Implementing referral guidelines: lessons from a negative outcome cluster randomised factorial trial in general practice

Abstract

Background: Few patients with lower bowel symptoms who consult their general practitioner need a specialist opinion. However data from referred patients suggest that those who are referred would benefit from detailed assessment before referral.

Interventions to reduce primary care delay in cancer referral: a systematic review

“…In contrast, the high-quality RCTs failed to show an improvement in aspects of management and knowledge using education, 18,19 diagnostic accuracy using audit and feedback, 28 and referral accuracy and investigation using decision-support software. 23,26 Mixed effects were found in aspects of management using educational material and a guideline. 32 It was not always possible to pinpoint which particular aspects of the interventions led to particular improvements.…”

“…20,22,25,32 Therefore, it cannot be determined whether any of the reported improvements persisted. Less than half of the 22 studies included recruited more than 100 participants, 11,15,17,21,23,24,26,29,30,32 and several studies suffered from a high dropout rate, 18,19,28,32,33 with only 18% of participants in 6 months. How intervention was assessed: a baseline clinical self-audit of skin excisions was carried out over 6 months, followed by a feedback report and provision of the educational module over the next 6 months.…”

“…Some studies had a high risk of selection bias, [13][14][15][16][17]19,20,22,24,25,27,[29][30][31] with little information given (if any) about whether those who participated were different from those who chose not to take part. Almost all studies reported a follow-up period of less than 1 year; 11,14,[17][18][19]21,23,24,27,28,31,33 several tested participants straight after the intervention; 15,16,29,30 and some did not include or state any follow-up period. 20,22,25,32 Therefore, it cannot be determined whether any of the reported improvements persisted.…”

“…17,33 Decision-support software and guideline use Four studies, including three good-quality RCTs, tested computer-based interventions to change PHP behaviour. 20,23,26,32 These studies were designed to improve the quality of referrals to secondary care as a proxy to reducing referral delay. Jiwa et al investigated the effectiveness of an educational outreach visit, 23 an 'electronic referral pro forma', or both, on changing the type of colorectal referrals to secondary care.…”

Impact of referral letters on scheduling of hospital appointments: a randomised control trial

“…A previous UK trial similarly found limited clinical value in a referral proforma. 12 An earlier systematic review failed to identify any robust studies that demonstrate an impact from the quality of referral letters on patient outcomes. 7 The data reported here suggest that semi-structured, guideline informed referral letters are unlikely to influence the scheduling of appointments by specialists.…”