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General Practitioners’ Referrals To Adult Orthopedic Services
Aile Hekimlerinden Erişkin Ortopedi Branşına Yapılan Sevkler
Levent Bayam, Karen Chung‐Ling Au Yeung, Jonathan Gregory

 

How to cite / Atıf için: Bayam L, Chung‐Ling Au Yeungal K, Gregory J. General Practitioners’ Referrals To Adult Orthopedic Services. Euras J Fam Med 2017;6(1):11-7

 

Original Research / Orijinal Araştırma


ABSTRACT

Aim: Referral is a mean of communication between primary and secondary cares. Musculoskeletal problems are common in the community and the orthopedic departments receive a multitude of primary care referrals. According to the literature, only 58% of referrals to orthopedic services were considered appropriate. The aim of the study is to assess the suitability of orthopedic referrals from primary care. 

Methods: Compilation of general practitioners referral letters from a randomized selection with duration of five months were studied prospectively. The study included all GP referrals to adult orthopedics clinic in Central Manchester Hospitals but excluded specialized referrals to a named consultant and referrals from other musculoskeletal practitioners. 

Results: 47 cases were included in the study with an average age of 48. 20 patients had one or more investigations (42.5%). The median waiting time for an orthopedic consult was 7 weeks. Whilst 34% of the patients were sent for further investigations, 23.4% were listed for surgery, and only 12.8% of the patient was discharged from the first appointment. Three patients had mismatching diagnosis.

Conclusion: Overall, appropriateness of referrals (91.5%, 4 out of 47) was remarkably high compared to the limited literature. Contributing factors may be attributed to the effective use of established guidelines, easier access of General Practitioners to investigations and imaging in the secondary care or related to General Practice training.  Further study into each of the contributing factors may help, and the study perhaps serve as a good model for other regions to improve appropriateness of referrals to secondary orthopedic care.   

Keywords: general practitioners, referral and consultation, Orthopedics    

ÖZET

Amaç: Sevk zinciri, birincil ve ikincil sağlık hizmetleri arasında bir iletişim mekanizmasıdır.  Toplumda iskelet-kas sistemi rahatsızlıkları oldukça yaygındır ve hastanelerin ortopedi bölümlerine, birincil sağlık hizmeti birimlerinden büyük miktarda sevkler yapılmaktadır. Literatüre göre, bu sevklerin ancak %58’i uygun bir şekilde yapılmaktadır. Bu çalışmanın amacı, birincil sağlık hizmeti birimlerinden ortopediye yapılan sevklerin uygunluğunu değerlendirmektir. 

Yöntem: Çalışmamızda, aile hekimlerinden gelen sevk mektupları 5 ay süre ile randomize ve prospektif olarak seçildi. Bu çalışmaya, Central Manchester Üniversite Hastanesi’nin erişkin ortopedi polikliniğine yapılmış bütün birincil sağlık sevkleri dahil edildi ancak belli bir uzman adına özel olarak yapılmış veya başka bir branştan yapılmış sevkler dahil edilmedi. 

Bulgular: Toplamda 47 vaka bu çalışmaya dahil edildi ve yaş oratalaması 48 idi. 20 hasta en az bir veya daha fazla tetkik sonrası birincil sağlık kurumundan sevk edildi (%42,5). En yoğunlukla (median) ortopediste görülmek için bekleme zamanı 7 hafta idi.  Ortopediye gelen hastaların %34’ü daha ileri tetkik için gönderilirken, %23,4’üne ameliyat için gün verildi. Sadece % 12,8’in ilk ortopedi muayenesinden sonra, tekrar görülmesine gerek kalmadı. 3 hastada, birincil sağlık hizmetleri biriminden gönderiliş sebebiyle ortopedide konan teşhis arasında uygunsuzluk vardı. 

Sonuç: Ortopediye yapılan sevklerin genel olarak uygunluğu % 91,5 ile beklenenin üzerinde ve az sayıda literatürle kıyaslandığında yüksek idi. Buna katkıda bulunan faktörler, aile hekimlerinin rehber veya yol göstericileri etkili bir şekilde kullanması, aile hekimlerinin ikincil sağlık birimlerinden/hastanelerden tetkik isteme imkanlarına sahip olması veya aile hekimliği eğitimi sırasında aldıkları eğitim tarzından olabilir. Bu çalışma, diğer bölgelerdeki ortopedi bölümlerine sevklerin uygunluğunu geliştirmek için iyi bir model olabilir. 

Anahtar kelimeler: genel pratisyenler, sevk ve konsültasyon, Ortopedi 


 

Introduction

Referral is a mean of communication between primary and secondary cares specialist referrals account for a significant proportion of GP or family medicine practice. Inappropriate referrals have huge implications on cost of health services not only as a result of over-referring of patients with conditions which could be treated in primary care but also the costs of delayed referrals which may cause unnecessary harm to patients.  Referral guidelines or criteria about specific diseases or symptoms that should be referred to a specialist (such as local guidelines) are available, although there may be minor variations between regions (1). GP in the UK generally means a doctor with at least 3 years post graduate training. In order to improve diagnostic accuracy, GPs may have already initiated preliminary investigations such as blood tests, plain radiographs and nowadays magnetic resonance imaging scans or nerve conduction studies, thereby reducing the proportion of inappropriate referrals. 

Musculoskeletal ailments account for a large proportion of the primary care practitioners’ workload, with conditions ranging from simple lower back pain to patients requiring hip or knee replacements, or in rare cases may even be presented with bony cancers (2). Every week, the orthopedic department receive a multitude of primary care referrals but according to the Speed and Crisp 2005, a Cambridge study comprising of over one thousand and eighty referrals, only 58% of referrals to orthopedic services were deemed appropriate. In these referral letters, 60% had insufficient content and no diagnoses were volunteered (3).  The number of studies describing appropriateness of referrals from primary care to orthopaedic specialist was very limited in the literature As a result, we aim to investigate the appropriateness of orthopedics referrals from primary care to secondary care management within the North West region of England. 

Methods

One hundred GP referral letters to adult orthopedics secondary care in Central Manchester with duration of five months was randomly selected and studied prospectively. Those with specialized referrals to a named consultant and direct referrals from the other musculoskeletal disciplines such as physiotherapy, orthotics and rheumatology, were excluded from the study (Table 1). Patients who did not attend clinic after the referral were also excluded from the study (eventually, a total of 53 patients), resulting in a total of 47 cases being included.  These numbers do not include the patients with trauma or fracture as mostly trauma patients were directly referred from emergency department not from a GP.

Table 1. Exclusions from the study

Exclusions  according to criteria

Patients
(n)

Referral from Physiotherapy

11

Referral from Orthotics

3

Referral from Rheumatology

4

Referral to a direct name (previous patient etc)

17

Missed the appointment/ did not attend the clinic

18

Total 

53

 

Parameters that were explored included the waiting time between referral and first orthopedic attendance, the amount of investigations performed in primary care prior to referrals, reasons for referral, the compatibility of GP diagnosis and that of clinic letter (mismatching diagnosis) and outcome of the consultation. Referrals were considered appropriate if one or more of the following criteria was present: surgery was likely to be required, a second orthopedic opinion was required, if the patient had been seen by an orthopedic consult for a problem affecting the same limb, or at the patient’s request, investigations were clearly indicated prior to making a decision on management, unclear diagnosis which may benefit from arthroscopy or that surgery may be indicated in the future. Although we looked into how diagnoses were established, but the referral appropriateness was justified by how convenient or necessary GP referrals were, rather than full and accurate orthopedic diagnoses. This study considered as service evaluation, therefore did not need ethical approval.

Results

Forty-seven patients who were referred by their GP and then proceeded to attend adult orthopedic outpatient clinic were included in the study. The average age was 48, ranging from 16 to 81.  

Referrals were made mostly by fully qualified GPs (89.4%), as seen in Table 2, with the remainder being made by locum GP (6.4%), GP Registrar (2.1%) and GP with specialty interest (GP with SI) (2.1%). Except one GP registrar, the rest were fully qualified. 

Table 2: Breakdown of GPs making referrals to adult orthopedic outpatient clinic

 

Total (n)

Percentage (%)

Practice GP

42

89.4

Locum GP

3

6.4

GP Registrar

1

2.1

GP with Special Interest

1

2.1

(Practice GP: fully qualified GP, Locum GP: already qualified but working temporarily in a GP practice, GP with Special Interest: already completed GP training and additionally did further training to specialize in one GP area for example, musculoskeletal, GP registrar: a trainee mostly towards the end of his/her training after other rotations)

Twenty-two patients had one or more investigations (plain radiographs, ultrasound, magnetic resonance imaging, nerve conduction studies, etc), physiotherapy, podiatry or consultation with other specialties before being referred (46.8%), whilst the remaining twenty-five patients had not undergone any investigations prior to the referral. Of the patients who had prior investigations, 8 underwent plain radiographs (17%), 4 underwent physiotherapy (8.5%), 3 underwent podiatry (6.4%), 2 had blood tests (4.2%), 2 consulted other specialties (4.2%) and ultrasound, magnetic resonance scan and nerve conduction studies had one patient per modality (2.1%) respectively (Table 3). 

Table 3: Investigations performed prior to being referred

 

Total (n)

Percentage (%)

Physiotherapy

4

8.5

Plain radiograph

8

17

Ultrasound imaging

1

2.1

Magnetic resonance imaging

1

2.1

Blood Tests

2

4.2

Nerve Conduction Study

1

2.1

Podiatry

3

6.4

Other specialty consultation

2

4.2

 

The median waiting time for an orthopedic consult was seven weeks (ranging from 2 and 19), and a mean of eight weeks. Ten patients were referred to subspecialty such as upper limb, or foot and ankle, 26 were referred to the first available consultant whilst the remainder went to the generic referral pool. The distribution of conditions in relation to body parts are shown in Table 4, where the most common consult, 18 (38%), were related to wrist-hand or 17 (36.1%) were related to hand-wrist problems.  

Table 4.  Referrals - Distribution of conditions in relation to body-parts, further investigations and outcome of consultation after orthopaedic outpatient consult

Bodypart

Total 

Diagnosis (number of pt)

Surgery

Physio

Further inv.

Discharge

Other/explanation

Hand-wrist

18

Dupuytren (2)

2

 

 

 

 

Carpal/cubital Tunnel (8)

2

1

5 (NCS)+1*(XR)

 

 

De Quervain (2)

 

2

 

 

 

Lump (3)

1

 

1(U/S)

1** (inapp)

 

Injury-finger (2)

 

2

 

1***

 

OA (1)

1

 

 

 

 

Foot-ankle

17

Bunion/H.Val (3)

2

 

 

 

1 (follow-up)

Arthritis (5)

1

1

1 (MR)+1 (XR)

 

1 (advised, to operate)

Skin lesion (1)

 

 

 

 

1 (ref. to podiatry-inapp.)

Deformity (5)

2

 

 

 

3 (orthotics)

S.tissue/tendon (3)

 

 

2 (MR)+1(NCS)

 

 

Knee 

7

Knee rep (3)

 

1

 

2

 

Hypermob. Pat (1)

 

1

1(MR)

 

 

Muscleweak (1)

(prev. KN)

 

1

1(MR)

 

 

OA (1)

 

1

 

 

 

Chon.Pat (1)

 

1

 

 

 

Hip 

2

T. Bursitis (1)

 

 

1(MR)

 

 

Hip pain (1)

 

 

 

1 ( inapp)

 

Elbow-
forearm

2

Elbow-# (1)

 

 

1(CT)

 

 

Forearm-# (1)

 

 

1(U/S)

 

 

Spine

1

Back-pain (1)

 

 

 

1 (inapp)

 

Total

47

 

11

11

17****

6

5

Note: The total number of outcome from visit to orthopaedics higher than total patient number as some patient had more than one investigation or other managaments  (such as physio and discharge or x-ray and NCS for the same patient).

(Further inv.: further investigations, Physio: physitherapy, NCS: nerve conduction study, #: fracture, inapp: inappropriate, t.bursitis: trochanteric bursitis, OA: osteoartritis, hypermob. Pat: hypermobile patella, knee rep: knee replacement, s. Tissue: soft tissue, h.val: hallux valgus, HR: hip replacement,  KN: knee replacement, prev.: previous)
*1 patient had 2 investigations (x-ray and nerve conduction studies); ** lump had already been disappeared; ***1 of 2  patients with hand injury was referred to physio and discharged from orthopaedics; ****Investigations: 6x MR (magnetic resonance), 6x NCS (Nerve conduction studies), 2x U/S (Ultrasound), 1xCT (computed tomography), 1xXR (x ray)

 

The majority of patients were assessed by a senior clinician, mostly by a consultant (61.7%), 23.4% by registrars (registrars at this particular hospital were senior and experienced, middle-grade orthopedists with many years (6-7) in the speciality) and 12.7% by physiotherapists (subspecialized in musculoskeletal) or podiatrists (Table 5). 

Whilst 34% of the patients were sent for further investigations from orthopedic clinic, 23.4% were listed for surgery, 23.4% were referred to physiotherapy and only 12.8 % of the patient was discharged from the first appointment (Table 4). From clinic, the investigations patients were referred for included 6 magnetic resonance imaging (MRI), 6 nerve conduction studies, 2 ultrasound scans, 1 computer tomography (CT) scan, and 2 plain radiographs (Table 4).

Two out of forty-seven patients (4.3%) were diagnosed with a different condition compared to the one they were initially labeled with. These included a patient referred for carpal tunnel syndrome when the signs and symptoms corresponded to ulnar neuropathy, and a patient labeled as ulnar nerve neuropathy, when in fact the symptoms were more akin to cervical spine spondylosis. A third patient was referred with back pain despite there being no spinal services offered in Central Manchester Hospitals. 

Within the study cohort, six patients were discharged after their first visit to the adult orthopedic department, raising the question about whether these referrals were really necessary. Amongst these patients, one was referred for a second opinion with previous knee replacement, whilst another suffered from complications relating to a previous knee replacement operation, both of which were necessary referrals. There was also a GP referral done on the basis of a physiotherapy assessment for possible hip impingement syndrome, but upon seeing the patient in clinic, the orthopedic consultant disagreed with the diagnosis and discharged the patient. Other patients included one whose symptoms had already resolved, although we marked this as inappropriate, indeed, we were not sure when the ganglion disappeared whether before or after referral. Another one finger injury who was discharged but given exercises advice and physiotherapy.

The main table (Table 4) showed that whilst the decision to list for surgery was made mostly for smaller body parts such as wrist-hand, foot-ankle, the main outcome for larger joints groups (hip and knees) was to send for further investigations or physiotherapy.

Table 5. Type of clinician who assessed patients in clinic 

Type of clinician

Patients (n)

%

Orthopaedic Consultant

29

61.7

Orthopaedic Registrar

11

23.4

Orthopaedic SHO

1

2.1

Physiotherapist / Podiatry

6

12.7

Registrars at this hospital were senior and experienced, middle-grade orthopaedists with many years (6-7) in the speciality, Physiotherapist/ Podiatry are specialised in musculoskeletal area.

 

Discussion

The present study showed that a remarkably high proportion of referrals to the Orthopedics department within the Central Manchester region was appropriate (91.5%, 43 out of 47) compared to the literature (58%) (3). Factors that contribute to the above discrepancy may include the effective use of established pathways or guidelines, possible easier access of GPs in this region to investigations performed in secondary care or may be related to improved GP training over time.  Drawbacks include the limited size of our study may not be fully representative of the whole population and a repeat study may help confirm the reproducibility of these results.

30 patients out 47 had diagnostic investigations before (13 patients) or after (17 patients)  referral. All patients except one have been assessed by experienced senior clinicians in orthopaedic clinic to establish diagnoses. As in every speciality, there may be very difficult cases to diagnose or it may take long time and further investigations to reach the final daignoses. On the other hand,  the aim of study was to establish the necessity of the referrals rather than diagnostic accuracy. Specialized  orthopedic doctors in  secondary care do not expect that primary care doctors will establish full diagnoses for orthopedic patients but what is expected is that primary care doctors should avoid unnecessary referrals, which will then help preventing waste of time and sources. Apart from referral accuracy, other issues important in patient management such as the duration of waiting times between referrals and first clinic visit, prioritization of patients via a feasible triage system and financial issues for patients’ treatment will need to be addressed.

There are not many publications in literature about referrals and in particular, referral to orthopedics. Therefore, this study may fill the gap up to some degree. There are some publications emphasize the importance of GP/family doctor referral to specialist. Basol, in their study mentioned that referral chain is very important in developing countries in order to have good health strategies (4). When the referral system is not fully established, in addition to other problems such as wrong treatment, delayed diagnoses, the cost of health system may not be efficiently controlled. This may lead to, for example, unnecessary doubling of medicine prescriptions. It may be difficult to detect how many repeat prescriptions may have been done in primary and secondary cares when the referral chain is not established well. As a result, the patients can apply to secondary or tertiary care centres without further referral (5). Eventually, this will increase the cost of the health in that country.  

There is a debate about best referral system and each country may have its own special circumstances. When referral system is not fully established, patients may go to their preferred specialists without proper guidance and this may lead to lack of information of patients’ background and histories for reviewing doctor and also communication problems between primary and secondary cares (6). Long waiting times to be seen by specialists are a major issue of patient inconvenience and complaints (2). Direct access to some specialties might be appropriate, but not all of them (7). In Denmark, GPs has access to most office-based specialists and inpatient and outpatient hospital care through a referral system. This preserves the GP's role as the first point of contact (8).

Training of the staff may play an important role in effective referral system. A Cochrane review emphasize that education is an important part of improving the referral system as part of  enhancement process. The referral process is most likely improved when guidelines for referral are circulated with standard forms and when the expert health care professionals are involved in teaching about referring (9). A study in Thailand compared general doctors (untrained) with family physicians and they found that family physicians tended to have lower referral rates and these referrals were judged by specialists as being more appropriate in terms of diagnoses, investigations, and reasons for referral (10). As GPs’ training and knowledge increase, this will lead to a better ability to diagnose and treat a broad range of problems, avoiding unnecessary referrals (7). Consequently, community-based management in primary care with appropriately trained staff can make sound economical sense and deliver high patient satisfaction within primary care, with low waiting times (2). 

Although the majority of hospitals in the UK are run by the National Health Service (NHS), patients are given the choice of receiving care from foundation trusts (NHS hospitals with greater freedom to manage themselves), private hospitals and independent sector treatment centre. If a patient is referred by his or her GP on the NHS, the treatment will be paid for by the public sector even if the patient attends a private hospital or independent sector treatment centre (9). Within this context, the Choose and Book system in the UK enables GPs to conveniently choose the hospital, date and time of the first outpatient appointment, providing patients with different options, allowing them greater flexibility (11). Once the referral steps are completed and a patient is referred to secondary-care, NHS consultant-led treatment is required legally to start within a maximum of 18 weeks from the time of referral unless valid reasons are provided (such as treatment no longer required, patient request for postponing treatment or patient failure to attend appointments) (12).  

In 2008, General practitioners (GPs) made more than 9 million hospital referrals for elective care, triggering billions of pounds of NHS spending.  As a result, referral management schemes such as the Central Triage Service described by Sinha to effectively divert primary care musculoskeletal problems to their appropriate specialists including pain management, GP specialists, podiatrists, rheumatology, orthotists and orthopedics has been set up (13). The primary care trusts (PCTs) reported that these services successfully diverted between forty to eighty percent of GP referrals from secondary care. One of the benefits of a multidisciplinary musculoskeletal service (provided that it engages a broad range of disciplines, such as physiotherapists, rheumatologists and orthopedic surgeons) is that the referred patients will most likely be seen by the most appropriate specialist, thereby reducing waiting times and costs of multiple referrals (14). However, issues relating to who should triage the referrals has been expressed and whether or not a non-doctor triage system may lead to controversial referral management (11). Additionally, guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects such as financial benefit (15).

In local areas, the majority of GPs (101 out of 104) use the referral pathway, with positive response. Feedback from GPs, the Triage and the Harmoni team help improve the pathway, making the patient journey more efficient (1). The high proportion of appropriate orthopaedic referrals illustrated in our study suggests that that the local referral system functions well. However, it would reflect the regional practice better if we were able to multicentre study in the region. 

Conclusion

Our study concluded that a well-established referral system with proper guidelines may lead to more accurate and appropriate orthopedic referrals.  In order to improve the referral system, further analysis into each of the contributing factors may help decipher which component is particularly successful, and perhaps serve as a good model for other regions to improve their referral quality to secondary orthopedic care.

Conflict of Interest

There was no conflict of interest for the current study. 

 

References

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2. Heron N. Musculoskeletal (MSK) and sport and exercise medicine (SEM) in general practice (GP): a novel GP-based MSK and SEM clinic for managing musculoskeletal symptoms in a GP. BMJ Qual Improv Report 2015;4:1-5. doi: 10.1136/bmjquality.u207172.w2905

3. Speed CA, Crisp AJ. Referrals to hospital-based rheumatology and orthopaedic services: seeking direction. Rheumatology (Oxford) 2005;44(10):469-71.

4. Basol E. Developing strategies ın developing countries: delivery chain in health systems. Balkan Journal of Social Sciences 2015;4(8):128-40. 

5. Benli AR. Rational drug use in geriartric population in primary health care services. Ankara Med J 2015;15(4):258-9.

6. Akman M. Strength of primary care in Turkey. Turkish Journal of Family Practice 2014;18(2):70-8. 

7. Tabenkin H, Oren B, Steinmetz D, Tamir A, Kitai E. Referral of patients by family physician to consultants: a survey of Israeli Family Practice Research Network. Fam Pract 1998;15(2):158-64.

8. Pedersen KM, Andersen JS, Sondergaard J. General practice and primary health care in Denmark. J Am Board Fam Med 2012;25(Suppl 1):S34-8. 

9. Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, et al. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2008;(4):CD005471. doi: 10.1002/14651858.CD005471.pub2.

10. Jaturapatporn D, Hathirat S. Specialists’ perception of referrals from general doctors and family physicians working as primary care doctors in Thailand. Quality in Primary Care 2006;14(1):41–8.

11. NHS [Internet]. NHS general practitioners (GPs) services [cited 2016 Jun 19]. Available from: http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-referrals.aspx#

12. NHS [Internet]. Guide to NHS waiting times in England [cited 2015 Jun 17]. Available from: http://www.nhs.uk/choiceinthenhs/rightsandpledges/waitingtimes/pages/guide%20to%20waiting%20times.aspx

13. Sinha A [Internet]. Musculoskeletal referral guidelines [cited 2015 Jun 17]. Available from: http://sinhaorthopaedics.co.uk/wp-content/uploads/2010/06/Musculoskeletal-Referral-Guidelines.pdf 

14. Imison C, Naylor C. Referral management: lessons for success. London: The King’s Fund; 2010. 76 p.

15. Clarke A, Blundell N, Forde I, Musila N, Spitzer D, Naqvi S, et al. Can guidelines improve referral to elective surgical specialties for adults? a systematic review. Qual Saf Health Care 2010;19(3):187-94.

 


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