Impact of referral templates on the quality of referrals from primary to secondary care: a cluster randomised trial

Abstract

BackgroundThe 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.MethodsA 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.ResultsIn 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.ConclusionIn this study, the dissemination of referral templates coupled with intermittent surgery visits produced higher quality referrals.Trial registrationThis trial has been registered at ClinicalTrials.gov. The trial registration number is NCT01470963.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1017-7) contains supplementary material, which is available to authorized users.

Improving quality of referral letters from primary to secondary care: a literature review and discussion paper

“…Evans (2009) 4 Improvement in referral quality and reducing inappropriate demand Xiang et al (2013) 3 Improvement in referral quality and decisions made will be more accurate Elwyn et al (2007) 3 Improving the quality of referrals and reducing demand Templates Haley et al (2015) 3 Improvement in documentation Rokstad et al (2013) 4 Improvement in referral quality and in time efficiency by the specialist reviewing the letters Wahlberg et al (2015) 3 Improvement in documentation Wahlberg et al (2016) 3 Sought to prove association with patient experience compared with control but none seen Wahlberg et al (2017) 3 Sought to prove association with improved quality of care through quality indicators but none seen Eskeland et al (2017) 3 Improvement in referral quality Jiwa et al (2014) 3 Improvement in documentation of clinically relevant data. Referral times unchanged.…”

“…There were problems with the implementation of the intervention as many GPs who agreed to use the template did not continue to do so, which may reflect a problem with usability of the template. Wahlberg et al (2015) conducted a randomised cluster trial using templates for four commonly encountered, potentially serious presenting complaints across 14 practices in Norway. Statistically significant improvements in quality of referral letters were associated with three of the four templates were reported.…”

Impact of referral templates on patient experience of the referral and care process: a cluster randomised trial

“…There was no major difference between the intervention and control group with regard to gender, age, urban or rural residency or questionnaire response. The effect of the referral intervention on referral quality has previously been shown to be clinically significant with an effect of 18% (95% CI 11 to 25, p<0.001) 12. However, this was for the full data set of 500 patients.…”

“…It hence seems that although the intervention has increased the referral quality significantly,12 this has not translated into a more positive patient experience with the referral process and treatment, as measured by self-report questionnaires. In the current study, indepth data analysis with imputation and multilevel regression modelling was employed to further explore the effect of clustering.…”

“…Previously, we have shown that the referral templates led to increased referral quality,12 and the effect on the main outcome, quality of care at the hospital, is in 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.…”