Interventions to improve outpatient referrals from primary care to secondary care

 

Abstract

Background

The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.

Objectives

To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.

Search methods

We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.

Selection criteria

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.

Data collection and analysis

A minimum of two reviewers independently extracted data and assessed study quality.

Main results

Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.

Authors' conclusions

There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

 

Plain language summary

Are there effective methods to improve the process of referring patients to specialised care?

Patients are referred to a specialist when more specialised care is needed. It has however been shown that the process by which patients are referred could be improved. Some patients may be referred to a specialist inappropriately or not be referred when they should have, or when they were referred have unnecessary tests or procedures.

This review found 17 studies that evaluated whether educating health care professionals about referrals, changing the organisation or system of referrals, and changing the fees or payments for referrals, could improve the referral process.

Education: The referral process will most likely improve when guidelines for referral are distributed with standard referral forms and when the health care professionals who are the consultants are involved in teaching about referring. But simply distributing guidelines and providing health care professionals with feedback about how they are referring may not improve the process.

Organisation: There is little evidence about organisational changes. But providing a second opinion before referring, or enhancing the services provided before a referral (e.g. providing access to a physiotherapist) may improve the referral process.

Financial: There is not enough evidence to draw firm conclusions about financial changes. Financial changes can change the number of referrals but it is not known whether they improve the quality or appropriateness of referrals.

 

摘要

背景

促進門診病人自基層照護轉診至次級照護的介入措施

基層照護專科醫師之介面為許多健康照護系統重要的組織特性。當研究或基層照護治療的選擇被耗盡且需要專科照護時，病人被轉診至專科醫師照護。轉診對於病人，健康照護系統及健康照護成本有重要的涵義。有重要的證據顯示轉診的過程可以被改善。

目標

評估介入措施的效果及效益以期改變門診轉診率或促進門診轉診的適當性。

搜尋策略

我們進行the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register之電子檢索。MEDLINE及EPOC的檢索更新至2007年10月。

選擇標準

介入措施用於改變或促進門診轉診之隨機對照試驗，對照臨床試驗，前後對照研究及間段時間序列。參與者為基層照護醫師。客觀地測量供給者的行為或健康結果。

資料收集與分析

最少兩名審閱者分別獨立摘錄資料並評估研究的品質。

主要結論

共納入17篇研究其包括23種個別的對照方式。九篇研究(14種對照方式)評估專業的教育介入措施。沒有效果的策略包括:被動宣傳當地轉診的指引(兩篇研究)，回饋轉診率(一篇研究)，及討論一個獨立的醫療顧問(一篇研究)。通常有效的策略包括宣傳結構性的轉診表指引(4/5的研究)及參與諮詢的教育活動(2/3的研究)。四篇研究評估組織的介入措施(比較家庭醫師與一般內科醫師的病人管理)，全部的結果都是有效的。四篇研究(五種對照方式)評估財務的介入措施。一篇研究評估自論人計酬改變為論量計酬，以及自論量計酬改變為以論人計酬為基礎的系統(連同次級照護服務風險分攤的要素)，發現轉診率減少。英國實施家庭醫師基金計畫(general practice fundholding scheme)後發現轉診率有適度的減少，其重要性不明。一篇研究評估提供私人專科醫師可近性的效果，其證實增加病患轉診至專科服務的比例，但轉診率則無整體的效果。

作者結論

有一些數量有限之基於政策的嚴格評估。主動式的當地教育介入措施包括次級照護的專科醫師，和結構化的轉診表是目前證據顯示唯一對於轉診率有影響的。基於門診病人轉診之替代方案，“居家”(‘inhouse’)的次佳選擇及其他中介初級照護的效果似乎是有希望的。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

當病人需要更多的專科照護時將被轉診至專科醫師。然而證據顯示病人轉診的過程可以被改善。某些病人也許會被不適當地轉診至專科醫師，或當他們應有需要時卻未被轉診，或他們被轉介至非必要的檢查或手術。這篇回顧找到17篇研究以評估是否健康照護專家參加有關轉診的教育，改變轉診的組織或系統，及改變轉診或支付制度可以改善轉診過程。教育:當轉診指引以標準形式傳播，且當健康照護專家身為諮詢者參與有關轉診之教育時，轉診的過程很有可能獲得改善。但只是宣傳指引及提供健康照護專家有關他們如何轉診的回饋也許不會改善過程。組織:組織的改變顯示有少量的證據。但在轉診前提供次佳的選擇，或轉診前增加服務的提供(如提供物理治療師的可近性)也許可以改善轉診的過程。財務:沒有足夠的證據說明有關財務改變之肯定的結論。財務的改變可以改變轉診的數量，但他們是否改善品質或轉診的適當性則是未知的。