Transcript Variability in GP Referral Rates to Secondary Care

Variability in GP Referral
Rates to Secondary Care
Adam Frosh FRCS(Ed), FRCS(ORL-HNS)
Consultant ENT Surgeon
Background
• 1989 White paper Working for Patients 20-fold variation in GP referral rates to
hospital
• Crombie and Fleming estimated that for a
practice population of ~2000 patients, the
hospital expenditure (at 1981 prices)
associated with the lowest and highest
rates of referral were £40,000 and
£408,000, a 10-fold difference
Questionable Assumptions
• Increases in referral rates are caused
directly and solely by GPs changing their
referral behaviour.
• An increase in referrals will represent an
increase in inappropriate referrals
• High referral rates reflect inefficiency, poor
practice or failure to treat adequately in
Primary care
Rise in the number of GP consultations
taking place per patient, per year
1995
3.9
2007
5.416
Hippisley-Cox, J. Jumbu, G (2008). Trends in Consultation Rates in General Practice 1995 to 2007:
Analysis of the QRESEARCH database. The NHS Information Centre.
Difficulties
• Appropriateness of a referral difficult to
define
• Threshold for referrals do not just
depend on rigid clinical criteria
• Perhaps – how we can help each other
in the referral process most important
issue
Is Variability of Referral Rates
Important?
• Appropriateness
– No association yet seen connecting referral
rates to appropriateness
• Outcomes
– Literature is poor
Analysis by C. O’Donnell 2000
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(i) patient characteristics;
(ii) practice characteristics;
(iii) GP characteristics; and
(iv) access to specialist care
Practice Characteristics
• Practice size
– 7 papers. Conflicting results
• Geographical location
– Some increase in referral activity with
closeness of hospital from the practice
• Fundholding
– Only explains 5% variation
GP Characteristics
• No relationship was found between referral rates
and age of GP, years of experience or
membership of the RCGP in some UK studies
• GPs with a specialist interest in ENT and
ophthalmology had high referral rates to these
specialities, which persisted after adjusting for
case mix
– Reynolds GA, Chitnis JG, Roland MO. General practitioner outpatient
referrals: do good doctors refer more patients to hospital? Br Med J
1991; 302: 1250–1252
Access to Specialist Care
• Increasing consultant numbers per area
increases referral rates
– Roland M, Morris R. Are referrals by general practitioners influenced by
the availability of consultants? Br Med J 1988; 297: 599–600.
• The opening of a district general hospital led to
an increase in referral rates for those specialities
now providing a local consultant-based service
– Noone A, Goldacre M, Coulter A, Seagroatt V. Do referral rates vary
widely between practices and does supply of services affect demand? A
study in Milton Keynes and the Oxford region. J R Coll Gen Pract 1989;
39: 404–407.
Influence of Health Initiatives and
Policies on Referral Rates
– Practice based commissioning;
– Local PCT demand management targets for general
practice;
– Care pathway reforms/care closer to home;
– Introduction of Clinical Assessment Services (CAS)
and Referral Management Services;
– Increase in availability of non-consultant providers
e.g. GPs with special interests (GPwSIs) and nurseled clinics.
Reasons for Referral to Secondary
Care
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Diagnosis
Investigation
Advice on treatment
Specialist treatment
Second opinion
Reassurance for the patient
Sharing the load, or risk, of treating a difficult or
demanding patient
• Deterioration in general practitioner-patient relationship,
leading to desire to involve someone else in managing
the problem
• Fear of litigation
• Direct requests by patients or relatives
Changing Secondary Care Practice
and Systems
• Restricting consultant to consultant referrals
• Hospital waiting list management eg restriction
of referrals at peak times
• Discharging DNA’s generating new referrals
• Early discharge from hospital
• 18 week target increasing supply for demand of
referrals
• GP visit for aftercare from independent
healthcare centres
Changing Primary Care Practice
and Systems
• Increasing patient access to primary care increases referral rates to
secondary care eg increases need for 2nd opinion
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Coulter, A (1998). Managing demand at the interface between primary and secondary care British Medical Journal 316:1974-1976
• QOF, and GMS contracts increase referrals
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Srirangalingam U. Sahathevan S. K. Lasker S. S. Chowdhury T. A. (2006). Changing pattern of referral to a diabetes clinic following implementation of the new UK GP contract. British Journal of General Practice.
56(529):624-6,
• NICE guidance
• Rise of multidisciplinary referrals
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Practice nurses
Opticians
• Rise of defensive medicine
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Salaried GPs
Locums
Part time working
Erosion of personal lists
Extended opening hours
Walk in centres
Summerton, N (1995). Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. British Medical Journal 310:27-29
Choose and Book
• Increased availability and awareness of
services
• Rejected referrals can generate new
referrals
• Inaccurate DOS may create re-referrals
PBR
• Increased accuracy in coding increases
apparent referral rates
• Perverse incentives for trusts to miscode
f/u as new patient
Changes to the Population
• Ageing population living with diseases
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hearing loss
Heart disease
Diabetes
COPD
CVA
Obesity
New technologies and medical advancement
Information age
Increasing sense of patient entitlement
Conclusions
• Highly complex area.
• No research into the relationship between national policies and
referral rates
• Variations between gp practices’ referral patterns and rates remain
largely unexplained.
• Patient, practice and gp characteristics account for less than half of
observed variation
• Impact of social class is not clear-cut
• No one variable or group of variables appears to be a predictor of
variation
• No relationship found between referral rates and age of GP, years of
experience or membership of the RCGP
• Conflicting evidence about the relationship between practice size
and variation in referral rates
Conclusions 2
• Vary from PCT to PCT, GP practice to GP
practice and even GP to GP
• Unique combination of factors
• Timing of impact of any one factor – for example
of choose & book – will not necessarily have
immediate effects
• NHS complexity – local health community
factors
• PCT-commissioned referral analysis schemes
• Analysis by specialty, rather than a focus purely
on average GP referral to hospital figures
And finally….
Simply increase the unmet need!
Primary care pathway for Sleep
disorders/ Sleep apnoea
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BMI >40 ( consider referral to specialist
bariatric services)
Epworth Sleepiness Scale (ESS) > 15
Comorbid disease (IHD, TIA, CVA, DM,
respiratory problems, cardiac problems
(heart failure, uncontrolled hypertension,
head injury before onset of symptoms)
Excessive and Intrusive
Sleepiness (EIS) whilst driving
Sleep violence/ unsocial activities
REM related symptoms (cataplexy, sleep
paralysis, sleep onset dreams)
Vigilance critical activity include
commercial driving, pilots.
Any obvious abnormality of nose and
throat
Any strong suspicion of specific sleep
disorder e.g Restless leg syndrome
ENT Treatments for Snoring
• Relieve obstruction/restriction to nasal
airflow
• Excise large tonsils
• UVPP
ENT in Primary Care
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GPwSI
ENT CATS
Microsuction
Impedance tympanometry
Pure tone audiometry
Thorough understanding of medical treatments
of rhinitis
• Minor operative procedures eg to earlobe
• Direct access to physiotherapy services for
dysequilibration
Regulation of Referrals from
Primary Care to ENT
• Recurrent tonsillitis
• Glue ear
• Hearing loss
Thresholds of benefit
– Those procedures which do work
– Those which don’t work
– Those procedures which work proportionately
better above a certain threshold eg
tonsillectomy for tonsillitis
Honesty to Patients About
Unfunded Procedures
• Admit to patients there are insufficient
funds
• Be honest about the evidence for a
treatment irrespective of its funding status
• Refrain from dismissing all unfunded
treatments as those which don’t work
Parachute Study