GP Requests Research Articles

Evidence-based radiology 5years on-a single-centre review of image referral appropriateness.

The iRefer guidelines provide evidence-based recommendations on imaging and are designed to facilitate appropriate referrals and limit unnecessary radiation exposure. In 2017, a review at this institution assessed the appropriateness of imaging referrals. This study provides an update 5years later on the referral appropriateness and aims to assess what impact the previous review has had on referral appropriateness. A retrospective study of 945 referrals across GPs, ED, and inpatients was audited against the iRefer guidelines with costs and cumulative dose estimates calculated for inappropriate referrals considering salaries of those involved, the average time spent performing and reporting radiographs, and the median effective dose values. Results show a decrease in the volume of requests overall with the relative proportion of inappropriate requests rising significantly. Inappropriate requests for abdominal X-rays from GPs decreased from 72 to 37.5%, whereas inappropriate ED referrals increased from 38 to 46% and inappropriate inpatient requests remained static at 30%. The proportion of inappropriate GP requests for spinal radiographs significantly increased for cervical, thoracic, and lumbar spine radiographs, respectively (18 to 66%; 47 to 72%; 53 to 80%; p-value < 0.001). Inappropriate radiographs represent an increased financial and dose-based burden. The volume of radiograph requests reduced after over a 5-year interval; however, the relative proportion of inappropriate requests rose significantly. The iRefer guidelines provide a useful resource to ensure that imaging is used appropriately, effectively, and safely; however, more work is needed to ensure that requests are adhering to these guidelines.

Requesting patterns for faecal calprotectin before and after the introduction of a Medicare rebate

Background: Faecal calprotectin (FC) is a sensitive and specific marker for differencing between Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD).1 FC testing is more economical than other available diagnostic measures.2 The aim of the following study was to evaluate the effects of public funding provided for FC testing by the introduction of MBS items on requesting patterns. Method: FC requests received during the 3 months prior to the introduction of MBS items were compared to data during the same 3 months in the subsequent year (2022). Results: There was a 35.9% increase in FC requests following the introduction of MBS items. The increase in GP requests and specialist requests were 53.2% and 19.7%, respectively. Of all GP requests, 76.49% and 75.04% were under 50 years of age, before and after the item was introduced, respectively. Specialist requests include 54% prior to and 52.5% after the MBS item to be under 50 years of age. Conclusion: Requests for FC increased significantly following MBS introduction. A greater rise was seen in the GP setting than the specialist setting, without a rise in the under 50 year age group. Targeted education campaigns may enhance update of FC testing in both settings.

Universal electronic consultation program (e-consultation) of a cardiology department: long-term results in mortality

Abstract Background Many health systems have initiated electronic consultation programs, although little is known about their impact on accessibility, safety and satisfaction (1). The implementation of integrated electronic medical record projects between healthcare levels allows all healthcare professionals access to all the clinical information of patients, which is a key factor in optimizing the management of healthcare resources, facilitating the communication between professionals and avoiding medical acts that do not add value, always from the premise of safety and quality for patients (2). In our model, a General Practitioner sends an e-referral to the Cardiology Department (CD). A Cardiologist can either answer without needing the face-to-face consultation, or schedule the patient for a single act consultation. In our health area, from 2009 to 2012, a “single act” cardiology consultation model was implemented, according to which the appointment includes, on the same day, all the complementary tests that might be necessary for the diagnosis. From 2013 until present, an electronic consultation or e-consultation model has been implemented; consisting of a telematic evaluation of the e-consultation by a cardiologist, who can either solve the GP's requests directly or book an appointment for the patient in person, in cases where it is considered necessary (3). Purpose The aim of this study is to assess the clinical impact of the implementation of a model of outpatient care that includes an initial electronic consultation (e-consultation), comparing it with a face-to-face single act model. Methods We selected patients with at least one visit to the Cardiology Department between 2010 and 2019. Using an interrupted time series regression model, we analysed the impact of incorporating the e-consultation into the healthcare model (started in 2013), evaluating: waiting time for care and mortality. Results We analysed 47,377 patients: 61.9% attended by incorporating the e-consultation and 38.1% in the face-to-face consultation model. The delay time for care in the e-consultation model (median [IQR]: 7 days [5–13]) was shorter than in the face-to-face model (median [IQR]: 33 days [14–81]), p&amp;lt;0.001. The regression model for interrupted time series showed that the incorporation of e-consultation contributed a very important decrease in the delay of attention, remaining around 9 days, although with slight oscillations, Figure 1. The patients evaluated via e-consultation had less mortality (2.5% vs 3.9%, p&amp;lt;0.001), Figure 2. Conclusions An outpatient care program that includes an e-consultation has shown to reduce waiting times significantly and is a safe model with a lower rate of mortality over the first year after the consultation. Funding Acknowledgement Type of funding sources: None.

Universal electronic consultation program (e-consultation) of a cardiology department: long-term results in mortality

Abstract Background Many health systems have initiated electronic consultation programs, although little is known about their impact on accessibility, safety and satisfaction (1). The implementation of integrated electronic medical record projects between healthcare levels allows all healthcare professionals access to all the clinical information of patients, which is a key factor in optimizing the management of healthcare resources, facilitating the communication between professionals and avoiding medical acts that do not add value, always from the premise of safety and quality for patients (2). In our model, a General Practitioner sends an e-referral to the Cardiology Department (CD). A Cardiologist can either answer without needing the face-to-face consultation, or schedule the patient for a single act consultation. In our health area, from 2009 to 2012, a “single act” cardiology consultation model was implemented, according to which the appointment includes, on the same day, all the complementary tests that might be necessary for the diagnosis. From 2013 until present, an electronic consultation or e-consultation model has been implemented; consisting of a telematic evaluation of the e-consultation by a cardiologist, who can either solve the GP's requests directly or book an appointment for the patient in person, in cases where it is considered necessary (3). Purpose The aim of this study is to assess the clinical impact of the implementation of a model of outpatient care that includes an initial electronic consultation (e-consultation), comparing it with a face-to-face single act model. Methods We selected patients with at least one visit to the Cardiology Department between 2010 and 2019. Using an interrupted time series regression model, we analysed the impact of incorporating the e-consultation into the healthcare model (started in 2013), evaluating: waiting time for care and mortality. Results We analysed 47,377 patients: 61.9% attended by incorporating the e-consultation and 38.1% in the face-to-face consultation model. The delay time for care in the e-consultation model (median [IQR]: 7 days [5–13]) was shorter than in the face-to-face model (median [IQR]: 33 days [14–81]), p&amp;lt;0.001. The regression model for interrupted time series showed that the incorporation of e-consultation contributed a very important decrease in the delay of attention, remaining around 9 days, although with slight oscillations, Figure 1. The patients evaluated via e-consultation had less mortality (2.5% vs 3.9%, p&amp;lt;0.001), Figure 2. Conclusions An outpatient care program that includes an e-consultation has shown to reduce waiting times significantly and is a safe model with a lower rate of mortality over the first year after the consultation. Funding Acknowledgement Type of funding sources: None.

EHub: Enhancing the emergence of the electronic consultation

BackgroundAlternatives to face-to-face consulting (F2F) with patients have been developed including telephone consulting and e-consulting. One area of concern about both alternatives is that they may act to increase total consultation time by generating additional F2F consultation activity.AimTo determine the proportion of clinical e-consults where a GP requested a follow-up F2F consultation and to determine whether e-consultation training reduced the proportion of GP requests for a follow-up F2F consultation.MethodA longitudinal study was conducted observing ‘remote closure’ rates (the proportion of clinical e-consults with no F2F follow-up appointment) before and after the launch of a dedicated at scale electronic consultation ‘eHub’ with a bespoke technical and clinical training programme. Remote closure rates were available for 42 months prior and 22 months following the intervention. A follow-up GP consultation was defined as the doctor requesting the patient to make a F2F appointment.ResultsThe remote closure rates were 63% (3019/4778) before and 87% (6957/7993) after the intervention. χ2 with Yates correction 1024.9; P&lt;0.001.ConclusionThe consultation as a core competency of GP training requires specific skills for e-consulting. We have devised a training package for e-consultation training. Following implementation of a package of intensive e-consultation training, remote closure rates of 87% were obtained. Some of the observed increase in remote closure rates may have been attributable to increased familiarity of both GPs and patients with new models of consultation. We plan to test our e-consulting educational package in other settings with low e-consultation closure rates.

A Report into the Requesting of Lyme Disease Tests in the Immunoserology Department at Nobles Hospital, Isle of Man

Introduction: Lyme disease is caused by a spirochete infection of the genus Borrelia, transmitted through bites of the sheep tick Ixodes Ricinus on the Isle of Man. This can lead to a number of short-term non-specific symptoms, and longer-term debilitating effects. Objective: This study analyzed the requesting of Lyme disease serology at the Immunoserology laboratory at Noble’s Hospital in order to look for money saving opportunities. Materials and Methods: A data grab was performed on the LIMS system in use at Noble’s Hospital, Isle of Man, for Lyme disease testing requested over a five-year period, with results transferred to an Excel spreadsheet. This data was then sorted into various categories, including year-by-year and month-by-month totals, percentage of requests honored, source of requests, in-depth investigations of GP requests, and results of tests. Results: Findings indicated that Lyme disease requesting had doubled over this five-year period, with over twothirds of requests being from General Practitioners. Several surgeries were found to be requesting significantly more than the proportion of the population served indicated was appropriate. Discussion: In order to ensure that clinicians made suitable judgments, and therefore the best use of resources, this report makes three recommendations: 1. Communication sent to GP practices reminding them of the importance of testing only in the event of clinical suspicion, characteristic rash, and evidence of a tick bite. Limitations of testing and details of specialist advice from Rare and Imported Pathogens Laboratory (RIPL) also included. 2. RIPL contact information also added to the comment automatically applied to a negative sample. Comment added to positive samples regarding the limitations of the test, and RIPL contact details. 3. Information disseminated to the public regarding the Public Health England (PHE) Tick Surveillance Scheme in order to maintain epidemiological data.

The Development and Refinement of a Regional Model for Medicines Optimisation in Older People in the Intermediate Care Setting

Introduction: In December 2011, the Compton Review ‘Transforming Your Care’ (TYC) outlined the remodelling of Health and Social Care in Northern Ireland (HSCNI)1. Target Population: In line with TYC, the Western Health and Social Care Trust (WHSCT) introduced a consultant pharmacist led medicines optimisation case management service for older people (aged ≥65 years) admitted from acute into intermediate care (IC). Practice Change: Prior to this, pharmacy had a supply-only role in IC. The consultant pharmacist assumed pharmaceutical care responsibility of patients throughout their stay in IC and for 30 days post-discharge. Data collected over a 12-month period (2012 to 2013) demonstrated improvement in appropriateness of drugs prescribed together with drug cost savings (£68k pa) and cost avoidance due to subsequent reduced healthcare resource usage (£63k to £144k)2. This model was then refined to reflect IC services delivered anywhere in Northern Ireland. The main refinement involved the ‘origin of admission’ which may include: Acute care; Rapid Access Clinics; Older People Assessment Liaison Services; or GP requests for a step-up bed. Timeline: In August 2015 two specialist pharmacists were employed under the mentorship of a consultant pharmacist, one based in the WHSCT and the second based in the Northern Health and Social Care Trust (NHSCT) where the service was to be rolled out. Data collection is ongoing until December 2016; full results will be reported early 2017. Aim: The aim of this work was to test the refined model for reproducibility in another trust so as to inform the Department of Health on the ability to extend the service throughout Northern Ireland. Highlights: The WHSCT have reported interim results on patients (aged 82.1 ± 7.2 years, n=210) seen over six months whilst the NHSCT have data on patients reviewed over a 12 month period (aged 82.1± 7.8 years, n=322). In both trusts, there has been a significant improvement in the appropriateness of prescribing [measured using the Medications Appropriateness Index (MAI)3] with estimated drug cost savings of £103k to £107k pa should the service be delivered to 500 patients annually. Cost avoidance due to reduced healthcare resource usage via application of the ScHARR model4 to clinical interventions made by the pharmacists is in the range of £260 344 - £505 700 (WHSCT) and £328 580 - £542 740 (NHSCT). Sustainability/Transferability: Interim results suggest the refined model is both reproducible and transferable. Lesson Learnt/Conclusion: This innovative pharmacy service can be integrated into existing pharmacy services in other trusts whilst continuing to deliver positive clinical and economic outcomes.

PTU-154 Differences In Coeliac Serology Outcomes Appear Dependant Upon The Origin Of The Request: A Seven Year Review Of Anti-tissue Transglutaminase Testing

IntroductionCoeliac disease is the most common genetically based food intolerance worldwide with a UK prevalence of 1 in 150. The condition poses a diagnostic difficulty due to the often non-specific...

Can Redesigning a Laboratory Request form Reduce the Number of Inappropriate PSA Requests without Compromising Clinical Outcome

Introduction: Unnecessary laboratory utilization due to inappropriate test-ordering behaviour among hospital clinicians and community general practitioners is an ongoing problem in many hospitals and primary care trusts throughout the UK and abroad. In January 2007, our hospital removed the ‘tick box’ for PSA from its laboratory tests request form, in a managed way, with the intention of reducing unnecessary requests for this test. Here we address the impact this action had on the number of PSA tests being requested and its downstream effects on prostate cancer diagnosis. Methods: Using our laboratory database we compared the number of hospital and local GP requests for PSA, before and after modification of our laboratory form (requests from 2004 to 2006 were compared to 2007). We then correlated this data with the number of fast-track target referrals (2 week wait) from primary care for suspected prostate cancer, the results of prostate biopsies, and the number of prostate cancers being diagnosed, over the same time period. Results: Mann—Whitney non-parametric testing demonstrated a 17% reduction in the median number of PSA requests since the change was introduced ( p = 0.001). Subset analysis revealed an 18% reduction in GP requests ( p = 0.002). However no change was found in the number of prostate cancer diagnoses being made ( p = 0.86) and the number of target referrals for suspected prostate cancer ( p = 0.59) in the months of April, May, June, July, August and September of 2004–2006 as compared to the same months in 2007. The rate of patients undergoing biopsy increased in the post intervention period from 15.5 to 18.5 patients per month. The rate of negative biopsies remained stable, changing from 7.2 to 7.3 per month, and the rate of positive biopsies increased from 8.3 to 11.2 per month. This change reduced the false negative rate (suspected cancer, negative biopsy) from 46% to 40% in the period following the intervention. The rate of target referrals leading on to cancer showed a small increase after the intervention from 2.9 to 3.3 per month. Conclusions: Our study shows that with this simple modification to the design of our laboratory request form, whereby the doctor must make an active written decision to order a PSA test, there was a significant reduction in the number of PSA requests, both in the hospital and in the community, without patient safety being compromised as measured by maintaining the number of fast-track target referrals for suspected prostate cancer and the number of prostate cancers diagnosed.

Assessment of risk factors given in GP referral letters for DEXA imaging

Osteoporosis poses a significant public health issue, causing significant morbidity and mortality. It leads to an increased fracture risk through a reduction in the bone mineral density (BMD), disruption of bone microarchitecture, and alteration of the amount and variety of noncollagenous proteins in bone. Treatment aims are to prevent fractures and maintain the quality of life of the aging adult. The advent of the WHO assessment tool ‘‘Fracture Risk Assessment Tool’’ (FRAX ) has been revolutionary in GP assessment of patients regarding need for treatment, need for further evaluation by dual-energy X-ray absorptiometry (DXA) imaging and those not requiring any treatment [1]. In response to this we conducted a retrospective audit to examine GP requests for DXA imaging and if they contain sufficient details to justify imaging. All requests were prior to the launch of FRAX . Two hundred randomly chosen GP request letters were analysed using the FRAX tool. All letters were from April 2007 to July 2008. Resulting data were analysed using the statistical package SPSS version 14.0. Of the 200 letters, 8 (4%) were male and 192 (96%) were female, with a mean age of 64.3 years. One GP service provided a proforma referral letter with the remaining letters being individually composed. Table 1 shows the percentage of letters containing each of the FRAX criteria. Of importance only one request (not a proforma letter) contained all the details allowing for FRAX assessment (p \ 0.005) despite the use of a proforma by one GP service. In conclusion, from this audit we can see that the majority of GP referral letters for DXA imaging do not contain adequate data to make recommendations using the FRAX tool. Incorporating this data into referrals is likely to improve requesting systems for DXA scanning to GPs. In the future it is planned to develop a proforma referral letter, containing a full FRAX assessment, for GPs requesting DXA scanning, and also to carry out a further study to assess if the advent of FRAX has improved GP awareness of osteoporosis risk factors. In the intervening period it is planned to ask patients, presenting for DXA

Acute referral of patients from general practitioners: should the hospital doctor or a nurse receive the call?

BackgroundSurprisingly little is known about the most efficient organization of admissions to an emergency hospital. It is important to know, who should be in front when the GP requests an acute admission. The aim of the study was to analyse how experienced ED nurses perform when assessing requests for admissions, compared with hospital physicians.MethodsBefore- and after ED nurse assessment study, in which two cohorts of patients were followed from the time of request for admission until one month later. The first cohort of patients was included by the physicians on duty in October 2008. The admitting physicians were employed in the one of the specialized departments and only received request for admission within their speciality. The second cohort of patients was included by the ED in May 2009. They received all request from the GPs for admission, independent of the speciality in question.ResultsA total of 944 requests for admission were recorded. There was a non-significant trend towards the nurses admitting a smaller fraction of patients than the physicians (68 versus 74%). While the nurses almost never rejected an admission, the physicians did this in 7% of the requests. The nurses redirected 8% of the patients to another hospital, significantly more than the physicians with only 1%. (p < 0.0001). The nurses referred significantly more patients to the correct hospital than the doctors (78% vs. 70% p: 0.03). There were no differences in the frequency of unnecessary admissions between the groups. The self-reported use of time for assessment was twice as long for the physicians as for the nurses. (p < 0.0001).ConclusionsWe found no differences in the frequency of admitted patients or unnecessary admissions, but the nurses redirected significantly more patients to the right hospital according to the catchment area, and used only half the time for the assessment. We find, that nurses, trained for the assignment, are able to handle referrals for emergency admissions, but also advise the subject to be explored in further studies including other assessment models and GP satisfaction.

Psychological determinants of primary care requests for urgent outpatient appointments in elective referrals

Wide variations in referral practice from primary to secondary care have been observed. Clinical, demographic and referrer characteristics explain little of this variation. Patient psychological characteristics have been suggested as a potential explanation of this, biasing referral. The objective of this study is to investigate, in a relatively homogeneous population, the effects of patient's psychological distress and illness beliefs upon GP's requests for urgent outpatient assessment. An inception cohort of 188 primary care referrals to a UK NHS Trust orthopaedic department for potential lower limb arthroplasty was assessed for disease-related pain and impairment, disability, psychological distress and illness beliefs. Associations between these and primary care requests for urgent outpatient appointments were estimated. Twenty-two referrals (12%) requested an urgent outpatient appointment. Illness beliefs of greater personal control (OR 2.18, 95% CI 1.18, 4.05) but not psychological distress (OR 0.39, 95% CI 0.11, 1.36) were independently associated with urgent requests. Greater pain and impairment, co-morbidity and disability were univariately associated with this request. In both fully adjusted and parsimonious models, only patient beliefs of greater control and disability were independent determinants of this request for urgency. Among patients referred for assessment for lower limb arthroplasty primary care practitioner's requests for urgent assessment are influenced by the patient's belief of how well they can control the symptoms, over and above clinical measures, suggesting patients coping better gain faster access. Global disability appears to be the main clinical determinant, which suggests GPs are making urgent referrals appropriately. There is no evidence of any bias on age, gender or socioeconomic status. This request for urgency leads to these patients waiting 2 months less for an outpatient appointment.