THE ART OF REFERRAL: LETTERS FROM THE HOME OFFICE

1
THE ART OF REFERRALLETTERS FROM THE HOME
OFFICE
2
ABSTRACT

• Dr. Goldenberg will review 100 recent referrals
  to his office for a gastrointestinal
  consultation. Using the actual referral, he will
  highlight the various aspects of a good (and a
  not-so-good) referral letter which will help the
  consultant give the referring physician the
  desired answer.

3
WHAT TO DO?

• (When all else fails, go to the literature)

4
THE IDEAL(for the system)

• Many FPs and many specialists

5
THE PROBLEM

• TK GANDHI, Harvard, J Gen Intern Med 2000
• 63 PCPs and 35 specialists dissatisfied
• T Lee, Harvard, Am J Med 1983
• The referring house-officer and the consultant
  disagreed in 14 of referrals on either the
  purpose for the consultation or the diagnosis in
  question. In 2 the house-officers didnt know
  why they requested the consultation!!
• contd

6
THE PROBLEM

• RF Westerman, Amsterdam, Brit J Gen Pract 1990
• General practitioners frequently criticize
  hospital colleagues about their communication,
  claiming that they do not read the referral
  letters, do not understand the problems of the
  patient outside the hospital, cross-refer within
  the hospital without referring back to general
  practitioners, and do not keep general
  practitioners informed or return the patient to
  their care once a specific problem has been
  identified.

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THE PROBLEM

• Problems PCPs Report
• Timeliness of reply 54
• Redundant aspects of process 35
• Time required creating referral note 31
• Difficulty in finding a specialist 29
• Lack of knowledge of role of medical 29
• management
• Time required for medical management 15
• approvals
• TK Gandhi, Harvard J Gen
  Intern Med 2000

8
THE PROBLEM

• Problems Consultants Report
• Timeliness of information from PCP 41
• Time required for insurance approval 39
• Time required for medical management approvals
  31
• Lack of clarity of note content from PCP 27
• Time required creating note for PCP 21
• Redundant aspects of the current process
  18
• TK Gandhi, Harvard J Gen
  Int Med 2000

9
WHAT I WOULD LIKE IN A REFERRAL LETTER

• Typewritten
• What question do you want answered?
• Medication list
• Important documentation
• Your description of the problem and psychosocial
  aspects
• True estimate of urgency
• No promises
• Respect for the patient and me
• Where are you now?
• Think ahead!
• Cancellations

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REASONS FOR REFERRAL

• MEDICAL REASONS
• Advice about therapy 63
• Assistance making a diagnosis 58
• Confirm a diagnosis 46
• Perform a diagnostic procedure 40
• Perform a therapeutic procedure 38
• Ruling out a dangerous condition 34
• Confirm management plan 32
• Too complicated to handle 19
• Take over care 16
• Opinion re lab/X-ray abnormality 7
• MT Donahoe,
  Stanford J Gen Intern Med 1999

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REASONS FOR REFERRAL

• Practice prevalence
• US Nat Amb Med Care Survey
• Practice prevalence strong inverse relationship
• to referral rate
• 14.8 of uncommon conditions
  referred
• 2.9 of common conditions
• Comorbidity strong direct relationship to
  referral
• rate
• 7.3 referral for high comorbidity
• 2.2 referral for low comorbidity
• CB Forrest Baltimore J Fam
  Pract 2001

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APPROPRIATENESS OF REFERRALS

• Issues
• What is appropriate?
• Apple pie
• Controlled studies
• Under vs over-referral
• Guidelines
• CA ODonnell Glascow Fam Pract 2000

13
APPROPRIATENESS OF REFERRALS

• How PCPs feel they can avoid referrals
• Training in procedures 17
• Consultation with another PCP 13
• Telephone consult with specialist 12
• Available practice guidelines 7
• More time for visit
  6
• MT Donahoe, Stanford J Gen Intern
  Med 1999

14
APPROPRIATENESS OF REFERRALS

• Ineffective strategies to improve the
• appropriateness of the referral process
• Passive dissemination of local referral
  guidelines.
• Feedback of referral rates.
• Conferencing with independent medical advisor re
  referrals.
• J M Grimshaw
• Cochrane Collaboration 2006

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APPROPRIATENESS OF REFERRALS

• Effective Strategies
• Structured guidelines
• Conferencing with the consultants
• Second in-house opinion
• JM Grimshaw Cochrane
  Collaboration 2006

16
APPROPRIATENESS OF REFERRALS

• Harvard a special case?
• 19 of referrals were re-referrals
• because the question the PCP wanted
• answered wasnt answered in the first
• referral.
• TK Gandhi, Harvard
  J Gen Intern Med 2000

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HOW OFTEN DO FPs REFER?

• 2.5-7.0 office visits require referrals.
• 40 patient demographics
• 10 practice and FP factors
• 50 ???
• CA ODonnell Glascow
  Fam Pract 2000

18
HOW OFTEN DO FPs REFER?US Experience

• 5.1 of office visits result in referrals
• (141 FPs in 31 states seeing 20 patients per day
  and referring 1.2 patients per day)
• CB Forrest Baltimore/Denver J Fam
  Pract 2002

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HOW OFTEN DO FPs REFER?US Experience

• 20 FPs referred lt 5 of patient visits
• 50 FPs referred 5-10 of patient visits
• 20 FPs referred 11-15 of patient visits
• 10 FPs referred gt15 of patient visits
• Median 8
• KS Kinchen Baltimore
  Ann Fam Med 2004

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HOW FPs CHOOSE A SPECIALIST

• PCPs considered of major importance
• Medical skills 88
• Positive experience with specialist 59
• Timeliness 55
• Quality of communication 53
• Good physician-patient rapport 52
• Specialist returns patient 51
• Insurance coverage 50
• Patient preference 41
• KS Kinchen Baltimore
  Ann Fam Med 2004
• contd

21
HOW FPs CHOOSE A SPECIALIST

• PCPs considered of major importance
• PCP relationship with specialist 36
• Board certification 34
• Opinion of colleagues 15
• Hospital affiliation 14
• Office location 9
• Specialist refers patients 4
• Medical School 0
• Fellowship training institute 0
• KS Kinchen
  Baltimore Ann Fam Med
  2004

22
HOW FPs CHOOSE A SPECIALISTPATIENT INITIATED
REFERRALS

• Before seeing PCP 13 wanted referral.
• PCP discussed referral in 71.
• Patients initiate request if
• 1. Know the PCP
• 2. Several concerns
• Albertson GA Denver
• J Gen Intern Med 2000
  contd

23
HOW FPs CHOOSE A SPECIALISTPATIENT INITIATED
REFERRALS

• More likely to be considered if
• 1. Health-care worker
• 2. Several reasons
• 3. Patient definite about need
• No effect on satisfaction
• Albertson GA Denver
• J Gen Intern Med 2000

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GATEKEEPER ISSUES

• 7700 California managed-care patients
• 94 wanted PCP for 1st-contact care.
• 89 wanted PCPs involvement in
• referrals although 46 felt they could
• make the decision themselves.
• 23 felt PCP interfered.
• low trust
• low satisfaction
• low confidence
• K. Grumbach San Francisco
  JAMA 1999

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GATEKEEPER ISSUES

• Private gatekeeping plans 3.2 referrals
• Private non-gatekeeping plans 1.9referrals
• Medicaid with gatekeeping 5.4 referrals
• Medicaid without gatekeeping 3.7 referrals
• Gatekeepers non-gatekeepers re
• satisfaction with specialist
• helpfulness of consult
• education value
• CB Forrest Baltimore
  Pediatrics 1999

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QUALITY OF THE REFERRAL LETTER

• The Problem
• 43 specialists dissatisfied with referral
  information
• 23 insufficient to answer the consult!
• TK Gandhi, Harvard
• J Gen Intern Med 2000

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QUALITY OF THE REFERRAL LETTER

• What Consultants want in the
  Referral Letter
• Items considered very important by 159
  consultants
• Outline of history of problem 94
• Current medication 92
• Reason for referral stated first 92
• Important medical history
  87
• J Newton Newcastle UK BMJ
  1992
• (contd)

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Items considered very important by 159
consultants

• FPs expectations from referral 80
• Important exam findings 79
• Important investigations results 73
• Allergies 61
• Patient expectations 55
• What patient/relative has been told 54
• Psychosocial issues 52
• Patient involvement in referral 37
• J Newton Newcastle UK BMJ
  1992

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Quality of the Referral LetterWhat the
Consultant Actually Gets

• Analysis of 141 consecutive FP
  referrals
• History of problem 90 Reason for referral
  86
• Provisional diagnosis 66
• Important exam findings 66
• Results of Therapy 51
• JP Hansen Durham NC
• J Fam Pract 1982

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Quality of the Referral LetterWhat the
Consultant Actually Gets

• Analysis of 141 consecutive FP referrals (contd)
• Results of Therapy 51
• Important investigations 45
• Formal request for reply 38
• Past medical history 29
• Expected return of patient 23
• JP Hansen Durham NC
• J Fam Pract 1982

31
QUALITY OF REFERRAL LETTER

• PCPs admit not sending NB information in gt25
  of referrals
• Problems to address 18
• Questions to answer 23
• Details patient cant provide 69
• Medical problems 68
• Medications 74
• TK Gandhi Harvard
• J Gen Intern Med 2000

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QUALITY OF REFERRAL LETTER

• LEGIBILITY
• 0.4 REFERRAL LETTERS ILLEGIBLE
• ID Cooper South Africa
• S Afr Med J 1996

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QUALITY OF REFERRAL LETTER

• Feedback Issues
• What effect does peer-feedback have on the
  quality of the referral letter?
• Before feedback both test group and control group
  scored poorly(34/100 and 28/100) on a validated
  test of quality of referral letter (good
  letter35/100)
• After peer feedback, test group improved (40/100)
  and control (no feedback) group was unchanged
  (29/100)
• M Jiwa Sheffield UK
• Br J Gen Pract 2004
• 
  
  contd

34
QUALITY OF REFERRAL LETTER

• Feedback Issues
• What effect does peer-feedback have the quality
  of the referral letter?
• 94 of FPs wanted to have this as a part of a
  q3month continuing improvement audit and 65
  indicated it would change how they compose a
  referral letter.
• Feedback group also referred more patients with
  pathology after feedback.
• M Jiwa Sheffield UK
• Br J Gen Pract 2004

35
QUALITY OF THE CONSULTANTS REPLY

• 405 Harvard specialists
• 28 of PCPs dissatisfied with consultant reply
• 19 rereferrals
• TK Gandhi Harvard
• J Gen Intern Med 2000
• contd

36
QUALITY OF THE CONSULTANTS REPLY

• 405 Harvard specialists
• of specialists admitting to not providing the
  information gt25 of the time
• Answers to specific questions 21
• Specialist assessment 12
• Results of tests and procedures 34
• Therapy initiated or proposed 21
• TK Gandhi Harvard
• J Gen Intern Med 2000

37
QUALITY OF THE CONSULTANTS REPLY

• Structured audit of 204 specialty clinic consult
  replies applied to quality attributes of
  consultants replies from literature
• Specific answers to specific questions 65
• Clearly stated diagnostic formulations 65
• Detailed management regimens which 43
• outline anticipated risks and benefits of
• proposed treatment
• Explicit comments on anticipated effects of
  18
• disease and/or its treatment on patients
  QOL
• and functional capacity
• Contingency plans in event of adverse
  16
• effects from or failure of first-choice
• interventions
• IA Scott Australia
• Intern Med J 2004 Contd
  
• 
  
  
  
  
  
  
  
  
  

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QUALITY OF THE CONSULTANTS REPLY

• Structured audit of 204 specialty clinic consult
  replies applied to quality attributes of
  consultants replies from literature
• Prognostic statements 9
• Enunciation of reasons underpinning 55
• actions and recommendations
• Follow-up arrangements 60
• Structured letters incorporating medication
  13
• lists and problem lists
• Short turnaround time between patient visit
  7 days
• and receipt of reply
• Expressions of professional courtesy 86
  
• IA Scott Australia
• Intern Med J 2004

39
QUALITY OF THE CONSULTANTS REPLY

• Lessons Learned
• List all active medical problems.
• Provide specific and substantiated answers to
  prioritized questions or issues.
• Provide contingency plans.
• Assess the patients role in decision-making.
• IA Scott Australia
• Intern Med J 2000

40
MISSED APPOINTMENTS

• - 20 of 494 FP patients referred to a consultant
  missed their appointment and didnt cancel.
• 7 more cancelled ahead of time.
• Missing appointments was NOT related to
• Nature of the presenting problem
• Severity (patient perception) and urgency of
• referral (GP perception)
• Duration
• Effect of problem on usual daily activities
• Associated anxiety at time of referral
• Improvement or worsening of problem between time
  of referral and appointment.
• Whether the patient had requested the referral
• M Lloyd London
• Fam Pract 1993
• Contd

41
MISSED APPOINTMENTS

• Missing appointments was NOT related to
• Whether the patient felt the GP could manage the
  problem without referral.
• Whether the patient expected the consultant would
  be able to help.
• Length of time between referral and consultation.
• Patients were least likely to attend the referral
  if they had been unable to fully discuss their
  health problem with their GP. This was
  independent of their GP explaining the reason for
  the referral.
• Concludes that the only positive indicator of
  attendance at referrals is the GP/patient
  communication.
• M Lloyd London
• Fam Pract 1993

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INFORMAL CONSULTATIONS

• 140,000 member HMO 125 PCPs
• 7 gastroenterologistsall salaried
• 7 hours/week for group (including
  after-hours)
• i.e. 1 hour/week/gastroenterologist
• 60 advice for acute problem
• 40 non-acute
• 22 resulted in formal consultation
• SD Pearson Harvard
• 
  J Gen Intern Med 1998

43
THE ART of REFERRALSUMMARY

• Both FPs and specialists are unhappy.
• FPs main c/o timeliness of reply.
• Specialists c/o timeliness and poor referral
  letters.
• What Id like in a letter.
• Referrals are usually to give advice on Dx or Tx
  or to perform a procedure not because FP cant
  handle it or to take over care.
• Most referrals are for uncommon conditions with
  high comorbidity.
• FPs can reduce referral rate by 1/3 by training
  in simple procedures, consultation with
  colleagues.
• Trying to eliminate inappropriate referrals may
  increase the overall referral rate.
• Structured guidelines should be considered.
• 5 of visits to FP result in referrals.
• FPs pick specialists based on their skill,
  previous positive experiences and timeliness.
• Patients want their FP as a gatekeepergatekeeping
  doesnt reduce referral rates.

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SUMMARY

• 13.A good referral letter outlines the problem
  and psychosocial issues and information the
  patient cant give, lists the medications,
  includes important documents and asks a specific
  question. FPs know this but dont do it.
• 14.Legibility is a local problem?
• 15.Impartial peer-feedback is an effective tool.
• 16.Specialist replies still fail despite
  knowledge of the problems in 1/3 of referrals.
• 17.Missed appointments can be avoided only with
  adequate patient care.
• 18.The importance of informal consultations.