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

Henrik Wåhlberg,Siri Malm,Per Christian Valle,Ann Ragnhild Broderstad

doi:10.1186/s12913-015-1017-7

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.

Highlights

The referral letter is an important document facilitating the transfer of care from a general practitioner (GP) to secondary care
To ensure intervention implementation by keeping it as simple as possible, we reduced the number of items in the referral template to include only those that the specialists felt were imperative in a referral for that clinical area
The groups appear similar, except that more referrals were initiated by male GPs in the control group than in the intervention group, which is probably caused by the slightly higher number of male GPs in the control group

Summary

Introduction

The referral letter is an important document facilitating the transfer of care from a general practitioner (GP) to secondary care. A high quality referral process will generally involve referral letters containing all necessary information in a context of shared understanding between GPs, patients and hospital staff [15]. In Norway, the Norwegian Centre for Informatics in Health and Social Care (KITH) has developed guidelines governing the content of electronic referral and discharge letters [17, 18]. These guidelines present headings and content categories, but do not specify the precise clinical information required for different clinical

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Discussion

Conclusion