Practical health co-operation - the impact of a referral template on quality of care and health care co-operation: study protocol for a cluster randomized controlled trial

Trials

Ann Ragnhild Broderstad¹  Siri Malm²  Per Christian Valle²  Henrik Wåhlberg² 

[1] Centre for Sami Health Research, University of Tromsø, 9037, Tromsø, Norway;University Hospital of North Norway Harstad, St. Olavsgate 70, 9480, Harstad, Norway

关键词: Referral;    Quality of care;    General practice;    Cluster randomized trial;   

Others  :  1094990
DOI  :  10.1186/1745-6215-14-7

 received in 2012-05-29, accepted in 2012-12-13,  发布年份 2013

【 摘 要 】

Background

The referral letter plays a key role both in the communication between primary and secondary care, and in the quality of the health care process. Many studies have attempted to evaluate and improve the quality of these referral letters, but few have assessed the impact of their quality on the health care delivered to each patient.

Methods

A cluster randomized trial, with the general practitioner office as the unit of randomization, has been designed to evaluate the effect of a referral intervention on the quality of health care delivered. Referral templates have been developed covering four diagnostic groups: dyspepsia, suspected colonic malignancy, chest pain, and chronic obstructive pulmonary disease. Of the 14 general practitioner offices primarily served by University Hospital of North Norway Harstad, seven were randomized to the intervention group. The primary outcome is a collated quality indicator score developed for each diagnostic group. Secondary outcomes include: quality of the referral, health process outcome such as waiting times, and adequacy of prioritization. In addition, information on patient satisfaction will be collected using self-report questionnaires. Outcome data will be collected on the individual level and analyzed by random effects linear regression.

Discussion

Poor communication between primary and secondary care can lead to inappropriate investigations and erroneous prioritization. This study’s primary hypothesis is that the use of a referral template in this communication will lead to a measurable increase in the quality of health care delivered.

Trial registration

This trial has been registered at ClinicalTrials.gov. The trial registration number is NCT01470963

【 授权许可】

   
2013 Wåhlberg et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]Lohr KN: Medicare: A Strategy for Quality Assurance, Volume I. Washington, DC: The National Academy Press; 1990.
• [2]Institue of Medicine: To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
• [3]Varkey P, Reller MK, Resar RK: Basics of quality improvement in health care. Mayo Clinic Proceedings 2007, 82:735-739.
• [4]The Norwegian Directorat of Health: and it’s going to get better! National Strategy for Quality Improvement in Health and Social Services (2005–2015). Oslo: The Norwegian Directorat of Health; 2005.
• [5]Piterman L, Koritsas S: Part II. General practitioner-specialist referral process. Intern Med J 2005, 35:491-496.
• [6]Coleman EA: Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 2003, 51:549-555.
• [7]Garasen H, Johnsen R: The quality of communication about older patients between hospital physicians and general practitioners: a panel study assessment. BMC Health Serv Res 2007, 7:133. BioMed Central Full Text
• [8]Tuomisto LE, Erhola M, Kaila M, Brander PE, Kauppinen R, Puolijoki H, Kekki P: The Finnish national asthma programme: communication in asthma care–quality assessment of asthma referral letters. J Eval Clin Pract 2007, 13:50-54.
• [9]Ong SP, Lim LT, Barnsley L, Read R: General practitioners’ referral letters - do they meet the expectations of gastroenterologists and rheumatologists? Aust Fam Physician 2006, 35:920-922.
• [10]Dentith GE, Wilson KE, Dorman M, Girdler NM: An audit of patient referrals to the sedation department of Newcastle Dental Hospital. Prim Dent Care 2010, 17:85-91.
• [11]Syed AA, Large DM: Quality of GPs’ referral letters to diabetes secondary care. Practical Diabetes International 2003, 20:165-169.
• [12]Newton J, Hutchinson A, Hayes V, McColl E, Mackee I, Holland C: Do clinicians tell each other enough? An analysis of referral communications in two specialties. Fam Pract 1994, 11:15-20.
• [13]Shaw I, Smith KM, Middleton H, Woodward L: A letter of consequence: referral letters from general practitioners to secondary mental health services. Qual Health Res 2005, 15:116-128.
• [14]Jacobs LG, Pringle MA: Referral letters and replies from orthopaedic departments: opportunities missed. BMJ 1990, 301:470-473.
• [15]Bodek S, Ghori K, Edelstein M, Reed A, MacFadyen RJ: Contemporary referral of patients from community care to cardiology lack diagnostic and clinical detail. Int J Clin Pract 2006, 60:595-601.
• [16]Thomas RE, Grimshaw JM, Mollison J, McClinton S, McIntosh E, Deans H, Repper J: Cluster randomized trial of a guideline-based open access urological investigation service. Fam Pract 2003, 20:646-654.
• [17]Jiwa M, Skinner P, Coker AO, Shaw L, Campbell MJ, Thompson J: Implementing referral guidelines: lessons from a negative outcome cluster randomised factorial trial in general practice. BMC Fam Pract 2006, 7:65. BioMed Central Full Text
• [18]Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C: Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2008, 4:cd005471.
• [19]Jiwa M, Mathers N, Walters S: Quality of information on referrals to colorectal surgeons: towards consensus. Curr Med Res Opin 2002, 18:72-77.
• [20]Nygaard E, Kårikstad V: Prioriteringsveileder – Fordøyelsessykdommer (Prioritization guidelines – digestive diseases). Oslo: Helsedirektoratet; 2009.
• [21]Jiwa M, Coleman M, McKinley RK: Measuring the quality of referral letters about patients with upper gastrointestinal symptoms. Postgrad Med J 2005, 81:467-469.
• [22]British Thoracic Society Standards of Care Committee: BTS statement on criteria for specialist referral, admission, discharge and follow-up for adults with respiratory disease. Thorax 2008, 63:16.
• [23]Nygaard E, Kårikstad V: Prioriteringsveileder – Lungesykdommer (Prioritization guidelines – respiratory diseases). Oslo: Helsedirektoratet; 2008.
• [24]Nygaard E, Kårikstad V: Prioriteringsveileder - Hjertemedisinske sykdommer (Prioritization guidelines – cardiac diseases). Oslo: Helsedirektoratet; 2009.
• [25]Snow V, Barry P, Fihn SD, Gibbons RJ, Owens DK, Williams SV, Weiss KB, Mottur-Pilson C: Evaluation of primary care patients with chronic stable angina: guidelines from the American College of Physicians. Ann Intern Med 2004, 141:57-64.
• [26]Malm S, Schirmer H: Hjertesak: riktigere prioritering av pasienter (Heart issue: more correct prioritization of patients). Fastlegenytt (2) 2010, 0012:3-6.
• [27]Erhardt L, Herlitz J, Bossaert L, Halinen M, Keltai M, Koster R, Marcassa C, Quinn T, van Weert H: Task force on the management of chest pain. Eur Heart J 2002, 23:1153-1176.
• [28]Sjetne IS, Bjertnæs ØA, Iversen HH, Olsen RV: Pasienterfaringer i spesialisthelsetjenesten. Et generisk, kort spørreskjema (Patient experiences in specialist health care: A short generic questionnaire). Oslo: Norwegian Knowledge Centre for the Health Services; 2009.
• [29]Skudal KE, Bjertnæs ØA, Holmboe O, Bukholm G, Rottingen JA: The 2010 Commonwealth Fund survey: Results from a comparative population survey in 11 countries. Oslo: Norwegian Knowledge Centre for the Health Services; 2010.
• [30]Parry C, Mahoney E, Chalmers SA, Coleman EA: Assessing the quality of transitional care: further applications of the care transitions measure. Med Care 2008, 46:317-322.
• [31]Bennett K, Haggard M, Churchill R, Wood S: Improving referrals for glue ear from primary care: are multiple interventions better than one alone? J Health Serv Res Policy 2001, 6:139-144.
• [32]Marshall MN, Shekelle PG, McGlynn EA, Campbell S, Brook RH, Roland MO: Can health care quality indicators be transferred between countries? Qual Saf Health Care 2003, 12:8-12.
• [33]Ashton CM, Kuykendall DH, Johnson ML, Wray NP: An empirical assessment of the validity of explicit and implicit process-of-care criteria for quality assessment. Med Care 1999, 37:798-808.
• [34]Ashton CM, Kuykendall DH, Johnson ML, Wun CC, Wray NP, Carr MJ, Slater CH, Wu L, Bush GR: A method of developing and weighting explicit process of care criteria for quality assessment. Med Care 1994, 32:755-770.
• [35]Lyons TF, Payne BC: The use of item importance weights in assessing physician performance with predetermined criteria indices. Med Care 1975, 13:432-439.
• [36]Eldridge S, Kerry S: A Practical Guide to Cluster Randomised Trials in Health Services Research. Chichester, UK: John Wiley & Sons, Ltd; 2012.
• [37]Smeeth L, Ng ES-W: Intraclass correlation coefficients for cluster randomized trials in primary care: data from the MRC Trial of the Assessment and Management of Older People in the Community. Control Clin Trials 2002, 23:409-421.
• [38]Cosby RH, Howard M, Kaczorowski J, Willan AR, Sellors JW: Randomizing patients by family practice: sample size estimation, intracluster correlation and data analysis. Fam Pract 2003, 20:77-82.
• [39]Adams G, Gulliford MC, Ukoumunne OC, Eldridge S, Chinn S, Campbell MJ: Patterns of intra-cluster correlation from primary care research to inform study design and analysis. J Clin Epidemiol 2004, 57:785-794.
• [40]Medical Research Council: Cluster Randomised Trials: Methodological and Ethical Considerations. London: Medical Research Council; 2002.
• [41]Hayes JH, Moulton LH: Cluster Randomised Trials. Boca Raton: Chapham & Hall/CRC; 2009.
• [42]Ukoumunne OC, Gulliford MC, Chinn S, Sterne JA, Burney PG: Methods for evaluating area-wide and organisation-based interventions in health and health care: a systematic review. Health Technol Assess 1999, 3:92.
• [43]Campbell MK, Elbourne DR, Altman DG: CONSORT statement: extension to cluster randomised trials. BMJ 2004, 328:702-708.
• [44]Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW: The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003, 138:161-167.
• [45]Richard IC, Marta R, David DW: Gaps in the continuity of care and progress on patient safety. BMJ 2000, 320:791-794.
• [46]Newton J, Eccles M, Hutchinson A: Communication between general practitioners and consultants: what should their letters contain? BMJ 1992, 304:821-824.
• [47]Hartveit M, Biringer E, Vanhaecht K, Haug K, Aslaksen A: The Western Norway mental health interface study: a controlled intervention trial on referral letters between Primary Care and Specialist Mental Health Care. BMC Psychiatry 2011, 11:177. BioMed Central Full Text
• [48]Faulkner A, Mills N, Bainton D, Baxter K, Kinnersley P, Peters TJ, Sharp D: A systematic review of the effect of primary care-based service innovations on quality and patterns of referral to specialist secondary care. Br J Gen Pract 2003, 53:878-884.
• [49]Augestad K, Revhaug A, Vonen B, Johnsen R, Lindsetmo RO: The one-stop trial: does electronic referral and booking by the general practitioner (GPs) to outpatient day case surgery reduce waiting time and costs? A randomized controlled trial protocol. BMC Surgery 2008, 8:14. BioMed Central Full Text
• [50]Coulter A, Noone A, Goldacre M: General practitioners’ referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics. BMJ 1989, 299:304-306.