Interventions to improve outpatient referrals from primary care to secondary care

Ayub Akbari, Alain Mayhew, Manal Alawi Al-Alawi, Jeremy Grimshaw, Ron Winkens, Elizabeth Glidewell, Chanie Pritchard, Ruth Thomas, Cynthia Fraser

Research output: Contribution to journalLiterature review

170 Citations (Scopus)

Abstract

Background

The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.

Objectives

To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.

Search strategy

We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.

Selection criteria

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.

Data collection and analysis

A minimum of two reviewers independently extracted data and assessed study quality.

Main results

Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.

Authors' conclusions

There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

Original languageEnglish
Article numberCD005471
Number of pages49
JournalCochrane Database of Systematic Reviews
Issue number4
DOIs
Publication statusPublished - 8 Oct 2008

Keywords

  • randomized controlled-trial
  • general-practitioners
  • joint consultation
  • breast-cancer
  • management
  • patterns
  • services
  • guidelines
  • outreach
  • access

Cite this

Akbari, A., Mayhew, A., Al-Alawi, M. A., Grimshaw, J., Winkens, R., Glidewell, E., ... Fraser, C. (2008). Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database of Systematic Reviews, (4), [CD005471]. https://doi.org/10.1002/14651858.CD005471.pub2

Interventions to improve outpatient referrals from primary care to secondary care. / Akbari, Ayub; Mayhew, Alain; Al-Alawi, Manal Alawi; Grimshaw, Jeremy; Winkens, Ron; Glidewell, Elizabeth; Pritchard, Chanie; Thomas, Ruth; Fraser, Cynthia.

In: Cochrane Database of Systematic Reviews, No. 4, CD005471, 08.10.2008.

Research output: Contribution to journalLiterature review

Akbari, A, Mayhew, A, Al-Alawi, MA, Grimshaw, J, Winkens, R, Glidewell, E, Pritchard, C, Thomas, R & Fraser, C 2008, 'Interventions to improve outpatient referrals from primary care to secondary care', Cochrane Database of Systematic Reviews, no. 4, CD005471. https://doi.org/10.1002/14651858.CD005471.pub2
Akbari, Ayub ; Mayhew, Alain ; Al-Alawi, Manal Alawi ; Grimshaw, Jeremy ; Winkens, Ron ; Glidewell, Elizabeth ; Pritchard, Chanie ; Thomas, Ruth ; Fraser, Cynthia. / Interventions to improve outpatient referrals from primary care to secondary care. In: Cochrane Database of Systematic Reviews. 2008 ; No. 4.
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abstract = "BackgroundThe primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.ObjectivesTo estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.Search strategyWe conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.Selection criteriaRandomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.Data collection and analysisA minimum of two reviewers independently extracted data and assessed study quality.Main resultsSeventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.Authors' conclusionsThere are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.",
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author = "Ayub Akbari and Alain Mayhew and Al-Alawi, {Manal Alawi} and Jeremy Grimshaw and Ron Winkens and Elizabeth Glidewell and Chanie Pritchard and Ruth Thomas and Cynthia Fraser",
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AU - Akbari, Ayub

AU - Mayhew, Alain

AU - Al-Alawi, Manal Alawi

AU - Grimshaw, Jeremy

AU - Winkens, Ron

AU - Glidewell, Elizabeth

AU - Pritchard, Chanie

AU - Thomas, Ruth

AU - Fraser, Cynthia

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N2 - BackgroundThe primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.ObjectivesTo estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.Search strategyWe conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.Selection criteriaRandomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.Data collection and analysisA minimum of two reviewers independently extracted data and assessed study quality.Main resultsSeventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.Authors' conclusionsThere are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

AB - BackgroundThe primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.ObjectivesTo estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.Search strategyWe conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.Selection criteriaRandomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.Data collection and analysisA minimum of two reviewers independently extracted data and assessed study quality.Main resultsSeventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.Authors' conclusionsThere are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

KW - randomized controlled-trial

KW - general-practitioners

KW - joint consultation

KW - breast-cancer

KW - management

KW - patterns

KW - services

KW - guidelines

KW - outreach

KW - access

U2 - 10.1002/14651858.CD005471.pub2

DO - 10.1002/14651858.CD005471.pub2

M3 - Literature review

JO - Cochrane Database of Systematic Reviews

JF - Cochrane Database of Systematic Reviews

SN - 1469-493X

IS - 4

M1 - CD005471

ER -