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.     

Current management of hypertension in hospital.

A study of the notes of 1784 patients new to two London hospitals found a blood-pressure recording in 1027 (58%). Only 423 (32%) of all outpatients had had a blood-pressure recording on their first visit. Of 144 patients with hypertension (systolic greater than or equal to 160 mm Hg or diastolic greater than or equal 100 mm Hg or both) a check recording was made in 89 (62%) and 18 (12%) were put on treatment. We conclude that the opportunity that a hospital visit provides for blood-pressure screening is being incompletely used, and that the discovery of hypertension often does not lead to further action.     

Bovine uterine torsion: 164 hospital referral cases

Uterine torsion is more common in the cow than any other domestic species. The etiopathogenesis of the condition remains open to speculation. Available hospital referral records of bovine uterine torsions (n = 164) were collated, and additional comparisons for season, age and breed were made using the VDMP data base of 24 North American veterinary schools. There was no effect of season. Brown Swiss cows were at a significantly higher risk (P = 0.0001), while Hereford, Angus, and Jersey cows were at a lower risk for uterine torsion when compared with Holstein-Friesian cows, the largest breed population (P = 0.01). Most cows (81%) were at term. Clinical signs of torsion included fever (23%), tachycardia (93%), tachypnea (94%), straining (23%), anorexia (18%) and vaginal discharge (13%). In 34% of the cases the torsion was precervical, with no vaginal involvement being noted. The severity of the torsion was predominately 180 to 270 degrees (57%) and 271 to 360 degrees (22%). Counter-clockwise torsion was present in 63% of the cases. Vaginal delivery was possible after manual correction (20%) or rolling of the cow (18%). Cesarean section was performed immediately in 35% of the cases, after failed detorsion attempts in 7%, and due to failure of the cervix to dilate following successful correction of the torsion in 20%. Calf birth weights exceeded breed means in 89% of the cases, and a significantly greater proportion (63%) of the fetuses were male. Fetal survival rate was 24% (14% of dead fetuses were emphysematous), and the cow survival rate was 78% (10% were euthanized). The fetal membrane retention rate was 57%. It was found that large term fetuses appear to predispose a cow to uterine torsion.     

Late referral for maintenance dialysis.

A study of patients accepted for maintenance dialysis at the Oxford renal unit in 1981 showed that 23 out of 55 patients were referred late, very shortly before the need for dialysis. This pattern of referral was associated with a higher morbidity at the start of dialysis which may have been preventable. In the late referral group 16 patients (70%) suffered major complications and three (13%) died; by contrast, in the early referral group three patients (9%) suffered complications and one died. Early referral to a renal unit plainly benefits the patient and allows Health Service resources to be used more economically.     

Relation between general practices' outpatient referral rates and rates of elective admission to hospital.

OBJECTIVE--To examine the variation in rates of admission to hospital among general practices, to determine the relation between referral rates and admission rates, and to assess the extent to which variations in outpatient referral rates might account for the different patterns of admission. DESIGN--A comparison of outpatient referral rates standardised for age and sex and rates of elective admission to hospital for six specialties individually and for all specialties combined. SETTING--19 General practices in three districts in Oxford Regional Health Authority with a combined practice population of 188 610. MAIN OUTCOME MEASURES--Estimated proportion of outpatient referrals resulting in admission to hospital, extent of variation in referral rates and admission rates among practices, and association between admissions and outpatient referrals. RESULTS--Patients referred to surgical specialties were more likely than those referred to medical specialties to be admitted after an outpatient referral. Overall, the estimated proportion of patients admitted after an outpatient referral was 42%. There were significant differences among the practices in referral rates and admission rates for most of the major specialties. The extent of systematic variance in admission rates (0.048) was similar to that in referral rates (0.037). Referral and admission rates were significantly associated for general surgery; ear, nose, and throat surgery; trauma and orthopaedics; and all specialties combined. For most specialties the practices with higher referral rates also had higher admission rates, casting doubt on the view that these practices were referring more patients unnecessarily. CONCLUSION--Rates of elective admission to hospital vary systematically among general practices. Variations in outpatient referral rates are an important determinant of variations in admission rates.     

Postoperative radio-chemotherapy for rectal cancer: A retrospective analysis from a tertiary referral hospital

AimTo report results of postoperative radio-chemotherapy (RT-CHT) for rectal cancer (RC).BackgroundTotal mesorectal excision (TME) is an essential treatment method in rectal cancer (RC). Perioperative radiotherapy in locally advanced RC improves loco-regional free survival (LRFS). Preoperative radiotherapy is a preferred option; however, some patients are not referred for it. In case of the risk of loco-regional failure postoperative radio-chemotherapy (RT-CHT) is indicated.Material and methodsBetween 2004 and 2010, 182 patients with pathological stage II-III RC (TME performed — 41%, resection R0 — 88%, circumferential resection margin evaluated — 55.5% and was above 2 mm in 66% of them) received postoperative RT-CHT in our institution. Overall survival (OS) and LRFS were estimated with the Kaplan–Meier method. Univariate and multivariate analysis were performed to compare the impact of prognostic factors on survival.ResultsFive-year OS and LRFS rates were 63% and 85%, respectively. Loco-regional recurrence and isolated distant metastases rates were 11.5% and 19%, respectively. Multivariate analysis showed stage (III vs. II), HR: 2.3 (95% confidence interval [CI]: 1.4–3.8), p = 0.0001; extent of resection (R1−2 vs. R0), HR: 2.14 (95%CI: 1.14–3.99), p = 0.017, and age (>65 vs. ≤65 years), HR: 1.66 (95%CI: 1.06–2.61), p = 0.027 as prognostic factors for OS. Extent of resection (R1−2 vs. R0), HR: 3.65 (95%CI: 1.41–9.43), p = 0.008 had significant impact on LRFS.ConclusionDespite a suboptimal quality of surgery and pathological reports, the outcome in our series is close to that reported in the literature. We confirm a strong impact of the extent of resection on patient’s outcome, which confirms the pivotal role of surgery in the management of RC.     

Divergent views of hospital staff on detecting and managing hypertension.

A questionnaire about detecting and managing hypertension was answered by 76 out of 110 (69%) doctors and 116 out of 195 (63%) qualified nurses in a large hospital. There was no general agreement on the method of taking diastolic blood pressures or on the level of hypertension requiring treatment. Most of the clinicians treated mild hypertension, although no proof exists that such treatment is beneficial. Almost everyone questioned agreed that measuring blood pressure in all patients attending hospital is important. Agreement should be reached, however, on which phase of diastolic blood pressure should be used.     

Persistence of divergent views of hospital staff in detecting and managing hypertension.

A questionnaire concerning views of hospital clinical staff was completed by 408 out of 542 staff (75%), comprising 214 medical staff of all clinical specialties, 106 first year clinical medical students, and 88 third year student nurses. On average 386 of 407 (95%) thought that blood pressure should be measured routinely in all inpatients but only 294 of 404 (73%) thought that this was appropriate for outpatients. Although 251 of 390 (64%) were taught to use the muffling of sounds (phase IV) as the diastolic blood pressure, only 219 of 406 (54%) actually used this phase alone. There were appreciable differences between the grades of staff in this respect, a small majority of most grades using phase IV. Roughly half (50 out of 102) of the medical student respondents were taught to use phase IV, but only 38 of 106 (36%) were actually using this phase. While only three out of 16 general practitioners were using phase IV diastolic blood pressure alone, the figure was 66 out of 88 (75%) for student nurses. The level of diastolic blood pressure at which clinicians would begin to treat a 50 year old asymptomatic man ranged from 90 to 121 mm Hg. When these figures were corrected to phase V values, assuming a 5 mm Hg difference between phases IV and V, the range was 85 to 116 mm Hg. Despite the general agreement among physicians interested in hypertension that the disappearance of sounds (phase V) should be used to denote diastolic blood pressure there is still considerable divergence of opinion among hospital medical staff.     

Mild hypertension: a clinical trial conducted in hospital general practice.

To compare findings in a hospital trial of hypotensive drugs with those in a general practice trial several patients with mild hypertension were studied at the same time in hospital and in general practice. They received bendrofluazide and potassium chloride or bendrofluazide, potassium chloride, and reserpine according to a double-blind crossover protocol, and blood biochemical values were studied over eight weeks and six months. When reserpine was withdrawn from nine women they followed a modified protocol comparing bendrofluazide and potassium chloride with potassium chloride alone. The blood pressure values measured by the general practitioners were similar to those measured in hospital. Both the diuretic alone and the diuretic with reserpine produced significant falls in blood pressures. Although plasma renin activity increased on diuretic treatment, continued treatment did not produce a further increase, and levels gradually declined towards normal.