Making better use of scarce resources: the Palestinian experience, 1995-1999. Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia. Modifying dyspepsia management in primary care: a cluster randomised controlled trial of educational outreach compared with passive guideline dissemination. Gatekeeping in primary care: a comparison of internal medicine and family practice. Effect of NHS reforms on general practitioners' referral patterns. Does the North Staffordshire slot system control demand of orthopaedic referrals from primary care?: A population-based survey in general practice. Do clinical guidelines improve general practice management and referral of infertile couples? Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface. Improving referrals for glue ear from primary care: are multiple interventions better than one alone? In-house referral: a primary care alternative to immediate secondary care referral? Specialists as consultants to GPs. Private sector services as an alternative way of organising consultant services in health care. Prepayment with office-based physicians in publicly funded programs: results from the Children's Medicaid Program. General practice based physiotherapy: its use and effect on referrals to hospital orthopaedics and rheumatology outpatient departments. The extent of the two tier service for fundholders. Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders. Cluster randomized trial of a guideline-based open access urological investigation service.
Until August 2, 1997, The Eye Hospital-Gaza (EH) provided both primary and secondary eye services to almost 1 million inhabitants in Gaza. This exerted a tremendous load on the hospital's facilities and prevented the hospital from performing its main role as a secondary eye care provider. The training and guidance of primary health care (PHC) providers are essential in order that they can do their share in eye care. A prevention of blindness awareness campaign, training, workshops, and practical instruction took place in Gaza over a three-year span. A new purpose designed referral system was started on August 2, 1997, that resulted in a great change and improvement of the services in the hospital. Primary eye care is an integral part of ophthalmic services. Proper continuous training of PHC providers is essential, not only for providing service to patients near their residence in the shortest time possible, but also to facilitate the smooth, effective, and efficient functioning of the hospital as a secondary and tertiary eye care provider. We believe the system and methodology used is efficient and reproducible in many developing countries. To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals.
                Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour.
                Southampton and South West Hampshire Health District, United Kingdom.
                179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group.
                Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines.
                Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents.
                Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care. Quality improvement initiatives in health services rely upon the effective introduction of clinical practice guidelines. However, even well constructed guidelines have little effect unless supported by dissemination and implementation strategies.
                To test the effectiveness of 'educational outreach' as a strategy for facilitating the uptake of dyspepsia management guidelines in primary care.
                A pragmatic, cluster-randomised controlled trial of guideline introduction, comparing educational outreach with postal guideline dissemination alone.
                One-hundred and fourteen general practices (233 general practitioners) in the Salford and Trafford Health authority catchment area in the northwest of England.
                All practices received guidelines by post in July 1997. The intervention group practices began to receive educational outreach three months later. This consisted of practice-based seminars with hospital specialists at which guideline recommendations were appraised, and implementation plans formulated. Seminars were followed up with 'reinforcement' visits after a further 12 weeks. Outcome measures were: (a) the appropriateness of referral for; and (b) findings at, open access upper gastrointestinal endoscopy; (c) costs of GP prescriptions for acid-suppressing drugs, and (d) the use of laboratory-based serological tests for Helicobacter pylori. Data were collected for seven months before and/or after the intervention and analysed by intention-to-treat.
                (a) The proportion of appropriate referrals was higher in the intervention group in the six-month post-intervention period (practice medians: control = 50.0%, intervention = 63.9%, P < 0.05); (b) the proportion of major findings at endoscopy did not alter significantly; (c) there was a greater rise in overall expenditure on acid-suppressing drugs in the intervention as compared with the control group (+8% versus +2%, P = 0.005); and (d) the median testing rate per practice for H pylori in the post-intervention period was significantly greater in the intervention group (four versus O, P < 0.001).
                This study suggests that educational outreach may be more effective than passive guideline dissemination in changing clinical behaviour. It also demonstrates that unpredictable and unanticipated outcomes may emerge. Five hundred twenty new patients were randomly and prospectively assigned to receive their care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. The patients were followed by residents in training under the supervision of board-certified internists or family physicians. After a mean length of care of slightly over two years, the charts were reviewed for frequency of visits to primary care providers (internal medicine or family practice), Emergency Room, Acute Care Clinic, and all clinics other than the two primary care clinics. The records were also reviewed for laboratory tests ordered. Frequency of visits to the clinic of primary care, Emergency Room, Acute Care Clinic, and broken appointments were all significantly higher for patients randomized to the Internal Medicine Clinic. In addition, the median total annual cost of laboratory tests for patients followed by internal medicine physicians was significantly higher, largely because of higher laboratory charges generated by the specialist consultants. Over the study period, internal medicine patients had a significantly higher number of visits to all nonprimary care clinics and specifically to the dermatology, obstetrics and gynecology, and general surgery consultant clinics. It can be concluded that in this clinical environment, the practice styles of internal medicine and family practice are different. To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991.
                Prospective collection of data on general practitioners' referrals to specialist outpatient clinics between June 1990 and March 1992 and detailed comparison of two time periods: October 1990 to March 1991 (phase 1) and October 1991 to March 1992 (phase 2).
                10 fundholding practices and six non-fundholding practices in the Oxford region.
                Patients referred to consultant outpatient clinics.
                After implementation of the NHS reforms there was no change in the proportion of referrals from the two groups of practices which crossed district boundaries. Both groups of practices increased their referral rates in phase 2 of the study, the fundholders from 107.3 per 1000 patients per annum (95% confidence interval 106 to 109) to 111.4 (110 to 113) and the non-fundholders from 95.0 (93 to 97) to 112.0 (110 to 114). In phase 2 there was no difference in overall standardised referral rates between fundholders and non-fundholders. Just over 20% of referrals went to private clinics in phase 1. By phase 2 this proportion had reduced by 2.2% (1.0% to 3.4%) among the fundholders and by 2.7% (1.2% to 4.2%) among the non-fundholders.
                Referral patterns among fundholders and non-fundholders were strikingly similar after the implementation of the NHS reforms. There was no evidence that fundholding was encouraging a shift from specialist to general practice care or that budgetary pressures were affecting general practitioners' referral behaviour. Attempts to manage general practice demand for orthopaedic outpatient consultations have been made in several areas of the NHS, with little robust evidence on whether or not they work.
                To evaluate the effect of the North Staffordshire 'orthopaedic slot system' on the demand for general practice referrals to orthopaedic outpatients.
                A prospective study of 12 general practices in the slot system, 24 controls, and the 63 other general practices in North Staffordshire. Comparison periods were the baseline year (0); the first calendar year (1); and the first half of the second calendar year (2). A multifactor linear regression model was used.
                Mean referral rate decreased 22% in the slot group in period 1, and was maintained in period 2 (9.40, 7.29, 7.31 referrals per 10,000 population per month for periods 0, 1 and 2, respectively). The control and other groups showed a small decrease in period 1, but in period 2 higher referral rates were observed. The reduction in referrals of 20-40% in participating practices compared to other practices equates to 2-4 referrals per 10,000 patients per month.
                Our study suggests that practices willing and able to take up an offer of a slot system for managing their orthopaedic referrals will be able to significantly reduce referral rates for their patients when compared to similar practices who do not. Further research on the generalisability, effectiveness and cost-effectiveness of such systems is warranted. To evaluate guidelines for general practice management and referral of infertile couples. Guidelines were implemented with a disease specific reminder at the time of consultation (the guidelines were embedded within a structured infertility management sheet for each couple).
                Pragmatic randomised controlled trial. Participating practices were randomised to a group that received the guidelines and a control group.
                82 general practices in Grampian region.
                100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners.
                Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately.
                Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline. Compliance with the guidelines increased for all targeted activities. General practitioners in the study group were more likely to take a sexual history (for example, couples' use of fertile period, 85% v 69%, p < 0.01); examine both partners (female partner, 68% v 52%, p < 0.05; male partner 39% v 13%, p < 0.01); and investigate both partners (day 21 progesterone, 72% v 41%, p < 0.001; semen analysis, 51% v 41%, p > 0.05). Improvements were greater when general practitioners used the disease specific reminder.
                Receiving guidelines led to improvements in the process of care of infertile couples within general practice. This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple. To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface.
                Cluster randomised controlled trial.
                General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area. Participants: All 221 general practices in Glasgow; 214 completed the trial.
                General practices in the intervention arm received clinical guidelines developed locally. Control practices received them one year later. Dissemination of the guidelines included educational meetings.
                The time from presentation to referral, investigations completed in general practice, the number and content of visits as a hospital outpatient, the time to reach a management plan, and costs for referrals from the two groups.
                Data on 689 referrals were collected. No significant difference was found in referral rates for infertility. Fewer than 1% of couples were referred inappropriately early. Referrals from intervention practices were significantly more likely to have all relevant investigations carried out (odds ratio 1.32, 95% confidence interval 1.00 to 1.75, P=0.025). 70% of measurements of serum progesterone concentrations during the midluteal phase and 34% of semen analyses were repeated at least once in hospital, despite having been recorded as normal when checked in general practice. No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan. NHS costs were not significantly affected.
                Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice, but there are no detectable differences in outcome for patients or reduction in costs. Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors. Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care. To evaluate the effect of a risk factor checklist and training video for general practitioners in reducing inter-practice variation and improving the appropriateness of referrals (assessed by their positive predictive value or PPV) of patients with suspected otitis media with effusion (OME or 'glue ear') to secondary care.
                Fifty general practices (177 practitioners) from the NHS Trent region and the West of Scotland were cluster-randomised either to a control group (n = 12) or to one of three intervention groups (training video (n = 16), checklist (n = 11), or both (n = 11)). Data on all paediatric ear, nose and throat (ENT) referrals and diagnostic results at ENT clinics were collected for a one-year period pre- and post-intervention. Referral rates for OME and for closely related conditions were calculated for children aged 0-15 years, based on each practice's list size. PPV was defined as the proportion of referrals resulting in bilateral hearing loss > or = 20 dB at the ENT outpatient department.
                There was a significant improvement in the PPV, adjusted for patients' waiting time between general practitioner (GP) referral and being seen at the ENT department. The improvement in PPV pre- and post-intervention was 15% (95% confidence interval, CI: -12.1% to 41.7%) for the practices receiving both interventions, compared with a degradation of 20% pre- and post-intervention (95% CI: -32.9% to -6.4%) for practices receiving only one intervention and a degradation of 34% for those receiving no intervention.
                Disseminating a risk factor checklist and training video on glue ear to GPs using a multi-channel approach can improve the quality of referrals to ENT. Methods are needed to ensure that those patients referred from primary to secondary care are those most likely to benefit. In-house referral is the referral of a patient by a general practitioner to another general practitioner within the same practice for a second opinion on the need for secondary care referral.
                To describe whether in-house referral is practical and acceptable to patients, and the health outcomes for patients.
                Practices were randomized into an intervention or a control group. In intervention practices, patients with certain conditions who were about to be referred to secondary care were referred in-house. If the second clinician agreed referral was appropriate the patient was referred on to secondary care. In control practices patients were referred in the usual fashion. Patient satisfaction and health status was measured at the time of referral, 6 months and one year.
                Eight intervention and seven control practices took part. For the 177 patients referred in-house, 109 (61%) were judged to need referral on to secondary care. For patient satisfaction, the only difference between the groups studied was that at 12 months patients who had been referred in-house reported themselves as being more satisfied than those referred directly to hospital. For health status, the only difference found was that at the time of referral, patients who had been referred in-house and judged to need hospital referral reported themselves as being less able on the 'Physical function' subscale of the SF-36 than patients who were referred in-house and judged to not need hospital referral.
                In-house referral is acceptable to patients and provides a straightforward method of addressing uncertainty over the need for referral from primary to secondary care. To assess the effect on referral rate when GPs are given a better opportunity to send their patients to specialists for consultation.
                Intervention study with a control group.
                A 34-month experiment in the City of Turku. The experimental group consisted of 10 GPs working in municipal health centres with a list system and serving 23000 residents. As a control group, there were four GPs without a list system serving 10800 residents.
                GP visits and their referrals to specialists.
                The number of patient visits was higher among GPs in the experimental group than among those in the control group. During the experiment, the referral rate of GPs in the experimental group increased from 5.7% to 6.8%, but there was no change among the control GPs. Of all referrals to specialists, the share to the private sector increased from 5% to 35%, while at the same time the share to the hospital outpatient clinic decreased.
                An enhanced possibility to consult private specialists increases the number of referrals, but there are no consequent changes in the relative shares of the consulted specialties. This paper is a report of the results of a demonstration designed to provide empirical evidence regarding the effects of alternative approaches to paying physicians for serving children in the Medicaid program: (1) visit fees set at twice regular Medicaid fees in return for physician agreement to manage utilization and (2) capitation and financial risk-sharing along with the same physician agreement to manage utilization. Participating physicians were assigned randomly to either of the two payment groups. Comparisons of utilization and expenditures were made between these two plans and the regular Medicaid program (fee-for-service, low fees). Results showed no adverse effect of capitation payments on primary care visits to office-based physicians. Capitation physician referrals to specialists decreased relative to all other groups studied, consistent with the theory that the financial incentives in capitation will lead primary care physicians to reduce referrals to specialists. In November 1992, a pilot scheme was established in Doncaster to provide an on-site physiotherapy service in six non-fundholding general practices covering a population of approximately 44,000 people.
                The aim of the pilot scheme was to transfer a hospital-based physiotherapy service, to which general practitioners had direct access, to a primary care setting and to reduce referrals to an orthopaedics outpatient department.
                Use of physiotherapy services and referrals to orthopaedics and rheumatology before and during the first year of the scheme were monitored. Comparisons were made with data over the same time periods for general practices that were not in the scheme. The location of management of patients referred to physiotherapy was monitored for an eight-month period during the scheme.
                In the first year the scheme had a utilization rate of 31 per 1000 patients in the participating practices, representing a 164% increase over the hospital-based physiotherapy utilization rate for the year prior to the scheme. Eight per cent of physiotherapy patients received hospital-based treatment during the scheme. Changes in hospital outpatient referral rates attributable to the scheme were reductions of 8% to the orthopaedics department and 17% to the rheumatology department.
                The increase in the use of the physiotherapy service was possibly caused, in part, by general practitioners sending patients to on-site physiotherapy who previously would have been referred to orthopaedics and, largely, by an increase in the treatment of patients who previously would not have been referred to hospital. Physiotherapy based in general practice can be a substitute for hospital-based physiotherapy and can contribute to a reduction in referrals to orthopaedics and rheumatology outpatient departments. However, it can result in an increase in use of physiotherapy services. To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners.
                Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995.
                District health authority in south-west England.
                10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients.
                Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times.
                In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5.
                Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients. Joint consultation sessions between general practitioners (GPs) and specialists to examine patients for whom decisions about referral are difficult are thought to be helpful, but their effects have not been evaluated. In a randomised, controlled trial we studied the effects of joint sessions of GPs and orthopaedic surgeons on referral and intervention rates. During 1.5 years, 12 GPs (in groups of three) held monthly joint consultation sessions with four participating orthopaedic surgeons: patients were seen by one orthopaedic surgeon in the presence of three GPs. Patients were included in the trial if the GP was uncertain about the diagnostic or therapeutic management and if referral was considered; and excluded if referral was urgently necessary or if there was some other clear indication for referral. By a randomised consent design, patients were assigned to joint consultation sessions (n = 144) or a usual-care control group (n = 128). A year later the patients were examined by an independent orthopaedic surgeon. There were significantly fewer referrals (51/144 [35%] vs 87/128 [68%], p < 0.01) and diagnostic actions in the intervention group than in the control group, without negative effects on health or functional status. More patients in the intervention group were symptom-free at 1 year (35% vs 24%, p < 0.05). Joint consultation sessions of GPs and orthopaedic surgeons within the framework of general practice resulted in more efficient care, with better targeted examination, treatment, and referrals. Out-patient services are trying to achieve effective and efficient health care in overcrowded, busy clinic settings. "One stop" and "open access" clinics have been advocated as a way of improving out-patient services.
                Our aim was to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service.
                General practices were randomized to receive either referral guidelines and access to the investigation service for lower urinary tract symptoms (LUTS) or referral guidelines and access to the investigation service for microscopic haematuria (MH). The study population comprised 66 general practices in the Grampian region of Scotland referring 959 patients. The outcome measures were compliance with guidelines (number of recommended investigations completed), number of general practice consultations, the number and case mix of referrals, waiting time to initial hospital appointment, and the number of patients with a management decision reached at initial appointment and discharged by 12 months after referral.
                GPs' compliance with referral guidelines increased (difference in means 0.5; 95% confidence interval 0.2-0.8, P < 0.001). Approximately 50% of eligible patients were referred through the new system. The number and case mix of referrals were similar. The intervention reduced the waiting time from referral to initial out-patient appointment (ratio of means 0.7; 0.5-0.9, patients with LUTS only) and increased the number of patients who had a management decision reached at initial appointment (odds ratio 5.8; 2.9-11.5, P < 0.00001, both conditions). Patients were more likely to be discharged within 12 months (odds ratio 1.7; 0.9-3.3, P = 0.11). There were no significant changes detected in patient outcomes. Overall the new service was probably cost saving to the NHS.
                The guideline-based open access investigation service streamlined the process of out-patient referral, resulting in a more efficient service with reduced out-patient waiting times, fewer out-patient and investigation appointments and release of specialist and clinic time.
There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.