Inappropriate Referrals Research Articles

An Audiologist’s Approach to Chronic Dizziness

An Audiologist’s Approach to Chronic Dizziness

EP.WE.485An Audit to Investigate the Incidence of Face-to-Face Patient Review by GPs Prior to Referral to Surgical Assessment Unit

Abstract Aims Since COVID-19, GP’s have been encouraged to do fewer face-to-face consultations to prevent unnecessary patient contact1. Anecdotally, this initially resulted in many patients being referred to SAU who had not been seen by a GP, and then being discharged back to the community the same day, causing potentially increased risk of contracting COVID-19 through hospital attendance. The aim of this audit was to investigate the incidence of patients referred to SAU not seen by a GP and discharged the same day. Methods GP referrals were identified over a 7 day period through the surgical take electronic system Aramis©. The case notes and GP documentation were reviewed to identify whether a face-to-face GP consultation occurred, and then whether the patient was admitted to SAU or discharged the same day. Results During a 7 day period, there were 24 (n = 24) GP referrals of which only 3 (12.5%) were not seen by the GP, all of whom were admitted for at least one night. However, of the patients referred and seen by GP, 7 (29%) were discharged the same day. Conclusions This demonstrates that during this 7-day period, there was no incidence of inappropriate GP referral to SAU of patients not seen by a GP, and the majority of GP referrals warranted admission. This suggests that in most cases, GPs are avoiding unnecessary emergency surgical referrals and attempt to review patients face-to-face prior to referral, thus reducing patient risk of contact with COVID-19 in the hospital setting.

The Role of Diet Modification in Atopic Dermatitis: Navigating the Complexity

Diet has long been understood to have an intricate association with atopic dermatitis, although much remains unelucidated. Skin barrier dysfunction with dysbiosis and consequent impairment of immune tolerance likely underly the pathogenesis of coincident atopic dermatitis and food allergy. There is a wide range of possible skin reactions to food, complicating the diagnosis and understanding of food allergies. Many patients, parents, and providers incorrectly suspect diet as causative of atopic dermatitis symptoms and many have tried elimination diets. This frequently leads to inaccurate labeling of food allergies, contributing to a dangerous spiral of inappropriate testing, referrals, and dietary changes, while neglecting established atopic dermatitis treatment essentials. Alternatively, certain dietary supplements or the introduction of certain foods may be beneficial for atopic dermatitis management or prevention. Greater consensus on the role of diet among providers of patients with atopic dermatitis is strongly encouraged to improve the management of atopic dermatitis.

Understanding the factors that affect the appropriateness of rheumatology referrals

BackgroundReducing inappropriate referrals to specialists is a challenge for the healthcare system as it seeks to transition from volume to value-based healthcare. Given the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Efforts to increase appropriate utilization through reductions in capacity may have the unintended consequence of reducing appropriate care as well. This highlights the challenges in increasing the appropriate use of high cost services as the health system transitions to value based care. The objective of this study was to analyze factors affecting appropriateness of rheumatology services.MethodsThis was a cross-sectional study of patients receiving Rheumatology services between November 2013 and October 2019. We used a proxy for “appropriateness”: whether or not there was any follow-up care after the first appointment. Results from regression analysis and physicians’ chart reviews were compared using an inter-rater reliability measure (kappa). Data was drawn from the EHR 2013–2019.ResultsWe found that inappropriate referrals increased 14.3% when a new rheumatologist was hired, which increased to 14.8% after wash-out period of 6 months; 15.7% after 12 months; 15.5% after 18 months and 16.7% after 18 months. Other factors influencing appropriateness of referrals included severity of disease, gender and insurance type, but not specialty of referring provider.ConclusionsGiven the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. These findings may apply to other specialties as well. This study is relevant for health care systems that are implementing value-based payment models aimed at reducing inappropriate care.

1426 Assessing the Impact Of COVID-19 On ENT Referrals at A West London General Practice

Abstract Aim The COVID-19 pandemic has resulted in initial GP consultations being conducted via telephone. This quality improvement initiative quantified this impact on ENT referrals conducted at a West London GP, using education to improve awareness of the relevant NICE guidance to reduce inappropriate referrals. Method An initial retrospective audit comparing number and urgency of ENT referrals and the appropriateness of ENT referrals (using NICE guidance) during the face to face (F2F) period (August 2019 – February 2020) and telephone period (March – September 2020) was performed. Results were presented locally to GPs, with education measures on relevant NICE guidance implemented. Further PDSA cycles occurred during October and November 2020. Results In total, 16 ENT referrals were made during the F2F period (routine n = 15; urgent n = 1); 3 were inappropriate. 31 referrals were made between March and September 2020 (routine n = 27, urgent n = 2, 2WW n = 2); 4 were inappropriate. Further cycles in October 2020, and November 2020 identified 13 referrals (routine n = 10, 2WW n = 3), and 2 referrals (routine n = 2) respectively. 1 inappropriate referral was made during October and none in November. Conclusions Locally, it appears that the number of routine referrals has increased since the advent of the initial lockdown. This may be partially explained by the practice losing the ability to perform some ENT services, such as ear wax micro-suctioning. Education to increase awareness of relevant guidance has been shown to reduce the number of inappropriate referrals to ENT services.

194 Referral of Paediatric Fractures from The Emergency Department to Virtual Fracture Clinic

Abstract Introduction Virtual Fracture clinics (VFCs) are an alternative to the traditional fracture clinic. Recent evidence reports them to be safe, cost-effective, and efficient model without significant compromise to patient care. Aim This audit aims to assess VFC referrals from the paediatric emergency department (ED) and ensure the appropriateness of these referrals. Method This was a retrospective audit done at a large district general hospital in the United Kingdom (UK). We included patients under 18 years old presented to the emergency department with suspected or confirmed fractures and referred to virtual fracture clinics within a period of one month. The performance was measured against both local and national guidance (NICE & BOAST 7). Results Thirty patients were eligible. Thirty-three per cent of patients were appropriately referred to the VFC and ’seen’ within 72 hours. Comparing those referred 63.3% were appropriate, with inappropriate referrals mainly due to false-positive fracture diagnosis or fractures safe to be discharged home. Only 67.8% per cent of patients were managed correctly as per suspected or confirmed diagnosis with regards to fixation (i.e., splint). Conclusions The target of 100% compliance has failed. Fractures deemed safe to be discharged home from the ED are being repeated referred, radiographic interpretations often over-diagnose, and management within the department in sub-optimal. Recommendations include improving junior radiographic interpretation skills and awareness of the local and national guidelines, with another audit cycle to assess for improvement.

Electronic Outpatient Referral System for Liver Transplant Improves Appropriateness and Allows First Visit Triage

Missed or inappropriate referrals of potential candidates for liver transplantation (LT) are common and traditional referral methods (tRs) do not allow for efficient triage. We investigated the effects of a website developed for electronic outpatient referral to LT (eRW-LT) on these issues. We prospectively collected data on all consecutive outpatient referrals to 2 Italian LT centers from January 2015 to December 2019. In the second half of the study, starting from July 2017, referring physicians had the option of using eRW-LT, quickly obtaining the judgment on the appropriateness and urgency of the visit from a transplant hepatologist. In the second half of the study, there were 99 eRW-LTs and 96 traditional referrals (new tRs), representing a 17.4% increase over the 161 traditional referrals (old tRs) of the first half. With eRW-LT, 11.1% of referrals were judged inappropriate online without booking a visit. Appropriateness, judged at the time of the first visit, was 59.6%, 56.2%, and 94.3% with old tRs, new tRs, and eRW-LT, respectively. Considering the appropriate visits, the median waiting time in days between referral date and first visit appointment was significantly shorter for urgent visits referred with eRW-LT (5.0; 95% CI, 4.8-9.3) compared with nonurgent visits sent with the same system (17.0; 95% CI, 11.5-25.0; P < .0001), those referred with old tRs (14.0; 95% CI, 8.0-23.0; P < .001) and with new tRs (16.0; 95% CI, 10.0-23.0; P < .001). eRW-LT allows an increase in the number of referrals for LT, ensuring effective triage and better appropriateness of visits.

Low back pain expert systems: Clinical resolution through probabilistic considerations and poset

ObjectiveProper diagnosis of Low Back Pain (LBP) is quite challenging in especially the developing countries like India. Though some developed countries prepared guidelines for evaluation of LBP with tests to detect psychological overlay, implementation of the recommendations becomes quite difficult in regular clinical practice, and different specialties of medicine offer different modes of management. Aiming at offering an expert-level diagnosis for the patients having LBP, this paper uses Artificial Intelligence (AI) to derive a clinically justified and highly sensitive LBP resolution technique. Materials and methodsThe paper considers exhaustive knowledge for different LBP disorders (classified based on different pain generators), which have been represented using lattice structures to ensure completeness, non-redundancy, and optimality in the design of knowledge base. Further the representational enhancement of the knowledge has been done through construction of a hierarchical network, called RuleNet, using the concept of partially-ordered set (poset) with respect to the subset equality (⊆) relation. With implicit incorporation of probability within the knowledge, the RuleNet is used to derive reliable resolution logic along with effective resolution of uncertainties during clinical decision making. ResultsThe proposed methodology has been validated with clinical records of seventy seven LBP patients accessed from the database of ESI Hospital Sealdah, India over a period of one year from 2018 to 2019. Achieving 83% sensitivity of the proposed technique, the pain experts at the hospital find the design clinically satisfactory. The inferred outcomes have also been found to be homogeneous with the actual or original diagnosis. DiscussionsThe proposed approach achieves the clinical and computational efficiency by limiting the shortcomings of the existing methodologies for AI-based LBP diagnosis. While computational efficiency (with respect to both time and space complexity) is ensured by inferring clinical decisions through optimal processing of the knowledge items using poset, the clinical acceptability has been ascertained reaching to the most-likely diagnostic outcomes through probabilistic resolution of clinical uncertainties. ConclusionThe derived resolution technique, when embedded in LBP medical expert systems, would provide a fast, reliable, and affordable healthcare solution for this ailment to a wider range of general population suffering from LBP. The proposed scheme would significantly reduce the controversies and confusion in LBP treatment, and cut down the cost of unnecessary or inappropriate treatment and referral.

Clarification of Eosinophilic Esophagitis Treatment in the DoD Retention Standards.

The DoD Instruction 6130.03, Volume 2, outlines the retention standards for the U.S. Military, providing guidance on medical conditions and treatments that are disqualifying for all branches of the military. This document states that patients with conditions requiring immunomodulating or immunosuppressant medications do not meet retention standards. Eosinophilic esophagitis is a common, chronic inflammatory disease of the esophagus that typically presents with dysphagia. Although proton pump inhibitors are effective at treating this disease in some cases, swallowed topical steroids are the most frequently used therapy within the DoD. These medications act locally in the esophagus and do not cause systemic side effects typical of oral steroid therapy, including immunosuppression. They are effective at inducing and maintaining disease remission and are generally well tolerated, with minimal side effects. We propose a brief amendment to this document to clarify the language used and avoid inappropriate Medical Evaluation Board referrals.

“One stop” clinic for upper gastrointestinal cancer—an alternative to “straight to test” referrals?

BackgroundPatients suspected to have upper gastrointestinal (UGI) cancer can be referred directly for investigation; however, at times this may result to inappropriate referrals. This study explores the model of a “one-stop” clinic as an alternative to the direct referral system. The current study aims to assess the feasibility and outcomes of a one-stop UGI clinic and evaluate sensitivity and specificity of “on-the-day” diagnoses.MethodsA retrospective analysis of case notes of patients seen in one-stop clinic, between January 2017 and January 2019, was conducted. All General Practitioner (GP) referrals were screened by a specialist nurse.ResultsAfter completion of the post-GP referral screening process, 252 patients (median age 68 years, IQR 58.8–77.3 years; M:F ratio 118:134) were allocated to the one-stop clinic. OGD was not required, contra-indicated or declined in 27 cases (10.7%). The records of three patients could not be found. One patient did not attend. Overall, 221 patients underwent testing and received “on-the-day” diagnoses. Sensitivity was 94% (range 87–100%), and specificity was 92% (88–96%). Ninety-six percent of patients received a diagnosis on the day.ConclusionsThe one-stop clinic was feasible and had good specificity and sensitivity. The finding of 10.7% of cases not being suitable for OGD indicates that a patient/specialist consultation is necessary to prevent misuse of endoscopy appointments. The authors recommend widespread adoption of one-stop clinics in UGI surgery.

Service evaluation for services for younger people with dementia in east locality of north Wales

AimsTo evaluate Young-onset dementia (YOD) services in terms of referral, its appropriateness, time to diagnosis and other criteria as per protocol that we have adapted.MethodCase notes of those under 65 referred to Memory service for cognitive assessment between July 2017 and June 2018 were retrospectively reviewed to look at the time to diagnosis, appropriate referrals, post-diagnostic support, etc.ResultCompared to the previous evaluation, the number of patients referred to had increased from 47–48/ year earlier to 63/year. Only 1/3 were appropriate referral over the 10-year period whereas between 2017 and 2018 more than half were appropriate referrals. More than half of them were seen within 12 weeks of referral (35/63 available). Only 132/252 were diagnosed as having some form of dementia in the previous evaluation which was about 13 cases of YOD a year. In contrast, in our new evaluation 19 patients were diagnosed with some form of dementia. Inappropriate referrals had reduced by more than 50%. Appropriateness and timely referral had improved in this time frame.ConclusionDementia is considered ‘young onset’ when it affects people under 65 years of age. It is also referred to as ‘early onset’ or ‘working age’ dementia. However, this is an arbitrary age distinction that is becoming less relevant as increasingly services are realigned to focus on the person and the impact of the condition, not the age. Teaching sessions to educate primary &amp; secondary care clinicians on appropriateness and timely referrals have helped in improving the care for patients with YOD. Services need to be developed further to be able to diagnose &amp; support those with YOD. Repeat evaluations every year would help to inform improvement in quality &amp; appropriateness of referrals.

Transfer and transition referrals of patients with intellectual disability from children's services to adult community learning disability teams

AimsThe audit aimed to assess if patients under the care of children's services in Wessex were transferred at the appropriate age and whether transition referrals to Community Learning Disability teams (CTLD) occurred timely. It also aimed to look at how many patients underwent transitions in a three month period, and if their transition support plan (TSP) was completed. A transition support plan should include chronological information on psychopharmacology, psychotherapy, and social support measures. Patients should be referred between the ages of 17–19 but require a justification after 18 years of age.MethodThe BI team was contacted to provide all IDs for patients referred within a three month period between the ages of 17–19. The BI team provided 42 patients with their ID. Patients discharged from services within a short time span were excluded for the following reason: inappropriate referral (9pts), discharged after 1st assessment (6pts), internal discussion (6pts), only referred to Autism team (4pts), moved out of area (1pts). From the initial 42 patients, 16 patients were analysed using the collection tool.Result4/16 had a TSP, and only two had a complete TSP and transitioned in another trust and were inter-team referrals.CAMHS services referred 1/16 patients.Psychotropic medication was prescribed to 12/16 prior to or on time of referral, but only two patients had a complete psychotropic medication history.8/16 patients' referral was commenced prior to their 18th birthday, and no information was provided for delay in transfer.Health records did mention psychotherapy, but apart from 2/16 TSP records, no additional information was available on the modality.ConclusionPatients with Intellectual Disability face challenges when transferring from children to adult services. Insufficient referral information may have a detrimental impact on patients wellbeing and long-term care.Access to a patient's chronological journey through the different children's services allows Adult CTLD health professionals to provide effective care. Historical psycho-social and pharmacological interventions provide a reference point for future interventions.Concerns included: limited information on most TSP regarding psycho-social and psychotropic treatments, lack of access to CAMHS/CHYPS paperwork and ineffective inter-trust communication for transition patients.This project highlighted the average number of transition cases in 3 months. It led to changes to the transition pathway, as awareness was raised in trust and CCG meetings to improve patient outcome. CTLD created the new role of transition facilitators to support children's services. They sit in meetings before patients transition referrals.

Improving quality and assessment of referrals to the Enfield Crisis Resolution and Home Treatment Team (ECRHTT)

AimsTriaging referrals to crisis resolution and home treatment teams is a significant undertaking requiring experienced and dedicated staff. We observed that the volume of inappropriate referrals to ECRHTT was high, and that staff processing these often felt inexperienced or lacking in confidence to discharge them back to the referrers and signpost them to appropriate services.The aims of this quality improvement project (QIP) were: a)to reduce the number of inappropriate referrals received by the teamb)to reduce the number of inappropriate referrals accepted by the teamThis would significantly improve access and flow to the service and facilitate better patient care.MethodA pilot study was first completed of the quality (appropriateness/ inappropriateness) and source of all referrals to ECRHTT in January 2019 (n = 177).Subsequently, the consultant psychiatrist for ECRHTT based himself within the assessment team. He was able to closely monitor the referrals, at the same time as providing medical input to patients at their first point of contact. To evaluate the impact of this intervention, the percentage of inappropriate referrals accepted pre- and post-change was compared by re-auditing all referrals received in February 2019 (n = 175).Further interventions were instigated to improve referral quality. These included continuation of psychiatric medical input to the assessment team, teaching sessions for GPs and the crisis telephone service, and weekly meetings with psychiatric liaison and community mental health teams (CMHTs). Change was measured by reassessing the quality of all referrals made to ECRHTT in February 2020 (n = 215).Result46.9% of inappropriate referrals to ECRHTT were accepted in January 2019 compared to 16.9% in February 2019 following the addition of medical input to the assessment team. The absolute difference was 30% (95% CI: 14%–44%, p &lt; 0.001).71% of referrals from GPs were inappropriate in January 2019 compared to 36% in February 2020 post-intervention (difference 35%, 95% CI: 8.84%–55.4%, p &lt; 0.05). Inappropriate referrals from CMHTs decreased from 55.5% to 12% (difference 43.5%, 95% CI: 9.5%–70.3%, p &lt; 0.05). Overall, the percentage of inappropriate referrals fell from 38% to 27.4%, a difference of 10.6% (95% CI: 1.3%–19.8%, p &lt; 0.05). The percentage of inappropriate referrals from liaison teams did not change significantly.ConclusionThis piece of work shows that better engagement with referral sources significantly improved the quality of referrals made to ECRHTT. Interventions included medical input at the point of referral, teaching sessions for general practitioners as well as ongoing liaison with referring teams.

MO527REFERRAL CRITERIA TO NEPHROLOGY AND MATCHING DEGREE WITH THE CONSENSUS DOCUMENT FOR CHRONIC KIDNEY DISEASE DETECTION AND MANAGEMENT

Abstract Background and Aims Consensus document of the Spanish Society of Nephrology and many Primary Care (PC) related societies for chronic kidney disease (CKD) detection and management provides to the PC doctor referral criteria (RC) to nephrology clinic. The aim of the study is to describe the referrals to our center nephrology clinic and evaluate the influencing factors for RC adequacy. Method Retrospective observational study. We included the referred patients to our nephrology clinic from October 2019 to May 2020. We recollected demographic variables, as well as comorbidity, renal function, RC adequacy and follow-up. Categorical variables are expressed as percentages and compared using Chi2 test. Quantitative variables are expressed as mean ± standard deviation and compared using t-student test. Cox regression was performed to determine independent predictors for RC adequacy. Statistical significance for a value of p&amp;lt; 0,05 or CI 95%. Statistical analysis was performed with SPSS 25.0. Results 238 patients, 55.5% male. Average age 63 ± 17 years, being 34% older than 75 years. 67.6% had at least 3 cardiovascular risk factors. 85.3% were referred from PC with 57.1% of them from a rural center. There was adequation to the RC on 55%. The most frequent RC was CKD progression (37.4%). Mean serum creatinine at the time of referring was 1.91 ± 0.59 mg/dl with a glomerular filtration rate 34 ± 11 ml/min/1.73m2 and 329.43 ± 992.01 mg/g or mg/24h of albuminuria. From the 45% of those who did not had RC adequacy 51.4% had CKD III stage and 21.5% had false refractory hypertension (controlled or under-treated). Mean time of follow-up was 5 ± 1.7 months. RC adequacy was related with being referred from PC (59.6% vs 28.6% p=0.001), smoking (65.9% vs 49% p=0.012), time of referring creatinine (1.54 ± 0.86 vs 1.18 ± 0.39 p=0.001) and albuminuria (43406 ± 1009.7 vs 136.13 ± 637.16 p=0.019) and end of follow-up albuminuria (265.84 ± 516.82 vs 81.67 ± 250.7 p=0.007). RC adequacy was associated with receiving follow-up on nephrology clinic (80.2% vs 19.8% p=0.001). Logistic regression showed that being referred from PC (OR 3.64 IC 95% 1.03-12.8 p=0.044) and a worse renal function at the referring (OR 2.49 IC 95% 1.19-5.24 p=0.015) were associated with RC adequacy. Conclusion The experience in our center shows that there is not an adequacy on the current RC from the Spanish Society of Nephrology in almost half of the patients. That proportion decreases when patients are referred from PC close to 40%. CKD progression is the main reason for referral with most of patients being elderly and with a high cardiovascular risk. The need for greater dissemination of RC can be inferred from the significant number of inappropriate referrals, encouraging us to propose their review.

809 Evaluation of the Two Week Wait Colorectal Cancer Pathway in a District General Hospital

Abstract Introduction Updated guidelines published by the National Institute for Health and Care Excellence in 2015 widened the referral criteria for the two week wait (2WW) pathway for suspected lower gastrointestinal cancer, in an attempt to increase early diagnosis. The aim of this study was to evaluate the compliance of referrals received via the (2WW) pathway for suspected lower gastrointestinal cancer. Method We conducted a retrospective study which utilised a local cancer registry to identify all patients who had been referred to United Lincolnshire Hospitals Trust over a two-month period. Electronic patient records were checked to establish whether patients fulfilled the 2015 referral criteria. Results Out of 615 patients referred, 51 (8%) had colorectal cancer. 92 (15%) referrals did not meet the criteria for the 2WW pathway. Whether or not the referral was ‘appropriate’ had no significant effect on the diagnoses of bowel cancer (X2 = .003, p&amp;gt;.05). Conclusions 16% of all referrals did not meet criteria. This may appear as an inefficient use of resources, however there was no difference in rates of cancer between appropriate and inappropriate referrals. The referral criteria are likely to evolve over the course of time, and perhaps clinicians’ judgement should be taken into account.

The justification of non-obstetric ultrasound referrals: A safe and effective practice.

In 2015 the British Medical Ultrasound Society released a referral justification document for rejection of inappropriate ultrasound referrals to help manage increasing demand and ensure correct utilisation of diagnostic imaging tests. In our trust, referrals that were not aligned with the guidance were cancelled and returned to general practitioners, providing reasons for cancellation and advising other diagnostic tests if appropriate.Methodology: In total, 1000 cases cancelled between April and August 2019 were retrospectively audited by a team of clinical specialist sonographers. Interoperator agreement against BMUS justification guidelines and safety of this cancellation process were established. Duplicate imaging referrals, referrals made that should have been placed on management pathways or referrals cancelled by the patient directly were excluded in the safety assessment. There was strong agreement amongst sonographers regarding cancellations. After exclusions, 389 cases were included for review. The majority (90.5%) required no onward imaging and were therefore deemed cancelled appropriately. There were 37 patients found with pathology on subsequent imaging, two of which were found to have cancer and the remainder with benign pathology. Overall, we found the cancellation process to be safe and the justification document easy to utilise in practice. This process has ensured a minimal waiting time for ultrasound imaging is maintained and that demand can be managed to meet the available capacity.

Triage of referrals in a child and adolescent mental health service in Qatar: reducing waiting times and promoting needs-based prioritisation.

This paper summarises the impact of a new triage process on referral prioritisation and waiting times in a community specialist child and adolescent mental health service (CAMHS) in Qatar. The process involves initial review of referrals by a CAMHS nurse to ensure that there is adequate clinical information, obtaining additional information from patients/families and referring clinicians by the psychiatric triage team, when necessary, followed by prioritisation and allocation of accepted referrals. The new process reduced the acceptance of inappropriate referrals, ensured prioritisation of referrals and significantly improved the service's compliance with waiting-time deadlines.

Nurse-led vetting of choose and book referrals into sub-specialty ear, nose and throat clinics

Background/Aims The electronic ‘choose and book’ referral system can lead to patients being allocated to inappropriate ear, nose and throat sub-specialty clinics. Internal re-referrals to the more appropriate sub-specialty clinic is inefficient, leads to wasted appointments and is frustrating for both clinicians and patients. This study aimed to implement a nurse-led vetting system to ensure that new referrals were sent to the appropriate sub-specialty for their first appointment. Methods A team of three nurses were given guidelines and trained to assess GP referrals so that they could re-allocate inappropriate referrals to more appropriate sub-specialty ear, nose and throat clinics before their first appointment. The number of referrals that were re-allocated was calculated. Results Implementing a nurse-led vetting system of GP referrals led to 110/400 (28%) of cases being re-allocated to a more suitable sub-specialty clinic before initial consultation. The expertise of the nurse-led team was found to be sufficient, particularly when supplemented with additional training, to perform this task. Conclusions Nurse-led vetting of choose and book referrals is an efficient way of checking referrals to ensure that patients are sent to the appropriate clinic. This can increase the overall efficiency of the clinic and prevent the wasting of time and resources on inappropriate referrals.

Orthodontic Referrals: Electronic versus Paper

The Cwm Taf Community Dental Service (CDS) has previously used a paper system to refer patients to the orthodontic specialists within the Cwm Taf CDS. However, at the beginning of June 2019, an electronic referral system was introduced. Although electronic referrals have had a minimal effect on the overall waiting time for a patient, there has been an improvement in the efficiency of transfer of orthodontic referrals within the CDS. Electronic referral systems have reduced the number of inappropriate referrals, improved patient confidentiality and maintained an accurate record that is accessible from any of the Cwm Taf CDS clinics. CPD/Clinical Relevance: The article highlights the benefits of an electronic referral system with respect to reducing both inappropriate referrals and waiting times.

Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study

BackgroundManaging low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals’ appropriateness.MethodsFour inexperienced students (chiropractic master’s students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or “other reasons” for inappropriate referrals.After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison.ResultsInter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55–0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58–0.91) and 0.82 (95% CI: 0.72–0.92), respectively.The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters’ results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84–92%, respectively, for the pairwise comparisons.ConclusionThe inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.