Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

OBJECTIVES--To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines. SETTING--Practices within Cambridge Health Authority and Addenbrooke''s Hospital, Cambridge. MAIN OUTCOME MEASURES--Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists. Effect of referral guidelines on referral patterns as judged by general practitioners using the guidelines in clinical practice. RESULTS--There was 2.5-fold variation in referral rates among general practices. According to the specialists, 9.6% (95% confidence interval 6.4% to 12.9%) of referrals by general practitioners and 8.9% (2.6% to 15.2%) of referrals from other specialists were judged possibly or definitely inappropriate. Against locally determined referral guidelines 15.9% of referrals by general practitioners were judged possibly inappropriate (11.8% to 20.0%). Elimination of all possibly inappropriate referrals could reduce variation in practice referral rates only from 2.5-fold to 2.1-fold. An estimate of the effect of using referral guidelines for 60 common conditions in routine general practice suggested that application of guidelines would have been unlikely to reduce rates of referral in hospital (95% confidence interval -4.5% to 8.6% of consultations resulting in referral). CONCLUSION--The variation in referral rates among general practitioners in Cambridge could not be explained by inappropriate referrals. Application of referral guidelines would be unlikely to reduce the number of patients referred to hospital.     

Referrals to hospital by general practitioners: a study of compliance and communication.

To determine the extent of non-attendance at first hospital appointments 269 hospital referrals made in one practice over 14 weeks were analysed retrospectively. Non-attendance was more likely among patients referred to outpatient departments than to casualty or for admission. Fifteen per cent (41/269) of all patients and 20% (33/167) of outpatients failed to keep their initial appointments. Prolonged waiting times from referral to appointment were significantly related to non-attendance. Twenty weeks after the last referral had been made no communication had been received by the practice for 24% (61/252) of all referral letters received by the hospital. Minimum delays to appointments and improved communication between hospitals and general practitioners would help general practitioners to make appropriate referrals and improve compliance.     

Effect of NHS reforms on general practitioners' referral patterns.

OBJECTIVE--To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991. DESIGN--Prospective collection of data on general practitioners'' referrals to specialist outpatient clinics between June 1990 and March 1992 and detailed comparison of two time periods: October 1990 to March 1991 (phase 1) and October 1991 to March 1992 (phase 2). SETTING--10 fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS--Patients referred to consultant outpatient clinics. RESULTS--After implementation of the NHS reforms there was no change in the proportion of referrals from the two groups of practices which crossed district boundaries. Both groups of practices increased their referral rates in phase 2 of the study, the fundholders from 107.3 per 1000 patients per annum (95% confidence interval 106 to 109) to 111.4 (110 to 113) and the non-fundholders from 95.0 (93 to 97) to 112.0 (110 to 114). In phase 2 there was no difference in overall standardised referral rates between fundholders and non-fundholders. Just over 20% of referrals went to private clinics in phase 1. By phase 2 this proportion had reduced by 2.2% (1.0% to 3.4%) among the fundholders and by 2.7% (1.2% to 4.2%) among the non-fundholders. CONCLUSIONS--Referral patterns among fundholders and non-fundholders were strikingly similar after the implementation of the NHS reforms. There was no evidence that fundholding was encouraging a shift from specialist to general practice care or that budgetary pressures were affecting general practitioners'' referral behaviour.     

Understanding hospital referral rates: a user's guide.

Detailed referral information from one practice was used to investigate the effect of calculating referral rates in several different ways. Referral rates for individual general practitioners should be related to the number of consultations carried out and not to the number of registered patients; for whole practices list size may be used as the denominator. Most doctors will not need to control for age and sex of patients when comparing referral rates but may need to control for case mix when comparing referral rates to individual specialties. In addition, a method is described for distinguishing systematic variation between the referral rates of individual doctors from the random variation that may arise from data based on fairly small numbers of referrals. The method indicates whether systematic variation is greater than would be expected by chance, and it can be extended to indicate whether variability in referral rates is greater in one specialty than another. Because of random variation with time a year''s data may not be sufficient to allow reliable interpretation of referral rates to individual specialties, except for the largest. At present there is no known relation between high or low referral rates and quality of care. Nevertheless, if doctors are to interpret their own rates of referral they need those rates to be reliable and valid. Use of the 10 guidelines described in this paper will help to prevent unwarranted conclusions being drawn from information on general practitioners'' rates of referral to hospital.     

General practitioners' referrals to specialist outpatient clinics. II. Locations of specialist outpatient clinics to which general practitioners refer patients.

Although linkage by computer of hospital administration systems across all clinics in a health district is becoming a practical possibility, complete records of general practitioners'' referrals to outpatient clinics will be difficult to achieve. Data from a large study of general practitioners'' referrals to such clinics were used to calculate the proportion of referrals that crossed district boundaries, the proportion that were made to the private sector; and the number of locations that each practice referred patients to. Of the 17,601 referrals from practices in Oxford Regional Health Authority, 13,857 (78.7%) were made to NHS outpatient clinics within practices'' own districts, 1524 (8.7%) to clinics in other districts in the same region, 420 (2.4%) to NHS clinics in other regions, and 1800 (10.2%) to the private sector; but these proportions varied considerably among the practices. The mean number of different NHS hospitals or clinics that each practice referred patients to was 15.8 (range 4-42).     

General practitioners' referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics.

There has been much concern about the wide variations in general practitioners'' referral rates and the consequent implications for cost and quality of care. This has led to a call to evaluate the appropriateness and effectiveness of referrals. A collaborative audit of referrals to outpatient clinics was conducted by 127 general practitioners in 33 practices in the Oxford region. Records were kept of 18,754 referrals, which included data on diagnoses and reasons for referral. Overall, 6553 (35.4%) of the referrals were for particular treatments or operations and a further 6475 (34.9%) were for specific investigation or diagnosis. Advice on management was the main reason for referral in 2656 (14.3%) cases, and in 1719 (9.3%) cases the general practitioners wanted the consultants to take over managing their patients. Reassurance of either the general practitioner or the patient was recorded as the main reason in only 762 (4.1%) referrals. There seems to be scope for rationalising the referral process. A programme with three stages for evaluating referrals to outpatient clinics is recommended.     

Can telemedicine be used to improve communication between primary and secondary care?

OBJECTIVE: To test feasibility and acceptability of teleconferencing routine outpatient consultations. DESIGN: Exploratory trial of teleconferenced outpatient referrals of general practitioners. SETTING: An inner city teaching hospital and surrounding general practices. SUBJECTS: Six general practices linked to hospital outpatient clinics. MAIN OUTCOME MEASURES: Levels of participants'' satisfaction measured with self administered questionnaires. RESULTS: 54 teleconsultations were performed in 10 different specialties. Few serious technical problems were encountered, and high levels of satisfaction with the consultations were reported by patients, hospital specialists, and general practitioners. CONCLUSIONS: Teleconferenced consultations for routine outpatient referrals with joint participation of general practitioner were feasible. These may have an important potential benefit for improving communication between primary and secondary care.     

The extent of the two tier service for fundholders.

OBJECTIVE--To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners. DESIGN--Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995. SETTING--District health authority in south-west England. SUBJECTS--10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients. MAIN OUTCOME MEASURES--Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times. RESULTS--In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5. CONCLUSIONS--Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients.     

Trends in deliberate self poisoning and self injury in Oxford, 1976-90.

OBJECTIVE--To review trends in deliberate self poisoning and self injury (attempted suicide) over 15 years (1976-90) on the basis of general hospital referrals. DESIGN--Prospective data collection by computerised monitoring system. SETTING--Teaching general hospital. SUBJECTS--All patients aged 15 and over (n = 9605) referred to the hospital after episodes (n = 13,340) of deliberate self poisoning or self injury. MAIN OUTCOME MEASURES--Rates based on population of Oxford city; changes in substances used for self poisoning; history and repetition of attempts; and rates of admission to the hospital and of referral to the psychiatric service. RESULTS--Attempted suicide rates for women declined during the late 1970s and early 1980s but increased again during the late 1980s. Those for men remained relatively steady throughout the period. Highest mean annual rates occurred in women aged 15-19 (711/100,000) and in 20-34 year old men (334/100,000). The proportion of overdoses with paracetamol increased from 14.3% (125/873) in 1976 to 42% (365/869) in 1990 (chi 2 for trend = 481, p less than 0.01). Throughout the period the proportions of referred patients admitted to hospital and of those attempting suicide for the first time (over two thirds) did not decrease. Annual rates of repetition of attempts by women declined from 15.1% (257/1700) in 1976-8 to 11.9% (161/1356) in 1987-9 (chi 2 for trend = 7.8, p less than 0.01). Lower repetition rates occurred in women admitted to hospital and referred to the psychiatric service (431/4585, 9.4%) than in those not referred (42/235, 17.9%; chi 2 = 17.2, p less than 0.0001). CONCLUSIONS--Rates of attempted suicide declined in the 1970s and early 1980s, in women, but there are probably at least 100,000 hospital referrals a year in England and Wales because of this problem. Prevention of paracetamol self poisoning requires urgent attention, and psychosocial assessment should be conducted with as many of those who attempt suicide as possible.     

How much variation in referral rates among general practitioners is due to chance?

A 20-fold variation in referral rates from general practitioners to hospital outpatient departments has been shown in studies published to date. Most of the hypotheses proposed to account for this variation have not been supported by these studies. A simple model was constructed, which showed that a significant part of the variation may be due to the fairly small numbers of referrals in most studies. Real differences may have been swamped by random variations in the small numbers of referrals. The statistical power of the studies may not have been high enough to determine which factors were significant in describing the variation and how much of the variation was due to differing clinical practice. There remains a substantial part of the variation that cannot be accounted for.     

Variation in rates of hospital admission for appendicitis in Wales.

In a study designed to investigate the variations in rates of admission to hospital for appendicitis in Wales Hospital Activity Analysis listings were analysed according to the sex and age of the patients and the month and day of the week of admission. The incidence of hospitalisation was greatest among boys aged 10-14 and girls aged 15-19. The number of admissions was higher on weekdays than at weekends, but there were no seasonal variations. Durations of stay differed between the 17 health districts. We conclude that admission rates vary mainly because of differing hospital admission policies. Admission is not wholly governed by the sudden onset of abdominal pain; other factors include the threshold of consultation of each patient, the referral habits of general practitioners, the availability of hospital beds, and the degree to which doctors and patients expect admission.     

Use of Radiological Facilities by General Practitioners

The 11,360 direct referrals to diagnostic radiological facilities by general practitioners in the Aberdeen area during 1973 were studied. These represented about 12% of the adult radiology performed in the main x-ray departments of the city, and barium meal examinations amounted to half of all such outpatient contrast examinations. Chest x-ray and barium meal examinations were the most frequently used procedures.Some abnormality was detected at 34% of all examinations, and the barium meal examinations requested by general practitioners showed a similar percentage of abnormal findings to those requested by Aberdeen hospital doctors.The average referral rate for all practices was 24·6 per 1,000 practice population per year. Singlehanded general practitioners referred fewer patients for diagnostic radiology than those working in group practices, and rural practitioners referred fewer than urban general practitioners. This trend was emphasized at a distance greater than 15 miles from the city.     

The effect of deprivation on variations in general practitioners' referral rates: a cross sectional study of computerised data on new medical and surgical outpatient referrals in Nottinghamshire.

OBJECTIVE: To determine the effect of deprivation on variations in general practitioners'' referral rates using the Jarman underprivileged area (UPA(8)) score as a proxy measure. DESIGN: Cross sectional survey of new medical and surgical referrals from general practices to hospitals (determined from hospital activity data). SETTING: All of the 183 general practices in Nottinghamshire and all of the 19 hospitals in Trent region. MAIN OUTCOME MEASURES: The relation between the referral rates per 1000 registered patients and the practice population''s UPA(8) score (calculated on the basis of electoral ward), with adjustment for the number of partners, percentage of patients aged over 65 years, and fundholding status of each practice. RESULTS: There was a significant independent association between deprivation, as measured by the UPA(8) score, and high total referral rates and high medical referral rates (P < 0.0001). The UPA(8) score alone explained 23% of the total variation in total referral rates and 32% of the variation in medical referral rates. On multivariate analysis, where partnership size, fundholding status, and percentage of men and women aged over 65 years were included, the UPA(8) score explained 29% and 35% of the variation in total and medical referral rates respectively. CONCLUSION: Of the variables studied, the UPA(8) score was the strongest predictor of variations in referral rates. This association is most likely to be through a link with morbidity, although it could reflect differences in patients'' perceptions, doctors'' behaviour, or the use and provision of services.     

How valuable is feedback of information on hospital referral patterns?

OBJECTIVES--To determine general practitioners'' responses to and explanations for variation in rates of referral to hospital and how feedback of data on rates of referral could be used to facilitate practices in auditing their own referral behaviour. DESIGN--Visits by audit facilitators to general practices after feedback of details of rates of referral to hospital derived from annual reports in general practice. SETTING--92 general practices in East Anglia. RESULTS--General practitioners judged that access to specialist care, the individual skill of general practitioners, patient demand, and fear of litigation were major determinants of referral behaviour. Because there was widespread scepticism about the accuracy of the data on which the feedback was based and because there is no clear relation between rates of referral and quality of care, it was extremely difficult to encourage doctors to use the feedback as a basis for auditing their own hospital referrals. CONCLUSION--If general practitioners are to contribute meaningfully to monitoring future changes in referral patterns it will be essential to develop reliable information systems in which doctors have confidence. Furthermore, audits need to be based on analysis of clinical cases rather than on rates of referral.     

Hospital work load produced by breast-cancer screening programme run by trained non-medical staff.

In a feasibility study of mass population screening for breast cancer by annual clinical examination and mammography the findings of non-medical staff (nurses and radiographers) were used to estimate the hospital work load generated by such a programme. Among 2490 women who attended for the first time by invitation the rate of referral for a surgical opinion based on the findings of the non-medical staff was 7.9% and the biopsy rate 2.5%. In the second and third years referral rates fell to 4.3% and 2.7% respectively and the biopsy rates to 1.1% and 1.4%. The rates of referral and biopsy among 1203 women who referred themselves for screening were higher, but many self-referred women were symptomatic; those without symptoms had rates of referral and biopsy similar to those of the invited women. Extrapolation of these findings to a population of 200,000 in a typical health district showed that the hospital work load would be high in the first year of screening with 44 outpatient referrals per week and 14 biopsies. By the third year, however, only seven referrals and four biopsies a week could be expected. The work load would be reduced by a third if screening were confined to women over the age of 50.     

Appropriateness of hospital referral for hypertension.

OBJECTIVE--To examine the efficiency of referral to an outpatient clinic and particularly the differences between referrals from general practitioners practising in health centres and those from other general practitioners. DESIGN--Retrospective audit of referral letters and case notes by comparison with externally set standards of appropriateness of referrals over two years. SETTING--Outpatient hypertension clinic at Western Infirmary, Glasgow. PATIENTS--306 Consecutive new referrals of patients over two years (1 May 1986 to 30 April 1988), for whom case notes were available in 298. MAIN OUTCOME MEASURES--Congruence of referrals with each of two standards of appropriateness based on published opinion on specialist referral (standard 1 was stricter than standard 2) and completeness of referral letters. RESULTS--Of the 298 referrals, those from general practitioners accounted for 205, from other hospital departments 68, and from other sources 25. Overall, 84 referrals of the 205 from general practice met the first standard and 134 met the second, more lenient standard. 58 Referral letters from outside the hospital had some item missing. Referrals from general practitioners working in health centres (a fifth of the total) were significantly more likely to meet both standards (p less than 0.01) and to send a complete referral letter (p less than 0.001) than the 145 referred by other general practitioners. CONCLUSIONS--According to the standards used, general practitioners in health centres made more appropriate referrals, and further investigation is needed to identify the underlying factors responsible.     

Influence of the Royal College of Radiologists' guidelines on hospital practice: a multicentre study. Royal College of Radiologists Working Party.

OBJECTIVE--To measure the effect on hospital radiology referral practice of introducing a strategy for change involving guidelines of good practice, monitoring, and peer review. DESIGN--Prospective data collection over a continuous 21-24 month period at each centre some time between January 1987 and December 1990. SETTING--Five district general hospitals and one district health authority. SUBJECTS--314,663 inpatient discharges, deaths, and day cases and 1,706,781 outpatient attendances under the care of 722 consultants from 25 clinical specialties. MAIN OUTCOME MEASURES--Number of referrals for x ray examination per 100 inpatient discharges, deaths, and day cases and per 100 new outpatient attenders. RESULTS--Most doctors were prepared to accept standards of clinical practice set by peers and also the monitoring and review of their practice with respect to these standards by local colleagues. 18% of firms were identified before guidelines were instituted as having persistently high referral rates. Appreciable, and often dramatic reductions in referral rates for individual x ray examinations were recorded by a substantial number of firms in every centre and in every specialty after guidelines were instituted. The major part of this reduction was achieved by some of the firms whose initial practice did not meet "high referral" criteria. Important variations in compliance with agreed standards of good practice were observed. CONCLUSIONS--The study offers strong experimental evidence to support a recent suggestion that at least a fifth of radiological examinations carried out in NHS hospitals are clinically unhelpful. The problem of how to assure compliance with agreed standards of practice needs to be resolved. Until this happens medical audit alone is unlikely to translate good practice into common practice.     

Open access to orthopaedic appliances for general practitioners.

A clinic to which general practitioners can refer patients for some types of orthopaedic appliances was opened in North Clwyd in 1983. During 1985, 956 patients were referred by 82 general practitioners; 860 patients received an appliance, and the average waiting time was less than five weeks. Most referrals were for soft collars (44%), lumbar sacral supports (30%), and dorsilumbar supports (7%). Thirty eight patients failed to attend, 54 declined an appliance, and four referrals were considered to be inappropriate. A few patients were subsequently referred to consultant outpatient clinics, 22 for physiotherapy and 34 were referred simultaneously to the open access clinic. The referral rates for general practitioners with access to community hospitals were low. Such an arrangement merits wider consideration.     

Determining the size of a total purchasing site to manage the financial risks of rare costly referrals: computer simulation model.

OBJECTIVE: To estimate the financial risks of 15 categories of rare costly referrals for total purchasing sites of different population sizes. DESIGN: Computer simulation of 100 fund years assuming Poisson distribution of referrals. SETTING: British general practices that have opted to become total purchasing sites. Referral rates and price estimates were supplied by South and West Devon Health Commission. MAIN OUTCOME MEASURES: Variation in referral costs to purchasers in relation to size of risk pool (person years at risk). RESULTS: Random variation in referral costs increased as the size of the risk pool decreased. Variation increased greatly below 30,000 person years. The mean simulated cost of the referral categories considered was 2.8% of total NHS hospital and community service costs, and the maximum simulated cost for 7000 person years was 6.8%. Simulated variation was robust to assumption about prices and referral rates for specific types of referral. CONCLUSION: Rare costly referrals seem unlikely to bankrupt total purchasing sites. The management of risk is not in itself justification for total purchasing to be based in several general practices in order to generate large populations. There are other ways of managing risk. Sites can easily explore options by simulations using local referral rates and prices.