Avoidable referrals? Analysis of 170 consecutive referrals to secondary care

BMJ 1994;309:576-578 (3 September)

General practice

Avoidable referrals? Analysis of 170 consecutive referrals to secondary care

G J Elwyn, N C H Stott

Loudoun Square Health Centre, Cardiff CF1 5UZ Department of General Practice, University of Wales College of Medicine, Cardiff CF3 7PN Correspondence to: Dr Jones Elwyn.

Abstract

Objective : To determine appropriateness of referrals fromprimary care to secondary care.
Design : Retrospective evaluation of appropriateness of referralsfrom a singlehanded general practice: evaluations carried outindependently by referring doctor and by second general practitionerwho worked in same area and had access to similar secondarycare services.
Subjects : 168 referrals made between 1 October 1990 and 31March 1991 and followed up for up to 12 months by matching withavailable information on outcome of episode of care.
Main outcome measures : Appropriateness of referral and reasonsfor inappropriate referrals.
Results : 110 referrals were agreed to be appropriate and 58were considered avoidable. The reason for 32 of the inappropriatereferrals was lack of resources: 10 were due to lack of information(mainly failure of hospitals to pass on information to generalpractioner), nine were due to a deficient primary health careteam; five were due to insufficient use of home care nurses,three were due to absence of direct access to day hospital,and five were due to lack of access to general practioner bedsor other facilities. Most of the remaining 26 avoidable referralswere because available resources had not been fully used, becauserecognised management plans had not been followed, or becauseof lack of skills to perform certain procedures.
Conclusions : Many theoretically avoidable referrals were dueto managers' and politicians' decisions about allocation ofresources, but some inappropriate referrals could be avoidedby assessment of general practioners' needs for further knowledgeand skills.

Practice implications

Practice implications
General practitioners' rates of referral vary widely, but relatively few studies have made objective attempts to assess how many referrals to hospitals might be avoided
In this study a general practitioner reviewed the appropriateness of 170 of his referrals with an independent assessor
A third of referrals were considered to be at least theoretically avoidable if adequate resources and direct access to intermediary were available
Poor communication with hospitals about patients who had been discharged was another reason for avoidable referrals
Demand on secondary care could be reduced if workforce and resources in primary care were made sufficient to cope with demand and if communication between hospitals and general practitioners was improved

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Relevant Article

Appropriateness of referrals to hospital: D T Lipman
BMJ 1994 309: 1233. [Extract] [Full Text]

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