Prioritisation of vascular outpatient appointments cannot be based on referral letters alone

Retrospective analysis of 1,203 cases of referral to a quaternary vascular surgery outpatient clinic within the Unified Health System, São Paulo, Brazil

OBJECTIVE

Through a retrospective analysis of 1,203 cases of referral from primary healthcare units to a specialized quaternary vascular surgical service, the findings of this study revealed a high proportion of inappropriate referrals, which may represent a substantial subutilization of this highly complex service. Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications.

METHODS

In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure.

RESULTS

Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments.

CONCLUSION

The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.

Communication between primary and secondary care: deficits and danger

BACKGROUND

Timely and accurate communication between primary and secondary care is essential for delivering high-quality patient care.

OBJECTIVE

The aim of this study is to evaluate the content contained in both referral and response letters between primary and secondary care and measure this against the recommended national guidelines.

METHODS

Using an observational design, senior medical students and their general practice supervisors applied practice management software to identify 100 randomly selected adults, aged greater than 50 years, from a generated list of consults over a 2-year period (2013-2015). All data included in referral and response letters for these adults were examined and compared with the gold standard templates that were informed by international guidelines.

RESULTS

Data from 3293 referral letters and 2468 response letters from 68 general practices and 17 hospitals were analysed. The median time that had elapsed between a patient being referred and receiving a response letter was 4 weeks, ranging from 1 week for Emergency Department referral letters to 7 weeks for orthopaedic surgery referral letters. Referral letters included the reason for referral (98%), history of complaint (90%) and current medications (82%). Less commonly included were management prior to referral (65%) and medication allergies (57%). The majority of response letters included information on investigations (73%), results (70%) and follow-up plan (85%). Less commonly, response letters included medication changes (30%), medication lists (33%) and secondary diagnoses (13%).

CONCLUSIONS

Future research should be aimed at developing robust strategies to addressing communication gaps reported in this study.

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

BACKGROUND

The 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.

METHODS

A 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.

RESULTS

In 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.

CONCLUSION

In this study, the dissemination of referral templates coupled with intermittent surgery visits produced higher quality referrals.

TRIAL REGISTRATION

This trial has been registered at ClinicalTrials.gov. The trial registration number is NCT01470963.

Do referral-management schemes reduce hospital outpatient attendances? Time-series evaluation of primary care referral management

BACKGROUND

Ninety-one per cent of primary care trusts were using some form of referral management in 2009, although evidence for its effectiveness is limited.

AIM

To assess the impact of three referral-management centres (RMCs) and two internal peer-review approaches to referral management on hospital outpatient attendance rates.

DESIGN AND SETTING

A retrospective time-series analysis of 376 000 outpatient attendances over 3 years from 85 practices divided into five groups, with 714 000 registered patients in one English primary care trust.

METHOD

The age-standardised GP-referred first outpatient monthly attendance rate was calculated for each group from April 2009 to March 2012. This was divided by the equivalent monthly England rate, to derive a rate ratio. Linear regression tested for association between the introduction of referral management and change in the outpatient attendance rate and rate ratio. Annual group budgets for referral management were obtained.

RESULTS

Referral management was not associated with a reduction in the outpatient attendance rate in any group. There was a statistically significant increase in attendance rate in one group (a RMC), which had an increase of 1.05 attendances per 1000 persons per month (95% confidence interval = 0.46 to 1.64; attendance rate ratio increase of 0.07) after adjustment for autocorrelation. Mean annual budgets ranged from £0.55 to £6.23 per registered patient in 2011/2012. RMCs were more expensive (mean annual budget £5.18 per registered patient) than internal peer-review approaches (mean annual budget £0.97 per registered patient).

CONCLUSION

Referral-management schemes did not reduce outpatient attendance rates. RMCs were more expensive than internal peer review.

The consultants' role in the referring process with general practitioners: partners or adjudicators? a qualitative study

Background

Within the health system, communication between the different levels of care is essential for the patients’ clinical pathways and medical treatment. This includes the referral process: how and why patients are sent from the primary care level to specialist health services. We wanted to identify and describe hospital consultants’ reflections on and attitudes to the referral process and cooperation with general practitioners (GPs).

Methods

A qualitative study of semi-structured interviews with 13 hospital consultants representing eight different specialties, analyzed using systematic text condensation. Interviews conducted from February 2011 to October 2012.

Results

The consultants reported a considerable workload assessing referrals from GPs and prioritizing patients for specialist services. National guidelines were used as well as individual standards and guidelines. Good referrals could make the prioritization process easier. The specialists expressed a deep concern about securing a fair priority of patients and a willingness to give reasonable advice back to the referring GP when rejecting a referral. Better communication, such as a telephone call to confer with a hospital specialist before referral, was wanted.

Conclusions

Better communication and cooperation between hospital consultants and GPs could make the referral process more balanced, and the participants more like partners.

Triage of referrals to outpatient hepatology services: an ineffective tool to prioritise patients?

Background. Appropriate and uniform prioritisation (‘triaging’) of outpatient referrals is critical to good patient outcomes, equity of access to services and efficient use of resources. Objective. To determine whether there is uniformity in the allocation of triage categories for hepatology outpatient referrals at public hospitals in Queensland. Methods. A series of 10 recent hepatology referrals were de-identified for both patient and referring clinician details and sent to nine gastroenterology or hepatology centres throughout Queensland. Consultant gastroenterologists and hepatologists (n = 25) were asked to triage the referrals using the process in place in their centre. Responses were de-identified and analysed. Each case was reviewed and allocated an ‘agreed triage category’ based upon the majority view of respondents. Results. Nineteen responses were received. There was substantial variation amongst consultants in the allocation of triage categories. Although almost two-thirds of respondents agreed with the majority view in 60–80% of cases, none agreed with the majority for every case and some agreed in as few as 50% cases. Disagreement with the majority view of an appropriate triage category was not associated with geography or specialist experience. Conclusions. Variability in triage categorisation suggests that similar cases may be allocated different priorities by those responsible for determining the urgency of outpatient review. This has implications for equity of access to treatment. The development of triage guidelines and formal training in their implementation, along with periodic audits of triage practices in different centres, may reduce variability. What is known about the topic? Outpatient clinic appointments are allocated within categories according to ‘agreed’ clinical urgency. The process of triaging referrals seeks to prioritise referrals based on the severity of patients’ conditions and the potential for improving outcomes. At present there are no statewide guidelines or training for the triaging process in hepatology and no recommendations for who should take responsibility for prioritising referrals. What does the paper add? In Queensland, gastroenterologists (including hepatologists) triage hepatology cases differently and most likely interpret and weight clinical information provided in the referral differently. Disagreement with the majority view of an appropriate triage category is not associated with geography or specialist experience. What are the implications for practitioners? Variability in triage categorisation suggests that similar cases may be allocated different priorities by those responsible for determining the urgency of outpatient review. This has implications for equity of access to treatment. The development of triage guidelines and formal training in their implementation, along with periodic audits of triage practices in different centres, may reduce variability.

Long-term clinical outcome following lower limb arterial angioplasty

INTRODUCTION

The aim of this study was to determine the clinical outcome of lower limb arterial angioplasty in a busy district general hospital practice.

PATIENTS AND METHODS

All angioplasties performed from January 1999 to December 2004 were identified and data collected included cardiovascular risk factors, indications for and complications of angioplasty, limb salvage and patient survival rates, and clinically significant re-stenoses.

RESULTS

471 interventions were performed in 385 patients (231 men, 154 women). The median age was 67.9 years (range: 39-93 years). Indications for angioplasty were critical ischaemia (n=247, 52%) and lifestyle-limiting intermittent claudication (n=224, 48%). Stenotic lesions accounted for 378 (80%) cases and occlusion for 93 (20%). Radiological success was obtained in 417 (88.5%), improving to 93.6% if only those in whom access was achieved were included. Post-angioplasty complications were observed in 42/471 (9.1%) of interventions. The actual patient survival at 1, 2, and 3 years was 87.4%, 85.1% and 83.2% respectively. Indication for angioplasty and the number of lesions present were identified as risk factors for outcome on multivariate analysis. The cumulative post-angioplasty patency rates at 1, 2 and 3 years were 86.0%, 83.1% and 81.6% respectively. The only factor associated with patency was the mode of presentation.

CONCLUSIONS

Angioplasty for lower limb peripheral vascular disease can be performed safely and efficaciously with a high technical success rate and a low complication rate. The patient survival and post-angioplasty patency data reflect the progressive and multi-site nature of the underlying disease process.