The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial

Abstract

BackgroundThe 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.ConclusionsIn 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2127-1) 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

“…The authors conceded that the study lacked a solid analytical framework. A final analysis (Wahlberg et al ., 2017) investigated the impact of the referral template on the quality of care received in the hospital and, similarly, no significant improvement in hospital care was observed. A large number of assessors were involved in grading the quality of referrals, which may have implications for reproducibility of the findings.…”

Examining the Association Between Referral Quality, Wait Time and Patient Outcomes for Patients Referred to an IBD Specialty Program

“…An intuitive first-step solution to address the quantity of low-quality referrals would be to develop and implement a mandatory standardized IBD referral form; however, we found that although a standard form was available, it was only used 7.5% of the time. Previous research also supports that standard forms are rarely used by referring providers ( 24 ). This study found that referring providers significantly influence patient wait time.…”

Electronic checklists improve referral letters in gastroenterology: a randomized vignette survey

“…The present study provides new evidence regarding the value of clinical checklists, and to our knowledge, it is one of few studies assessing the impact of electronic checklists on the clinical assessment of referral letters [ 21 , 25 ]. Studies evaluating the impact of improved referral quality on patient outcomes are also scarce [ 25 – 29 ].…”

“…However, no significant changes were detected in patient outcomes. Wahlberg et al [ 22 ] showed improved referral quality after implementing referral templates for dyspepsia, colorectal cancer, chest pain and chronic obstructive pulmonary disease, but were not able to show any impact on prioritization of the patients [ 29 ].…”