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.     

Relation between night visit rates and deprivation measures in one general practice.

OBJECTIVE--To compare night visit rates in different electoral wards of one general practice with the Jarman and Townsend deprivation scores and unemployment rates. DESIGN--Analysis of computerised workload data. SETTING--General practice in centre of Mansfield, Nottinghamshire. OUTCOME MEASURE--Visits made in 588 nights to the 11,998 patients on the practice list. RESULTS--Night visit rates in 15 electoral wards varied from 19.6 to 55.3 visits per 1000 patients per year. The rates showed a significant association with the Townsend score (p = 0.004) and the unemployment rate (p = 0.03) but not with the Jarman score (p = 0.3). The Townsend score explained 49% of the variability; unemployment explained 31% and the Jarman score explained 9%. CONCLUSIONS--Even in a general practice not eligible for deprivation payments there was a 2.8-fold variation in night visit rates between wards. In this practice the Townsend score was significantly better at predicting night visit rates than the Jarman score. This method of looking at internal variation in workloads in computerised practices could give more direct data on the relation between deprivation and general practice workload than has previously been available.     

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.     

Referrals from general practice to hospital outpatient departments: a strategy for improvement.

OBJECTIVE--To determine the appropriateness of referrals from general practice to hospital outpatient departments. DESIGN--Prospective audit of referrals from a group practice over one year. SETTING--Six handed practice in a southern coastal town. SUBJECTS--All patients referred during the study period for whom a copy of the referral letter was available. MAIN OUTCOME MEASURES--The investigations carried out by the consultant that led to the diagnosis; the diagnosis reached; and the management. RESULTS--Of roughly 3000 patients referred during the year, 277 with various skin and soft tissue disorders could probably have been managed solely by the general practitioner. Referrals for cryotherapy (96 in this series) and diabetes (19) could probably also have been avoided by specialist training of the general practitioner. In addition, in cases of haematuria and prostatic hypertrophy (34 and 22 referrals) substantial time could have been saved for both the patient and the consultant had the general practitioner supplied the results of relevant investigations. Probably the most important outcome was the model that the study offered for other general practitioners to improve the appropriateness of referrals. CONCLUSION--This approach to determining the appropriateness of referrals benefits the general practitioners, the consultant, and the patient.     

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.     

Management of acute illness in infants before admission to hospital.

Parents and family doctors were questioned about the management of 150 infants with acute illness before their admission to hospital. When 108 of the children were first assessed the family doctor did not consider that admission was necessary, but follow-up was arranged in only 14 of these cases. Thus in 94 cases the initiative for recall was left to the parents, who in 44 cases already wanted their child to be admitted. Forty-eight infants were referred because the doctors thought that the parents could not cope. The parents of 31 of the children delayed in seeking help. As over half the children were ill for more than three days before they were admitted to hospital, regular follow-up could have been arranged. Doctors should normally retain the initiative for this rather than leave it to the parents'' discretion.     

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.     

Prescribing at the hospital-general practice interface. II: Impact of hospital outpatient dispensing policies in England on general practitioners and hospital consultants.

OBJECTIVE--To assess the impact on general practitioners and hospital consultants of hospital outpatient dispensing policies in England. DESIGN--Postal questionnaire and telephone interview survey of general practitioners and hospital consultants in January 1991. SETTING--94 selected major acute hospitals in England. PARTICIPANTS--20 general practitioners in the vicinity of each of 94 selected hospitals and eight consultants from each, selected by chief pharmacists. MAIN OUTCOME MEASURES--Proportions of general practitioners unable to assume responsibility for specialist drugs and of consultants wishing to retain responsibility; association between dispensing restrictions and the frequency of general practitioners being asked to prescribe hospital initiated treatments. RESULTS--Completed questionnaires were obtained from 1207 (64%) of 1887 general practitioners and 457 (63%) of 729 consultants. 570 (46%) general practitioners felt unable to take responsibility for certain treatments, principally because of difficulty in detecting side effects (367, 30%), uncertainty about explaining treatment to patients (332, 28%), and difficulty monitoring dosage (294, 24%). Among consultants 328 (72%) wished to retain responsibility, principally because of specialist need for monitoring (93, 20%), urgent need to commence treatment (64, 14%), and specialist need to initiate or stabilise treatment (63, 14%). The more restricted the drug supply to outpatients, the more frequently consultants asked general practitioners to prescribe (p less than 0.01) and complete a short course of treatment initiated by the hospital (p less than 0.001). CONCLUSIONS--Restrictive hospital outpatient dispensing shifts clinical responsibility on to general practitioners. Hospital doctors should be able to retain responsibility for prescribing when the general practitioner is unfamiliar with the drug or there is a specialist need to initiate, stabilise, or monitor treatment.     

Concordance of effects of medical interventions on hospital admission and readmission rates with effects on mortality

Background:

Many clinical trials examine a composite outcome of admission to hospital and death, or infer a relationship between hospital admission and survival benefit. This assumes concordance of the outcomes “hospital admission” and “death.” However, whether the effects of a treatment on hospital admissions and readmissions correlate to its effect on serious outcomes such as death is unknown. We aimed to assess the correlation and concordance of effects of medical interventions on admission rates and mortality.

Methods:

We searched the Cochrane Database of Systematic Reviews from its inception to January 2012 (issue 1, 2012) for systematic reviews of treatment comparisons that included meta-analyses for both admission and mortality outcomes. For each meta-analysis, we synthesized treatment effects on admissions and death, from respective randomized trials reporting those outcomes, using random-effects models. We then measured the concordance of directions of effect sizes and the correlation of summary estimates for the 2 outcomes.

Results:

We identified 61 meta-analyses including 398 trials reporting mortality and 182 trials reporting admission rates; 125 trials reported both outcomes. In 27.9% of comparisons, the point estimates of treatment effects for the 2 outcomes were in opposite directions; in 8.2% of trials, the 95% confidence intervals did not overlap. We found no significant correlation between effect sizes for admission and death (Pearson r = 0.07, p = 0.6). Our results were similar when we limited our analysis to trials reporting both outcomes.

Interpretation:

In this metaepidemiological study, admission and mortality outcomes did not correlate, and discordances occurred in about one-third of the treatment comparisons included in our analyses. Both outcomes convey useful information and should be reported separately, but extrapolating the benefits of admission to survival is unreliable and should be avoided.Health care decisions often rely on effects of interventions described using rates of admission or readmission to hospital.^1,2 These outcomes are typically regarded as indicators of insufficient quality of care and inefficient spending of health care resources;^1,2 however, whether they can predict other serious clinical outcomes, such as death, is unknown.Although effects on admission or readmission rates are often analyzed using large sets of routinely collected data, such as from administrative databases and electronic health records, many randomized controlled trials (RCTs) also collect data on admission rates, and some RCTs collect mortality data. Moreover, some trials combine death and admission to hospital as the primary composite outcome³ to increase the study’s power to detect significant differences and reduce the required study size.⁴ However, the interpretation of such a combination is difficult when the treatment effects on the 2 components are not concordant,⁵ for example, when more patients survive but rates of admission increase. In such cases, composite outcomes may dilute or obscure clinically significant treatment effects on important individual components,^4,6 and incomplete disclosure of individual effects may mislead the interpretation of the results.⁴We investigated systematic reviews of treatment comparisons that included meta-analyses of RCTs assessing effects on both rates of admission and mortality. We used the reported trial data to assess whether effects on admission rates were concordant with effects on mortality or whether it was possible to identify interventions and diseases in which these 2 outcomes would provide differing pictures of the merits of the tested interventions.     

Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes

Background

Previous studies examining sex-related differences in the treatment of coronary artery disease have focused on patients in hospital. We sought to examine sex-related differences at an earlier point in care — presentation to the emergency department.

Methods

We collected data on ambulatory care and hospital admissions for 54 134 patients (44% women) who presented to an emergency department in Alberta between July 1998 and March 2001 because of acute myocardial infarction, unstable angina, stable angina or chest pain. We used logistic regression and Cox regression analyses to determine sex-specific associations between the likelihood of discharge from the emergency department or coronary revascularization within 1 year and 1-year mortality after adjusting for age, comorbidities and socioeconomic factors.

Results

Following the emergency department visit, 91.3% of patients with acute myocardial infarction, 87.4% of those with unstable angina, 40.7% of those with stable angina and 19.8% of those with chest pain were admitted to hospital. Women were more likely than men to be discharged from the emergency department: adjusted odds ratio (and 95% confidence interval [CI]) 2.25 (1.75–2.90) for acute myocardial infarction, 1.71 (1.45–2.01) for unstable angina, 1.33 (1.15–1.53) for stable angina and 1.46 (1.36–1.57) for chest pain. Women were less likely than men to undergo coronary revascularization within 1 year: adjusted odds ratio (and 95% CI) 0.65 (0.57–0.73) for myocardial infarction, 0.39 (0.35–0.44) for unstable angina, 0.35 (0.29–0.42) for stable angina and 0.32 (0.27–0.37) for chest pain. Female sex had no impact on 1-year mortality among patients with acute myocardial infarction; it was associated with a decreased 1-year mortality among patients with unstable angina, stable angina and chest pain: adjusted hazard ratio (and 95% CI) 0.60 (0.46–0.78), 0.60 (0.46–0.78) and 0.74 (0.63–0.87) respectively.

Interpretation

Women presenting to the emergency department with coronary syndromes are less likely than men to be admitted to an acute care hospital and to receive coronary revascularization procedures. These differences do not translate into worse outcomes for women in terms of 1-year mortality.For patients experiencing a new-onset acute cardiac event, the emergency department is usually the point of first contact with the health care system. A fraction of patients presenting to the emergency department are admitted to an acute care hospital for treatment or continued observation. Given that decisions made in the emergency department govern not only immediate but also longer-term treatment and outcomes, it is imperative that these decisions be appropriate.The issue of gender bias in the treatment and outcomes of coronary artery disease has been examined extensively. The current guidelines of the American College of Cardiology and American Heart Association state that the treatment of acute coronary syndromes in women should be no different from that in men.^1,2 However, several studies have found evidence to the contrary. There is general consensus that the frequency of cardiac catheterization is lower among women and that they undergo fewer revascularization procedures.^3–11 Whether these lower rates are due to an inherent gender bias or indicate appropriate care continues to be debated.Most studies of gender bias in cardiovascular care have focused either on patients in an acute care facility or on selected patient populations, such as those who have undergone cardiac catheterization. The few studies that have examined sex-specific differences in treatment decisions earlier in the process of care (i.e., in the emergency department) have either been single-centre studies¹² or have involved clinical trial patients.¹³ Moreover, examination of sex-specific differences in cardiac care has traditionally been limited to more acute conditions, such as acute myocardial infarction and unstable angina.^{5,10,11,14–21} There is a need to expand our evaluation to a wider spectrum of coronary syndromes. We undertook the current study (a) to examine differences in rates of admission to acute care hospitals between men and women presenting to the emergency department with a main ambulatory care diagnosis of acute myocardial infarction, unstable angina, stable angina or chest pain and (b) to determine whether a patient''s sex is an independent predictor of 1-year treatment and outcomes in this cohort of patients.     

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).