Evaluation of four quality assurance initiatives to improve out-patient referrals from general practice to hospital
The study evaluated the effectiveness of four quality assurance initiatives to improve out-patient referrals from general practice to hospital including two educational interventions (dissemination of referral guidelines and small group discussions between general practitioners and specialists) and two administrative interventions (feedback of referral rates and discussion with an independent medical adviser). The educational interventions were tested within a 4 x 4 Latin square design with an embedded controlled trial within the Latin Square to test the administrative interventions. Approximately one third of Grampian general practitioners participated in the intervention phase of the study. Data were collected before and after the interventions by a survey of referral letters, computer assisted telephone interviews with general practitioners about the pre-referral management of patients referred with tracer conditions and abstraction from the hospital notes for patients referred with tracer referrals. Date were analysed by general linear modelling. The survey of referral letters provides the best dataset on general practitioners referral behaviour currently available. Mean referral rates are comparable to those previously published. Variation between the 20th - 80th centiles was only two-fold suggesting that professional and policy concerns about previously reported variations in referral rates were probably overstated. The survey of pre referral management suggested that there were opportunities for improvement. The results of the intervention study suggest that the interventions had little or no effect on aspects of referral behaviour. Despite the lack of effectiveness of the interventions, they continue to be commonly used at the time of writing. Given the considerable opportunity costs associated with the provision of such interventions, local policy makers should consider carefully whether the costs are worth the small (if any) benefits. The results of the current study support the need for further rigorous evaluations of interventions to improve referral behaviour.