An Audit of the Quality and Content of Periodontal Referrals and the Effect of Implementing Referral Criteria

Strengthening Saudi Arabia's Primary Health Care through an e-Referral System: A Case Study

Health systems are becoming more complex, regulatory bodies are increasing their vigilance, and reimbursement practices are shifting toward value, making closing the referral loop an imperative for patient safety, regulatory oversight, and financial viability. The aim of this study was to examine the referral pattern in PHC services and whether a significant variation exists among them based on geographic accessibility to a referred hospital. This was a cross-sectional retrospective study that included all sequentially referred patients between 1 January 2019 and 30 December 2021. A pre-initiative comparison could not be performed, as previous data on the traditional referral system could not be collected. The primary outcome measures considered in this study were the referral rate, and the proportion of the documented appointment date. The healthcare facilities’ geographic locations and data of the hospital departments to which the patients were referred were also available. Between 2019 and 2021, the hospital received 52,143 referrals from the 9 designated PHC centres covering 34 districts. In the PHC centres located within the ≤13 km zone, 1 in every 14 patients were referred to the hospital, whereas 1 in every 20 patients visited PHC centres outside this zone. Since the introduction of the Ehalati e-referral system, the number of documented appointment schedules of the referred patients has improved over time by 16.1% (from 79.6% to 95.7%, p < 0.001). Ophthalmologic (17.1%) and dental services (15.4%) received the most referrals among all other specialties, whereas the referral rate for cardiology services was the lowest (2.5%). The documented appointment scheduling record of referred patients has improved significantly since the introduction of the Ehalati e-referral system. However, the results of this study indicate that the proximity of PHC centres to specialised hospitals is more likely associated with higher referral and documented appointment scheduling rates. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve the closing rates of the referral loop.

Impact of a referral management "gateway" on the quality of referral letters; a retrospective time series cross sectional review

Background

Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care.

This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters.

Methods

Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral).

Results

Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of ‘past medical history’ (from 71% to 84%, p < 0.001) and ‘medication history’ (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods.

Conclusion

Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement.

Contemporary issues in the provision of restorative dentistry

This review highlights current issues in the provision of restorative dentistry both in primary and secondary care settings. Current challenges in the provision of restorative procedures are reviewed and methods in improving care and efficiency are proposed. Possible changes to the infrastructure and delivery of care are suggested in order to improve effectiveness and the patient pathway.

Improving Compliance with NICE Guidelines on Parkinson's isease: A Quality Improvement Study

Parkinson's disease can progressively affect daily function and multidisciplinary teamwork is essential to provide high quality care. The National Institute of Health and Clinical Excellence (NICE) issued guidelines regarding diagnosis, follow-up, and multidisciplinary care. This quality improvement project sought to measure and improve the compliance of service provision against the guidelines.

In total, 3 audit cycles were completed. Each audit involved reviewing notes of patients attending a Parkinson's disease outpatient clinic against the PD NICE guidelines audit criteria. The first and second audits showed compliance was high for the criteria relating to initial diagnosis and referral but poor for those criteria relating to multidisciplinary referral.

A pro forma stamp was recommended to be placed in the notes at each regular Parkinson's outpatient review by a specified date (October 2009), with re-audit occurring in June 2011 as part of the official hospital audit plan.

Compliance to the NICE criteria improved to 100% on all criteria measured. However, it was evident from the notes that the pro forma that had been recommended by the previous audit had been in use but was not at present. In fact the pro forma had been so successful that the clinicians had made each of the criteria a routine part of their consultations and so did not need to rely on it.

Use of a checklist can have a lasting improvement on compliance with NICE guidelines, even if the intervention itself is transient.

A study to assess the quality of information in referral letters to the orthodontic department at Kingston Hospital, Surrey

AIM

To assess the quality of information included in referral letters sent to the orthodontic department at Kingston Hospital, Surrey, UK.

METHODS

Referral letters sent by both general dental practitioners (GDPs) and specialist orthodontists were analysed retrospectively in order to ascertain the percentage meeting the inclusion criteria as suggested by Mossey (2006) and the British Orthodontic Society (2008) for the quality of information included in an ideal orthodontic referral letter. Thirty-five consecutive letters sent between May and September 2005 and 206 letters sent in the same period in 2008 were collected by hand and analysed against the inclusion criteria. The numbers of referral letters received from GDPs, specialist orthodontists, and others sources were also determined.

RESULTS

Most of the referrals sent in 2005 and 2008 included 40-50% of the referral inclusion points. This was despite an almost twofold increase in the number of referral letters received from specialist orthodontic practitioners in 2008. The majority of the letters, from both GDPs and specialists, did not include details of the oral hygiene or caries status of the patient, or an indication of their motivation towards treatment. None of the referral letters included a plaque score.

CONCLUSION

The main weaknesses in the quality of information provided in referral letters were that in more than 80% of the letters there was no mention of the patient's medical history and no comment on caries status, the standard of oral hygiene, patient motivation for treatment, or an Index of Orthodontic Treatment Need score. The quality of information included in referral letters sent to Kingston Hospital orthodontic department needs to be improved.

An audit of patient referrals to the sedation department of Newcastle Dental Hospital

AIM

To audit the quality of external referral communications sent to the Department of Sedation at Newcastle Dental Hospital.

METHODS

A retrospective analysis was undertaken of a sample of 226 consecutive external referrals received by the sedation department of Newcastle Dental Hospital during May-July 2008. A data-collection form was used to record information provided in referrals relevant to the practice of sedation and the set standard was based on the recommendations of the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

Of the 226 referrals sampled, the majority (222; 98.2%) were from general dental practitioners. Seventy-six per cent were by letter and 24% by pro forma. Although of particular relevance to sedation referrals, a medical history was provided in only 59.0% of referrals and details of previous dental treatment in only 27.5%. The use of a pro forma significantly increased the provision of information compared to a letter in the following areas: patient's telephone number, patient's medication, doctor's name and doctor's address. Significantly less information was provided in the pro forma compared to the letters concerning the name of the referring practitioner and referring practitioner's telephone number. No difference was found between letter and pro forma referrals for medical history, treatment already attempted and reason for referral.

CONCLUSIONS

The findings indicate a need to improve the amount of information provided in referrals to the sedation department of Newcastle Dental Hospital in order to ensure appropriate allocation to sedation services. The quality of referrals may be improved by the distribution of referral guidelines, the use of electronic referral templates or changes to the current pro forma.