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The impact of psoriasis guidelines on appropriateness of referral from primary to secondary care: a randomized controlled trial

Authors

  • C.E.M. Griffiths,

    1. The Dermatology Centre, Hope Hospital, The University of Manchester, Salford, Manchester M6 8HD, U.K. Cancer Research UK Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham B15 2TT, U.K.
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  • H. Taylor,

    1. The Dermatology Centre, Hope Hospital, The University of Manchester, Salford, Manchester M6 8HD, U.K. Cancer Research UK Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham B15 2TT, U.K.
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  • S.I. Collins,

    1. The Dermatology Centre, Hope Hospital, The University of Manchester, Salford, Manchester M6 8HD, U.K. Cancer Research UK Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham B15 2TT, U.K.
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  • J.E. Hobson,

    1. The Dermatology Centre, Hope Hospital, The University of Manchester, Salford, Manchester M6 8HD, U.K. Cancer Research UK Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham B15 2TT, U.K.
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  • P.A. Collier,

    1. Pendleton Medical Centre, Paddington Close, Salford, Manchester M6 8HD, U.K.
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  • R.J.G. Chalmers,

    1. The Dermatology Centre, Hope Hospital, The University of Manchester, Salford, Manchester M6 8HD, U.K. Cancer Research UK Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham B15 2TT, U.K.
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  • E.J.C. Stewart,

    1. The Dermatology Centre, Hope Hospital, The University of Manchester, Salford, Manchester M6 8HD, U.K. Cancer Research UK Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham B15 2TT, U.K.
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  • P. Dey

    1. University of Central Lancashire, Preston PR1 2HE, U.K.
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  • Conflicts of interest
    C.E.M.G. has received honoraria from, and has acted as a paid consultant to, Leo Pharmaceuticals and Galderma.

C.E.M. Griffiths.
E-mail: christopher.griffiths@manchester.ac.uk

Summary

Background  Most patients with psoriasis have limited disease which can be managed effectively in primary care. There is a marked variation in the frequency of referrals between practices reflecting, in part, inadequate training of general practitioners (GPs) in the management of psoriasis.

Objectives  To assess the effectiveness of guidelines and training sessions on the management of psoriasis in reducing inappropriate referrals from primary care.

Methods  Patients aged 18 years or over with psoriasis were eligible for the cluster-randomized, randomized controlled trial if they were referred by their GP between 9 September 2002 and 31 December 2003 to one of four hospital dermatology departments in Greater Manchester, North-West England. All GPs from 165 health centres were invited to a lecture by a local dermatologist on the diagnosis and management of psoriasis. Health centres in the intervention arm received guidelines on the management of psoriasis in primary care, developed by local dermatologists, supplemented by the offer of a practice-based nurse-led training session; those in the control arm received neither guidelines nor training sessions.

Results  Eighty-two health centres were randomized to the intervention arm and 83 to the control arm. Outcome data were available for 188 of the 196 eligible patients referred during the study period. Patients in the intervention arm were significantly more likely to be appropriately referred in comparison with patients in the control arm [difference = 19·1%; odds ratio (OR) 2·47; 95% confidence interval (CI) 1·31–4·68; intracluster correlation coefficient (ICC) = 0]. Only 25 (30%) health centres in the intervention arm took up the offer of training sessions. There was no significant difference in outcome between health centres in the intervention arm that received a training session and those that did not (OR 1·28, 95% CI 0·50–3·29, ICC = 0).

Conclusions  Dissemination of guidelines on the management of psoriasis in primary care can significantly enhance the appropriateness of referral of patients to secondary care.

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