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The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial.

ABSTRACT: The assessment of quality of care is an integral part of modern medicine. The referral represents the handing over of care from the general practitioner to the specialist. This study aimed to assess whether an improved referral could lead to improved quality of care.A cluster randomized trial with the general practitioner surgery as the clustering unit was performed. Fourteen surgeries in the area surrounding the University Hospital of North Norway Harstad were randomized stratified by town versus countryside location. The intervention consisted of implementing referral templates for new referrals in four clinical areas: dyspepsia; suspected colorectal cancer; chest pain; and confirmed or suspected chronic obstructive pulmonary disease. The control group followed standard referral practice. Quality of treatment pathway as assessed by newly developed quality indicators was used as main outcome. Secondary outcomes included subjective quality assessment, positive predictive value of referral and adequacy of prioritization. Assessment of outcomes was done at the individual level. The patients, hospital doctors and outcome assessors were blinded to the intervention status.A total of 500 patients were included, with 281 in the intervention and 219 in the control arm. From the multilevel regression model the effect of the intervention on the quality indicator score was insignificant at 1.80% (95% CI, -1.46 to 5.06, p?=?0.280). No significant differences between the intervention and the control groups were seen in the secondary outcomes. Active use of the referral intervention was low, estimated at approximately 50%. There was also wide variation in outcome scoring between the different assessors.In this study no measurable effect on quality of care or prioritization was revealed after implementation of referral templates at the general practitioner/hospital interface. The results were hindered by a limited uptake of the intervention at GP surgeries and inconsistencies in outcome assessment.The study was registered under registration number NCT01470963 on September 5th, 2011.

SUBMITTER: Wahlberg H

PROVIDER: S-EPMC5341470 | biostudies-literature | 2017 Mar

REPOSITORIES: biostudies-literature

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The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial.

Wåhlberg Henrik H Valle Per Christian PC Malm Siri S Hovde Øistein Ø Broderstad Ann Ragnhild AR

BMC health services research 20170307 1

<h4>Background</h4>The assessment of quality of care is an integral part of modern medicine. The referral represents the handing over of care from the general practitioner to the specialist. This study aimed to assess whether an improved referral could lead to improved quality of care.<h4>Methods</h4>A cluster randomized trial with the general practitioner surgery as the clustering unit was performed. Fourteen surgeries in the area surrounding the University Hospital of North Norway Harstad were ...[more]

PMID: 28270128

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Project description:ObjectivesTo investigate the effectiveness of the systematic default provision of smoking cessation support to all adult smokers admitted to hospital, relative to usual care.DesignOpen, cluster randomised controlled trial.SettingAcute medical wards in one large teaching hospital in the United Kingdom.Participants264 patients randomised to intervention and 229 to usual care; primary outcome data were available at four weeks for 260 and 224 patients, respectively. All adult smokers and recent ex-smokers able to give informed consent were eligible for entry into the study.InterventionsThe intervention comprised systematic smoking ascertainment and default provision of behavioural support and cessation pharmacotherapy for the duration of the hospital stay for all smokers and recent ex-smokers, with follow-up and referral to community services after discharge. Usual care comprised cessation support delivered at the initiative and discretion of clinical staff. All staff and patients were aware of group assignment.Main outcome measuresSmoking cessation at four weeks, validated by measuring exhaled carbon monoxide. Secondary outcomes were uptake of inpatient behavioural support, use of cessation pharmacotherapy, referral to and uptake of community support after discharge, and validated smoking cessation at six months. Participants lost to follow-up were assumed to have reverted to smoking.ResultsAll patients in the intervention group received at least brief advice to quit smoking, compared to 106 (46%) patients in the usual care group. Cessation at four weeks was achieved by 38% (n=98) of intervention patients and 17% (n=37) of usual care patients (adjusted odds ratio 2.10 (95% confidence interval 0.96 to 4.61), P=0.06, number of patients needed to treat 8). Uptake of inpatient behavioural support, use of pharmacotherapy, and referral to and uptake of community support after discharge were all substantially and statistically significantly higher in the intervention group than in the usual care group. Cessation at six months was achieved by 19% (n=47) of intervention and 9% (n=19) of usual care patients, although this difference was not significant (adjusted odds ratio 1.53 (95% confidence interval 0.60 to 3.91); P=0.37).ConclusionsSubstantial improvements in smoking cessation among smokers admitted to hospital can be achieved by systematic ascertainment and delivery of cessation support in secondary care.Trial registrationInternational Standard Randomised Controlled Trial Number ISRCTN25441641.

Project description:BackgroundAssessing physicians' clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.ObjectiveDetermine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients.DesignRetrospective cohort study.ParticipantsNine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty.Main measuresThe ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimally-acceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure's relative importance and the Dunn-Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome.Key resultsPhysicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p = 0.01 and p = 0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p = 0.005 and p < 0.001, respectively), and primarily worked as solo practitioners (p = 0.02).ConclusionsThe standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.

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The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial.

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The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial.

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