Practical Health Co-operation - The Impact of a Referral Template on Quality of Health Care

• Collated quality indicator score [ Time Frame: The care period for each patient (approx. 3 weeks up to 1 year) ] [ Designated as safety issue: No ]
  Based on treatment guidelines and international quality assessment tools we have developed quality indicators score sets for each of the 4 diagnostic groups in the study. The scores will be compared between intervention and control GP offices to assess the effect of the referral template.
  
  

• Improved referral quality [ Time Frame: The care period for each patient (approx. 3 weeks up to 1 year) ] [ Designated as safety issue: No ]
  The investigators will evaluate each referral against the referral template, and then compare between intervention and control groups.
  
  
• Waiting time from referral to appointment [ Time Frame: The care period for each patient (approx. 3 weeks up to 1 year) ] [ Designated as safety issue: No ]
  
• Time from referral to initiation of treatment [ Time Frame: The care period for each patient (approx. 3 weeks up to 1 year) ] [ Designated as safety issue: No ]
  Compare the time from referral to initiation of treatment/"decision no treatment" necessary between intervention and control groups
  
  
• Percentage of patients seen within investigation deadline [ Time Frame: Assessed at end of study - approx 2 years ] [ Designated as safety issue: No ]
  Compare the number of patients in the two groups seen within the limit set in national prioritisation guidelines
  
  
• Number of patients designated with investigation deadline [ Time Frame: Assessed at end of study - approx 2 years ] [ Designated as safety issue: No ]
  Compare the number of patients in the intervention vs. control group that were designated with a investigation deadline according to national prioritisation guidelines
  
  
• Patient satisfaction [ Time Frame: The care period for each patient (approx. 3 weeks up to 1 year) ] [ Designated as safety issue: No ]
  Patient satisfaction as measured by self report questionnaire
  
  
• Positive predictive value of referral [ Time Frame: The care period for each patient (approx. 3 weeks up to 1 year) ] [ Designated as safety issue: No ]

  Compare the percentage of referrals between the intervention and control groups which have lead to

  1. a diagnostic clarification, or
  2. a histological diagnosis, or
  3. a change in medical management
  
  
• Number of appointments needed for diagnostic clarification [ Time Frame: The care period for each patient (approx. 3 weeks up to 1 year) ] [ Designated as safety issue: No ]
  Compare the number of appointments needed to clarify diagnosis between intervention and control groups
  
  

There is a continuous work to improve the quality of health care delivered to an individual patient, both in primary and secondary care. The referral from primary to secondary care represents a key component in the communication between the levels of care, and therefore an important tool in developing the quality of care. There has been many attempts at improving the quality of referrals, but less work has been focussed on the consequence of such improvement on quality of health care. This study is designed as a randomised controlled intervention study where we intent to implement a referral templates, at the level of the general practitioner (GP). These templates will be for the referral of patients within 4 separate diagnostic groups:

• dyspepsia/upper GI symptoms
• colonic cancer investigation/lower GI symptoms
• chronic obstructive pulmonary disease (COPD)
• chest pain

Following the course of the health care process we will assess the quality of the care process by using predefined quality of care criteria, together with patient satisfaction (as measured by questionnaire) and other health process indicators.

Our primary hypothesis is that the implementation of a referral template in the communication between primary and secondary care, will lead to a measurable increase in the quality of health care delivered.

Secondary hypothesis include:

• the use of a referral template in the communication between the GP and secondary care, will lead to better patient satisfaction.
• the use of a referral template in the communication between the GP and secondary care, will lead to a change (up or down) in the amount of patients defined as being in need of prioritisation (as defined pr. national guidelines for prioritisation in health care)
• the use of a referral template in the communication between the GP and secondary care, will lead to a measurable referral quality improvement
• the use of a referral template in the communication between the GP and secondary care, will increase the "appropriateness" of the referrals