Ir J Med Sci DOI 10.1007/s11845-014-1075-6
ORIGINAL ARTICLE
General practitioner ENT referral audit J. C. Oosthuizen • D. McShane • J. Kinsella B. Conlon
•
Received: 22 October 2013 / Accepted: 26 January 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Background During 2009, there were 3.3 million outpatient attendances at outpatient clinics across Ireland. Up to 20 % of these are directed towards ENT services. Aims To determine the compliance rate of general practitioners with the ICGP referral guidelines. Methods One-hundred referrals received were compared to the ICGP standardised form and graded accordingly. Each referral letter was graded to a maximum of 37 points. Results The average score recorded for referrals was 16/37. The referrer detail section scored the highest with a mean of 75.42 % (paediatric referrals) and 72.9 % (adult referrals). The clinical information provided demonstrated compliance rates of 34 % (paediatrics) and 35 % (adults). In total, only 32 letters made any reference to findings on examination. Both paediatric and adult referrals scored an average of 42 % when patients’ details are considered. Conclusion This study demonstrates poor compliance rates with the introduced ICGP standardised referral form, which has implications for the accurate grading of referral letters received. Keywords ENT General practitioner Out patient Standardised Referral Otolaryngology
Introduction During 2009, there were *3.3 million outpatient attendances in Ireland at consultant led clinics of which J. C. Oosthuizen (&) D. McShane J. Kinsella B. Conlon The Adelaide and Meath, Incorporating the National Children’s Hospital, Dublin, Ireland e-mail: [email protected]
*900,000 patients attended for first appointments [1]. Between 9 and 20 % of all referrals received from the primary care sector are directed towards ENT hospital services and there has been a continued increase in demand for ENT outpatient appointments [2, 3]. It is not surprising therefore that waiting times for an ENT outpatient appointment can exceed 2 years in certain centres [4]. Furthermore, Ireland has the lowest ratio of ENT surgeons per population in the whole of Europe with only 53 surgeons for a patient population of 4.58 million which translates to one surgeon per 86,000 patients. In comparison, Greece would appear to have an abundance of ENT surgeons with one ENT surgeon for every 8,000 inhabitants. In the remainder of Europe, however, rates vary between 1:13,000 (Austria) and 1:30,000 (Netherlands) [5]. The unfavourable effects of extensive waiting lists are well established. It includes the need for additional administrative support and is ultimately related to increased mortality and morbidity rates [6]. General practitioner referral letters are an invaluable source of information and are often the only information available when these referrals are graded. Paucity of information can result in the inappropriate grading of referral letters, potentially resulting in inordinate delays in the investigation and management of patients requiring urgent review and similarly patients who may not necessarily have warranted urgent review may take up an outpatient slot which would have been better suited to a patient requiring urgent review [6]. In a bid to improve current referral pathways, the Irish Health Information and Quality Authority (HIQA) released a report and recommendations on patient referrals from primary care to outpatient service during 2011. This report also contained a standardised referral template which was developed in conjunction with the Irish College of General Practitioners (ICGP) [7] (Fig. 1).
123
Ir J Med Sci
Fig. 1 National standardised patient referral template
The aim of this audit was to determine the compliance rate of general practitioners with the above mentioned guidelines and to establish the quality of referrals received from general practitioners in an effort to improve the current ENT outpatient services provided in the Adelaide and Meath incorporating the National Children’s Hospital.
Methodology One-hundred (50 adult and 50 paediatric) new outpatient referrals received from GPs during the month of June 2013 were compared to the ICGP standardised form and graded accordingly. Referrals were limited to GP referrals. In hospital or other referrals were excluded from analysis. The ICGP standardised form was divided into five separate sections and each awarded a maximum numerical value for the information contained within each section. These sections included the referral details (6 points), patient details (12 points), referrer details (7 points), patient’s usual GP (2 points) and clinical information (10 points). Each referral
123
letter was studied and graded for each of the above sections to a maximum of 37 points.
Results Only one of the 100 received referral letters was completed on the standardised ICGP form, the remainder were all either hand written or typed letters with a wide variation of formats employed. The amount of information contained within the referral letters was universally lacking when compared with the accepted ICGP guidelines and format. The average score recorded for referrals was 16 (out of a maximum total of 37) for both adult and paediatric referral letters with a range of 10–23. The most consistent area of oversight was the patient’s usual GP with not a single letter (including the referral in the ICGP format) making reference to this. The referrer detail section scored the highest with regard to adherence to the guidelines with a mean of 75.42 % for paediatric referrals and 72.9 % in adult referrals. The clinical information provided within referral letters demonstrated compliance rates of 34 and 35 % for
Ir J Med Sci Table 1 Comparison of standardised ICGP form and received referral letters
100% 80% 60% 40% 20% 0% Referral Details
Patient Details
Referrer Details
Adult Referrals
paediatric and adult referral letters, respectively. In total, only 32 letters made any reference to findings on examination (14 paediatric and 18 adult). Both paediatric and adult referrals scored an average of 42 % when patients’ details are considered. Finally, paediatric details scored marginally higher with regard to referral details compared to their adult counterparts (45 vs. 39.67 %) (Table 1).
Patient's Usual GP Clinical Information
Paediatric Referrals
rate of only 34 and 35 % for paediatric and adult referral letters, respectively. It is needless to point out that the information contained in this section is of the utmost importance when grading referrals. Furthermore, the fact that in total only 34 % referrals made any reference to findings on clinical examination of the patient significantly hampers the safe and efficient grading of referral letters. Limitations of this study include the lack of a second independent reviewer of referrals as well as the fact that it does not represent a fully completed audit cycle.
Discussion Comprehensive referral letters, containing adequate relevant information, have a significant impact on specialists’ ability to grade referral letters adequately [8]. Conversely, deficient referrals present a significant risk management issue, as this can ultimately result in the delay of investigation of high-risk patients [6]. Whilst it is recognised that structured or standardised referral forms provide superior information compared to unstructured referral forms [9] and the guidelines published by HIQA are welcomed, it is clear that despite the fact that these guidelines have been in existence for more than 2 years it is not commonly in use. This is clear from the fact that only a single one of the 100 received referrals was completed on the HIQA/ICGP standardised form and only scored 21 out of a possible 37 marks. Whilst the currently recommended ICGP standardised form may appear daunting due to the fact that it comprises two full pages and consists of five different sections that require completion, measures have been introduced which allows the use of current electronic practice management systems to produce referrals in the proposed format and will automatically populate the required fields from the patient’s electronic notes. When the quality of received referrals are considered, it is not surprising that the section that consistently scored the highest totals were the referrer detail sections as all letters received were printed on a letterhead, containing a large amount of the required details i.e. GP name, address, telephone/fax numbers and IMC registration number. Of significant concern is the fact that the clinical information section ranked lowest of all sections (apart from the patient’s usual GP as mentioned above) with a compliance
Conclusion Whilst the reasons for the poor compliance rates with the ICGP standardised form are purely speculative and further surveys of the topic may be beneficial, findings published by French et al. [10] would suggest that close liaison with GPs and regular feedback with regard to extended waiting time information results in altered referral practice. Therefore, we would suggest the introduction of a GP liaison officer who can provide general practitioners with regular updates regarding waiting list times and the importance of adherence to the HIQA/ICGP guidelines. If effective, this will ultimately result in a better, safer outpatient service. Conflict of interest
None.
References 1. Authority HIaQ (2011) Report and recommendations on patient referrals from general practice to outpatient and radiology services, including the National Standard for Patient Referral Information 2. Twomey COD, Martin T (2005) Comhairle na nOspide´al report: otolaryngology services. Comhairle na nOspide´al Ireland 3. Alan J (2006) Evidence submitted by the British Association of Otorhinolaryngologists (WP 57). http://www.parliament.uk 4. Gary C (2013) ENT outpatient waits of nearly three years. Irish Medical Times 5. W. MH. ENT Specialists within EU member countries and other associated countries (2012) European Union of Medical Specialists––
123
Ir J Med Sci ORL section; (cited 2013). Available from http://www.orluems.com/ index.asp?seccion=8&apartado=13 6. Stainkey LA, Seidl IA, Johnson AJ, Tulloch GE, Pain T (2010) The challenge of long waiting lists: how we implemented a GP referral system for non-urgent specialist’ appointments at an Australian public hospital. BMC Health Serv Res 10:303 7. Health, Information, and, Quality, Authority (2011) Report and recommendations on patient referrals from general practice to outpatient and radiology services, including the National Standard for Patient Referral Information
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8. Jiwa M, Dhaliwal S (2012) Referral writer: preliminary evidence for the value of comprehensive referral letters. Qual Prim Care 20(1):39–45 9. Jenkins S, Arroll B, Hawken S, Nicholson R (1997) Referral letters: are form letters better? Br J Gen Pract 47(415):107–108 10. French JA, Stevenson CH, Eglinton J, Bailey JE (1990) Effect of information about waiting lists on referral patterns of general practitioners. Br J Gen Pract 40(334):186–189
ORIGINAL ARTICLE
General practitioner ENT referral audit J. C. Oosthuizen • D. McShane • J. Kinsella B. Conlon
•
Received: 22 October 2013 / Accepted: 26 January 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Background During 2009, there were 3.3 million outpatient attendances at outpatient clinics across Ireland. Up to 20 % of these are directed towards ENT services. Aims To determine the compliance rate of general practitioners with the ICGP referral guidelines. Methods One-hundred referrals received were compared to the ICGP standardised form and graded accordingly. Each referral letter was graded to a maximum of 37 points. Results The average score recorded for referrals was 16/37. The referrer detail section scored the highest with a mean of 75.42 % (paediatric referrals) and 72.9 % (adult referrals). The clinical information provided demonstrated compliance rates of 34 % (paediatrics) and 35 % (adults). In total, only 32 letters made any reference to findings on examination. Both paediatric and adult referrals scored an average of 42 % when patients’ details are considered. Conclusion This study demonstrates poor compliance rates with the introduced ICGP standardised referral form, which has implications for the accurate grading of referral letters received. Keywords ENT General practitioner Out patient Standardised Referral Otolaryngology
Introduction During 2009, there were *3.3 million outpatient attendances in Ireland at consultant led clinics of which J. C. Oosthuizen (&) D. McShane J. Kinsella B. Conlon The Adelaide and Meath, Incorporating the National Children’s Hospital, Dublin, Ireland e-mail: [email protected]
*900,000 patients attended for first appointments [1]. Between 9 and 20 % of all referrals received from the primary care sector are directed towards ENT hospital services and there has been a continued increase in demand for ENT outpatient appointments [2, 3]. It is not surprising therefore that waiting times for an ENT outpatient appointment can exceed 2 years in certain centres [4]. Furthermore, Ireland has the lowest ratio of ENT surgeons per population in the whole of Europe with only 53 surgeons for a patient population of 4.58 million which translates to one surgeon per 86,000 patients. In comparison, Greece would appear to have an abundance of ENT surgeons with one ENT surgeon for every 8,000 inhabitants. In the remainder of Europe, however, rates vary between 1:13,000 (Austria) and 1:30,000 (Netherlands) [5]. The unfavourable effects of extensive waiting lists are well established. It includes the need for additional administrative support and is ultimately related to increased mortality and morbidity rates [6]. General practitioner referral letters are an invaluable source of information and are often the only information available when these referrals are graded. Paucity of information can result in the inappropriate grading of referral letters, potentially resulting in inordinate delays in the investigation and management of patients requiring urgent review and similarly patients who may not necessarily have warranted urgent review may take up an outpatient slot which would have been better suited to a patient requiring urgent review [6]. In a bid to improve current referral pathways, the Irish Health Information and Quality Authority (HIQA) released a report and recommendations on patient referrals from primary care to outpatient service during 2011. This report also contained a standardised referral template which was developed in conjunction with the Irish College of General Practitioners (ICGP) [7] (Fig. 1).
123
Ir J Med Sci
Fig. 1 National standardised patient referral template
The aim of this audit was to determine the compliance rate of general practitioners with the above mentioned guidelines and to establish the quality of referrals received from general practitioners in an effort to improve the current ENT outpatient services provided in the Adelaide and Meath incorporating the National Children’s Hospital.
Methodology One-hundred (50 adult and 50 paediatric) new outpatient referrals received from GPs during the month of June 2013 were compared to the ICGP standardised form and graded accordingly. Referrals were limited to GP referrals. In hospital or other referrals were excluded from analysis. The ICGP standardised form was divided into five separate sections and each awarded a maximum numerical value for the information contained within each section. These sections included the referral details (6 points), patient details (12 points), referrer details (7 points), patient’s usual GP (2 points) and clinical information (10 points). Each referral
123
letter was studied and graded for each of the above sections to a maximum of 37 points.
Results Only one of the 100 received referral letters was completed on the standardised ICGP form, the remainder were all either hand written or typed letters with a wide variation of formats employed. The amount of information contained within the referral letters was universally lacking when compared with the accepted ICGP guidelines and format. The average score recorded for referrals was 16 (out of a maximum total of 37) for both adult and paediatric referral letters with a range of 10–23. The most consistent area of oversight was the patient’s usual GP with not a single letter (including the referral in the ICGP format) making reference to this. The referrer detail section scored the highest with regard to adherence to the guidelines with a mean of 75.42 % for paediatric referrals and 72.9 % in adult referrals. The clinical information provided within referral letters demonstrated compliance rates of 34 and 35 % for
Ir J Med Sci Table 1 Comparison of standardised ICGP form and received referral letters
100% 80% 60% 40% 20% 0% Referral Details
Patient Details
Referrer Details
Adult Referrals
paediatric and adult referral letters, respectively. In total, only 32 letters made any reference to findings on examination (14 paediatric and 18 adult). Both paediatric and adult referrals scored an average of 42 % when patients’ details are considered. Finally, paediatric details scored marginally higher with regard to referral details compared to their adult counterparts (45 vs. 39.67 %) (Table 1).
Patient's Usual GP Clinical Information
Paediatric Referrals
rate of only 34 and 35 % for paediatric and adult referral letters, respectively. It is needless to point out that the information contained in this section is of the utmost importance when grading referrals. Furthermore, the fact that in total only 34 % referrals made any reference to findings on clinical examination of the patient significantly hampers the safe and efficient grading of referral letters. Limitations of this study include the lack of a second independent reviewer of referrals as well as the fact that it does not represent a fully completed audit cycle.
Discussion Comprehensive referral letters, containing adequate relevant information, have a significant impact on specialists’ ability to grade referral letters adequately [8]. Conversely, deficient referrals present a significant risk management issue, as this can ultimately result in the delay of investigation of high-risk patients [6]. Whilst it is recognised that structured or standardised referral forms provide superior information compared to unstructured referral forms [9] and the guidelines published by HIQA are welcomed, it is clear that despite the fact that these guidelines have been in existence for more than 2 years it is not commonly in use. This is clear from the fact that only a single one of the 100 received referrals was completed on the HIQA/ICGP standardised form and only scored 21 out of a possible 37 marks. Whilst the currently recommended ICGP standardised form may appear daunting due to the fact that it comprises two full pages and consists of five different sections that require completion, measures have been introduced which allows the use of current electronic practice management systems to produce referrals in the proposed format and will automatically populate the required fields from the patient’s electronic notes. When the quality of received referrals are considered, it is not surprising that the section that consistently scored the highest totals were the referrer detail sections as all letters received were printed on a letterhead, containing a large amount of the required details i.e. GP name, address, telephone/fax numbers and IMC registration number. Of significant concern is the fact that the clinical information section ranked lowest of all sections (apart from the patient’s usual GP as mentioned above) with a compliance
Conclusion Whilst the reasons for the poor compliance rates with the ICGP standardised form are purely speculative and further surveys of the topic may be beneficial, findings published by French et al. [10] would suggest that close liaison with GPs and regular feedback with regard to extended waiting time information results in altered referral practice. Therefore, we would suggest the introduction of a GP liaison officer who can provide general practitioners with regular updates regarding waiting list times and the importance of adherence to the HIQA/ICGP guidelines. If effective, this will ultimately result in a better, safer outpatient service. Conflict of interest
None.
References 1. Authority HIaQ (2011) Report and recommendations on patient referrals from general practice to outpatient and radiology services, including the National Standard for Patient Referral Information 2. Twomey COD, Martin T (2005) Comhairle na nOspide´al report: otolaryngology services. Comhairle na nOspide´al Ireland 3. Alan J (2006) Evidence submitted by the British Association of Otorhinolaryngologists (WP 57). http://www.parliament.uk 4. Gary C (2013) ENT outpatient waits of nearly three years. Irish Medical Times 5. W. MH. ENT Specialists within EU member countries and other associated countries (2012) European Union of Medical Specialists––
123
Ir J Med Sci ORL section; (cited 2013). Available from http://www.orluems.com/ index.asp?seccion=8&apartado=13 6. Stainkey LA, Seidl IA, Johnson AJ, Tulloch GE, Pain T (2010) The challenge of long waiting lists: how we implemented a GP referral system for non-urgent specialist’ appointments at an Australian public hospital. BMC Health Serv Res 10:303 7. Health, Information, and, Quality, Authority (2011) Report and recommendations on patient referrals from general practice to outpatient and radiology services, including the National Standard for Patient Referral Information
123
8. Jiwa M, Dhaliwal S (2012) Referral writer: preliminary evidence for the value of comprehensive referral letters. Qual Prim Care 20(1):39–45 9. Jenkins S, Arroll B, Hawken S, Nicholson R (1997) Referral letters: are form letters better? Br J Gen Pract 47(415):107–108 10. French JA, Stevenson CH, Eglinton J, Bailey JE (1990) Effect of information about waiting lists on referral patterns of general practitioners. Br J Gen Pract 40(334):186–189
