Quality referrals

Key Points

• Describes the appraisal of a standardised proforma used by practitioners to refer patients to the Periodontal Department of a teaching hospital.

• Suggests that the use of such a proforma may guide the referring practitioner into providing the details required by the receiving clinician.

• Reports that a higher percentage of acceptable referral communications appeared to result when the proforma, rather than a traditional referral letter was used.

Abstract

Aim

The primary objective was to assess the standard of new-patient referral communications to the Periodontology Department of a teaching hospital and evaluate any differences in referral quality between referrals that used a standardised proforma and conventional letters. Secondary objectives were to evaluate the potential influence on referral performance of age, postgraduate qualifications and country of qualification of the referring practitioners.

Design

A retrospective analysis of a randomised sample of all referral letters and proformae received during a nine-month period.

Setting

Letters and referral proformae received by the Periodontal Department of the teaching hospital between 1 January and 30 September 1995 were surveyed.

Methods

An objective Categorisation System for Periodontal Referral Quality (CSPRQ) was devised and tested for inter- and intra-examiner reproducibility. The referral communications in the random sample were then categorised for quality. The year, country of qualification (UK or non-UK) and possession or otherwise of postgraduate qualifications for each of the referring dentists was ascertained from the Dentists' Register. A Standard Normal Deviants (SND), or Z-test was applied to the resulting data.

Outcome measures

Acceptability or unacceptability of referral letters and proformae, related to the age (assessed by year of qualification), country of qualification and possession or otherwise of postgraduate qualifications.

Results

A random sample of 378 referral communications (from a total of 2663) was analysed. Sixty-three of the random sample were referral proformae. The use of the referral proforma was associated with a highly significantly better (P<0.01) referral performance, than the use of referral letters. There was a trend for referrals from the small numbers of practitioners who were Fellows in Dental Surgery or Masters of Science to be better than those from other practitioners. There was also a trend for use of the referral proforma to enhance the referral performance of practitioners who had been qualified for more than 20 years. Use of the referral proforma highly significantly (P<0.01) improved the quality of referrals from non-UK qualified practitioners.

Conclusions

In this study, the quality of periodontal referrals was associated for the better with the use of a referral proforma.

Main

Appraisal of a standardised periodontal referral proforma Snoad R. J., Eaton K. A., Furniss J. S., and Newman H. N., Br Dent J 1999; 187: 42–46

Comment

Dental practitioners today have a wide range of diagnostic tools at their disposal, with a similarly extensive choice of treatments available. Yet, there are always those patients who, for one reason or another, present with problems that can not be managed totally within the confines of general dental practice. Improvements in the recognition of periodontal disease, admittedly sometimes rather later than ideal, coupled with the increasing threat of medico-legal action have led to an increasing use of specialists.

The act and manner of referral to specialists is as important to a patient's dental health as treatment itself. This paper clearly quantifies the rather poor quality of referral letters sent to a Department of Periodontology. For many, it seems, writing a referral letter is a task often squeezed to a minimum by the pressures of running a busy practice. Similarly, few referrals contained radiographs. Perhaps practitioners have a fear of losing them, but this must lead to unnecessary duplication and exposure to radiation.

It is reassuring, therefore, to find that a referral proforma, such as that illustrated in the study, can have a positive influence on the quality of referrals and, presumably, on the quality and appropriateness of patient care. Of course, this latter point remains to be demonstrated, although experience shows that referrals containing the minimum of information may at least delay the start of treatment. A further study of the effect of the standard of referral letters on treatment outcomes would be welcome.

The incorporation of a standardised referral proforma into practices would appear to be a worthwhile and relatively simple step toward improving patient care. Even computerised administration systems might have this included in the software package. Ideally, this would permit automated transfer of all relevant personal information together with clinical details such as medical history and periodontal chartings, with a reminder to enclose relevant radiographs. However, such developments would require careful co-ordination and standardisation and perhaps this would be a role for the various UK Specialist Societies.

This paper provides evidence of the poor standard of many referral letters. It issues a clear call to all those of us sending patients for specialist care to look at the quality of our referral letters, to recognise the role that these play in patient care and hence improve our communication with specialists. This will obviously take both time and effort but the well-being of our patients is at stake.