Interventions to improve outpatient referrals from primary care to secondary care

  • Review
  • Intervention

Authors

  • A Akbari,

  • A Mayhew,

  • MA Al-Alawi,

  • JM Grimshaw,

  • RAG Winkens,

  • E Glidewell,

  • C Pritchard,

  • R Thomas,

  • C Fraser


Dr Ayub Akbari, Associate Professor of Medicine, Department of Medicine/Division of Nephrology, Kidney Research Center/University of Ottawa, The Ottawa Hospital, Riverside Hospitall, 1967 Rverside Drive, Suite 5-25, Ottawa, Ontario, K1H 7W9, CANADA. aakbari@ottawahospital.on.ca.

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 strategy

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

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.

Ancillary