Scot Med J 1992; 37: 179-180
0036-9330/92/02892/179 $2.00 in USA © 1992 Scottish Medical Journal
MEDICAL CLINIC REFERRAL LETTERS DO THEY SAY WHAT THEY MEAN? DO THEY MEAN WHAT THEY SAY? JA.H. Hodge, A. Jacob. M.J. Ford. J.F. Munro Eastern General Hospital, Seafield Street, Edinburgh EH6 7LN Abstract: Consecutive general practitionerreferralsto three generalmedical clinicswere examinedprospectively to assess whether the reasonfor referral was being correctlyinterpretedby consultants. The resultantdata revealed that although thiswas not always the case.suchmisunderstandings did not appearto affectsubsequentmanagement. Explicit reasonsfor referral in the referral letter howevercouldimproveboth the quality and valueofout-patientconsultations.
Introduction
M
uch attention has recently been focused on the reasons for which patients are referred to out-patient departments by their general practitioners and on variations in referral rates between different pracrices.i" While these rates are clearly one part of the sum that makes up the demands on an out-patient service, the other significant portion is the subsequent management, and it is here that the coincidence or discrepancy between the expectations of patient, general practitioner and consultant may influence the course of events. In medical out-patients, for example, the alternative aims of absolute diagnosis versus simple reassurance may lead to very different paths of action, intervention, and follow up. In this context, consultants' perceptions of the indications for referral may be of importance in influencing responses to clinical findings. We have studied medical out-patient referrals to determine to what extent reasons for referral are wrongly perceived, and to examine whether or not this affects subsequent management.
Patients and Methods Consecutive referrals to general medical out-patient clinics in three hospitals (EGH, LH and ED) serviced by two consultants were studied. One of these hospitals (LH) has no in-patient facility, and at ED the radiology service is confined to plain radiographs. At EGH, facilities for exercise testing, echocardiography, and upper and lower GI endoscopy are available, but none of these is possible at the other two hospitals. One of the consultants has an interest in gastroenterology and this is reflected in the referrals to the clinic at LH and in his use of the endoscopy facilities at EGH. The majority of referrals to all three clinics came from local general practitioners well known to the consultants involved in the clinics. Following receipt of the general practitioner referral letter to the clinic, a questionnaire was sent to the general practitioner concerned, asking him/her to indicate the prime reason or reasons for referral using one or more of the following four categories: 1. for DIAGNOSIS 2. to initiate a specific INVESTIGATION, eg gastroscopy 3. for MANAGEMENT advice on a condition already diagnosed Correspondence to: Dr J F Munro, Consultant Physician, Eastern General Hospital, Seafie1d Street, Edinburgh EH6 7LN
4. for REASSURANCE of patient, relative, or general practitioner. At the out-patient consultation, the consultants completed a questionnaire, in which they stated what they believed to be the reason or reasons for each referral based on the referral letter and the consultation; the same four categories were used. In addition, the consultants were asked the following questions relating to their management practice. 1. Was the patient's investigation completed at the first visit? 2. Was the patient referred on to any other hospital for investigation? 3. Was the patient admitted following out-patient consultation? Thereafter the completed pairs of questionnaires were compared and divided into groups according to whether there was a "match", "partial match" or "mismatch" between the reasons for referral given by the general practitioner and those perceived by the consultants. Partial matches were identified by the presence of reasons for referral recorded by the general practitioner but not the consultant or vice versa. Using the additional questions answered by the consultants, these groups were then sub-divided into those whose investigation had been completed at the first visit and those who were either admitted or referred on to another hospital. Comparisons were then drawn between the outcome of consultations occurring at different clinics, and for different reasons of referral, both real and perceived.
Results Questionnaires were completed for 297 consecutive referrals to the three clinics. Only five questionnaires were not returned or were completed inadequately. Table I shows the numbers referred in each category, as perceived by the consultants, divided according to the degree of matching with the general practitioners given reasons. Tables II and III examine the "diagnostic" referral group and the outcome of the consultations in more detail, showing the variation in patterns of investigation, further referral, and admission that exist between the different groups of match and mismatch. It will be seen that the quest for diagnosis was considered to be the primary reason for referral in 191/297 cases (64%) but that this perception was erroneous or incomplete in 137/191 cases
179
Medical clinical referral letters
Hodge, Jacob, Ford, Munro
Table I Degree of matching of reasons for referral between general practitioner and consultant
Referral Groupings Diagnostic Investigation Management Reassurance Total
Match
Partial Match
Mismatch
Total
54 10 18 11 93
115 18 22 10 165
22 9 7 1 39
191 37 47 22 297
Chi square
=9.5 (N.S.)
Tablell Medical referrals considered necessary for diagnostic reasons Fully investigated at first visit Not fully investigated at first visit Referred elsewhere Admitted Total
Match
Partial Match
Mismatch
Total
18
35
5
58
12 14
27 45 8 115
8 6 3 22
57 65 21 191
10
54 Chi square
=8.6 (N.S.)
Table ill Investigational consequences of referral Fully investigated at first visit Referral Groupings Diagnostic Investigation Management Reassurance Total
58 4
29 14 105
Not fully investigated at first visit 47 10 8 3 68
Referred Admitted elsewhere
65 21 9 3
98
21 2 3
o
26
Total
191 37 49 20 297
Chi square =39.4 (p
0036-9330/92/02892/179 $2.00 in USA © 1992 Scottish Medical Journal
MEDICAL CLINIC REFERRAL LETTERS DO THEY SAY WHAT THEY MEAN? DO THEY MEAN WHAT THEY SAY? JA.H. Hodge, A. Jacob. M.J. Ford. J.F. Munro Eastern General Hospital, Seafield Street, Edinburgh EH6 7LN Abstract: Consecutive general practitionerreferralsto three generalmedical clinicswere examinedprospectively to assess whether the reasonfor referral was being correctlyinterpretedby consultants. The resultantdata revealed that although thiswas not always the case.suchmisunderstandings did not appearto affectsubsequentmanagement. Explicit reasonsfor referral in the referral letter howevercouldimproveboth the quality and valueofout-patientconsultations.
Introduction
M
uch attention has recently been focused on the reasons for which patients are referred to out-patient departments by their general practitioners and on variations in referral rates between different pracrices.i" While these rates are clearly one part of the sum that makes up the demands on an out-patient service, the other significant portion is the subsequent management, and it is here that the coincidence or discrepancy between the expectations of patient, general practitioner and consultant may influence the course of events. In medical out-patients, for example, the alternative aims of absolute diagnosis versus simple reassurance may lead to very different paths of action, intervention, and follow up. In this context, consultants' perceptions of the indications for referral may be of importance in influencing responses to clinical findings. We have studied medical out-patient referrals to determine to what extent reasons for referral are wrongly perceived, and to examine whether or not this affects subsequent management.
Patients and Methods Consecutive referrals to general medical out-patient clinics in three hospitals (EGH, LH and ED) serviced by two consultants were studied. One of these hospitals (LH) has no in-patient facility, and at ED the radiology service is confined to plain radiographs. At EGH, facilities for exercise testing, echocardiography, and upper and lower GI endoscopy are available, but none of these is possible at the other two hospitals. One of the consultants has an interest in gastroenterology and this is reflected in the referrals to the clinic at LH and in his use of the endoscopy facilities at EGH. The majority of referrals to all three clinics came from local general practitioners well known to the consultants involved in the clinics. Following receipt of the general practitioner referral letter to the clinic, a questionnaire was sent to the general practitioner concerned, asking him/her to indicate the prime reason or reasons for referral using one or more of the following four categories: 1. for DIAGNOSIS 2. to initiate a specific INVESTIGATION, eg gastroscopy 3. for MANAGEMENT advice on a condition already diagnosed Correspondence to: Dr J F Munro, Consultant Physician, Eastern General Hospital, Seafie1d Street, Edinburgh EH6 7LN
4. for REASSURANCE of patient, relative, or general practitioner. At the out-patient consultation, the consultants completed a questionnaire, in which they stated what they believed to be the reason or reasons for each referral based on the referral letter and the consultation; the same four categories were used. In addition, the consultants were asked the following questions relating to their management practice. 1. Was the patient's investigation completed at the first visit? 2. Was the patient referred on to any other hospital for investigation? 3. Was the patient admitted following out-patient consultation? Thereafter the completed pairs of questionnaires were compared and divided into groups according to whether there was a "match", "partial match" or "mismatch" between the reasons for referral given by the general practitioner and those perceived by the consultants. Partial matches were identified by the presence of reasons for referral recorded by the general practitioner but not the consultant or vice versa. Using the additional questions answered by the consultants, these groups were then sub-divided into those whose investigation had been completed at the first visit and those who were either admitted or referred on to another hospital. Comparisons were then drawn between the outcome of consultations occurring at different clinics, and for different reasons of referral, both real and perceived.
Results Questionnaires were completed for 297 consecutive referrals to the three clinics. Only five questionnaires were not returned or were completed inadequately. Table I shows the numbers referred in each category, as perceived by the consultants, divided according to the degree of matching with the general practitioners given reasons. Tables II and III examine the "diagnostic" referral group and the outcome of the consultations in more detail, showing the variation in patterns of investigation, further referral, and admission that exist between the different groups of match and mismatch. It will be seen that the quest for diagnosis was considered to be the primary reason for referral in 191/297 cases (64%) but that this perception was erroneous or incomplete in 137/191 cases
179
Medical clinical referral letters
Hodge, Jacob, Ford, Munro
Table I Degree of matching of reasons for referral between general practitioner and consultant
Referral Groupings Diagnostic Investigation Management Reassurance Total
Match
Partial Match
Mismatch
Total
54 10 18 11 93
115 18 22 10 165
22 9 7 1 39
191 37 47 22 297
Chi square
=9.5 (N.S.)
Tablell Medical referrals considered necessary for diagnostic reasons Fully investigated at first visit Not fully investigated at first visit Referred elsewhere Admitted Total
Match
Partial Match
Mismatch
Total
18
35
5
58
12 14
27 45 8 115
8 6 3 22
57 65 21 191
10
54 Chi square
=8.6 (N.S.)
Table ill Investigational consequences of referral Fully investigated at first visit Referral Groupings Diagnostic Investigation Management Reassurance Total
58 4
29 14 105
Not fully investigated at first visit 47 10 8 3 68
Referred Admitted elsewhere
65 21 9 3
98
21 2 3
o
26
Total
191 37 49 20 297
Chi square =39.4 (p
