Improving the quality of oral surgery referrals

The appropriateness of oral surgery referrals and treatment in contracted intermediate minor oral surgery practices in East Kent

Objectives To assess the appropriateness of oral surgery referrals, after triage, to intermediate minor oral surgery (IMOS) practices in East Kent and whether or not referrals vary according to the referring general dental practitioner's (GDP's) place of qualification and experience.Design A retrospective study of the records of 441 triaged referrals sent to three IMOS practices in East Kent, over a ten-week period. An assessment tool was developed in line with local and national referral guidelines. Information on all referrals was obtained from the IMOS provider and referral records. Descriptive analysis of the data was performed.Results The most common reason for referral was for extraction of teeth requiring bone removal (n = 155; 35%). However, the majority of teeth removed were recorded as a non-surgical extraction (n = 363; 82%). Medical histories were included appropriately in the referral communications, with only 0.2% of all referrals being inappropriate. The proportion of appropriate and inappropriate referrals was very similar and it was found that referral rate was lower from dentists who had been qualified for more than ten years. GDPs working in the same location as the IMOS provider made a greater total number of referrals as well as more inappropriate referrals.Conclusions In the group of GDPs and IMOS providers studied, a wide variation was observed between the GDP's reason for referral and the treatment provided. It may be concluded that the vast majority of extractions were safely completed in an IMOS dental practice in a primary care setting.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Background

Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.

Research questions

Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?

Design

A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.

Setting

The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.

Participants

Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.

Interventions

A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.

Main outcome measures

Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.

Results

In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.

Conclusions

Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.

Study limitations

The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.

Future work

The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Quality of oral surgery referrals and how to improve them

Aim

To assess the quality of routine oral surgery referrals received at Halmstad Hospital and Växjö Hospital and to emphasize areas for improvement.

Method

A retrospective study was performed on all routine oral surgery referrals received between 2014 and 2015 at both Halmstad Hospital and Växjö Hospital. A total of 1,891 referral letters were assessed for their quality against a predetermined checklist of basic requirements of a satisfactory referral. The referrals were also categorized according to if it was sent by a male, female, private dental service, or the Swedish Public Dental Health service.

Results

A diagnosis was missing in 30% of all referrals. Radiographs and information about previous radiographic examinations were not included in 10% of the referrals. Of those referrals that included radiographs, only around half were deemed adequate for diagnostic purposes. The presenting complaint was missing in 40% of all referrals. Current medical history was absent in 40% and current medication was omitted in 60% of the referrals. Information about tobacco use was only included in 10% of all referrals. Overall, female referrers performed better than male colleagues. Private referrals more regularly included information about diagnosis, previous treatment, and current medication. On the other hand, referrals from the public dental health service more frequently included radiographs, tobacco use, and current medical history.

Conclusion

There is plenty of room for improving the standards of oral surgery referrals. We suggest that future electronic referral systems should only allow for submission once all of the essential information has been considered.

Referrals to a facial pain service

AIM

To assess the quality of referral letters to a facial pain service and highlight the key requirements of such letters.

METHOD

The source of all referral letters to the service for five years was established. For one year the information provided in 94 referrals was assessed. Using a predetermined checklist of essential information the referral letters were compared to these set criteria.

RESULTS

The service received 7,001 referrals and, on average, general dental practitioners (GDPs) referred 303 more patients per year than general medical practitioners (GMPs). Seventy-one percent of all referrals were from primary care practitioners, the rest were from specialists. Over 70% of GMP and 52% of GDP letters included a past medical history, with GMPs more likely to suggest a possible diagnosis and include previous secondary care referrals. The mean score for GMP referrals compared to the standard proforma (maximum of 12) was 5.6 and for GDP referrals 5.0. A relevant drug history was included by 75.6% GMP compared to 38.7% of GDPs. GMPs were more likely to include any relevant mental health history.

CONCLUSIONS

The overall quality of referral letters is low which makes it difficult for the specialists to provide robust treatment plans.