at Birmingham Dental Hospital were analysed and practitioners interviewed. Whilst acceptable for general purposes, most letters did not contain sufficient information to allow effective prioritisation. Interviews disclosed a misunderstanding amongst practitioners about the way in which referrals were handled. A number of barriers to increasing the information included in letters were identified. Referral guidelines and a standardised proforma might help improve the ability of the service to operate a fast-track system.

The two-week wait cancer initiative on oral cancer; the predictive value of urgent referrals to an oral medicine unit

“…10 Among 120 oral cancers diagnosed in a hospital setting, only 75% had an indication of a suspected malignancy. 10 White et al 11 speculated that a high proportion of dental practitioners were unaware of the mechanisms in place for urgent oral medicine referrals. The fi nding that only four of the letters suspecting a malignancy or giving features of a malignancy were received on a two-week wait cancer pro-forma suggest that improvements in communication on cancer referral guidelines by primary care trusts with local medical and dental practitioners is needed.…”

The use of tools to support oral lesion description in oral medicine referrals

“…9 In order to be useful, referral documents must provide organized information, rhetorical relevance, appropriate level of detail, and be concise. 12,14 However, several studies have reported that referral letters often lack important information, 7,8,9,10,12,13,15,16 which can result in problems such as improper scheduling, prioritization errors, 9,11,13 unnecessary repetition of tests 7 and, ultimately, inadequate care and delay in treating the illness. 10 Several studies aimed at defining the necessary information for the referral of patients.…”

“…8,9,10,12,16,17 Depending on the specialty, the clinical description of the lesion is considered essential. 9,12,13,16 Lesion details may include type (primary morphology), 13,16 size, 9,16 location, 12,13,16 color and eventual ulceration, 9,13 shape and consistency, 9 thickness, texture, presence of rolled margin (in the case of oral squamous cell carcinoma), 13 duration, 12,16 symptoms, 12,16 clinical diagnosis, 12,16 suspicion of malignancy, 17 risk factors for disease, and management details, such as use of medications/mouthwash, previous biopsy or denture/tooth adjustment. 13 Specific strategies have been suggested to improve the content of referral documents, such as the use of support tools, 6,10,16 investment in education and training of professionals, 6,10 and the use of electronic referrals.…”

“…8,18,19 Some studies evaluated the quality of the referral documents specifically within the Oral Medicine field. 9,12,13,16 The use of guidelines or forms seems to result in the inclusion of a greater amount of information and detail in the referral documents, resulting in improved quality. 9,10,13,16,20 Some authors, however, found no improvement with the use of these instruments.…”

“…7,8,9 In some situations, referral documents are the only means available for this exchange, 10,11,12 and may also affect the quality of care offered to the patients. 9,10,13 The quality of these documents is therefore essential for proper health care, and its contents should allow assessing the clinical need and the urgency for appointments. 9 In order to be useful, referral documents must provide organized information, rhetorical relevance, appropriate level of detail, and be concise.…”