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Evaluation of the impact of orthopaedic guidelines on referrals from primary care to a specialist department

Yvonne R West , Benjamin JL Kendrick , David M Williamson

Introduction This study was designed to assess the impact of written guidelines on general practitioner (GP) referrals to an orthopaedic outpatient department. We looked at referrals of six common, yet diverse, orthopaedic conditions and planned a prospective audit to assess the number of referrals from GPs before and after the provision of referral guidelines. A secondary part of the study involved assessing the ‘usefulness’ of the guidelines.Methods All GP referral letters for new patients with the chosen conditions in a 13-week period were audited. Paper copies of referral guidelines were then distributed to all local GPs. After a period of four weeks for distribution, the process was repeated for a further 13 weeks. Each letter was analysed for its content of therapy or management already tried by the GP prior to referral, as suggestedin the guidelines. A feedback questionnaire was sent to GPs in the Swindon Primary Care Trust to assess the distribution and use of the guidelines.Results In total 471 referral letters were assessed, 304 before the provision of guidelines and 167 afterwards. The first 13-week period had 195 (64%) referrals that consisted of patients who either had not received the recommended management, or for whom this had not been mentioned in the referral letter. The second period had 103 (61%). There was no statistically significant difference (P = 0.49) and therefore little evidence that the implementation of guidelines had an effect on the management of patients prior to referral orthe consequent timing of seeking specialist opinion.Conclusion The provision of orthopaedic written referral guidelines to GPs does not affect the prereferral management of patients, or the overall number of referrals to the specialty. Further work with primary care trusts to develop a referral system that gives all the information required by the hospital specialist may help promote greater awareness of referral guidelines, and more strict criteriaon the timing of referral.