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

Practical Health Co-operation - a Randomised Controlled Intervention Study. The Impact of a Referral Template on Quality of Care and Health Care Co-operation Between Primary and Secondary Care

The purpose of this study is to examine whether the implementation of a referral template will increase quality of health care delivered and the quality of health care co-operation. The investigators intent to implement a referral template, at the level of the general practitioner (GP), 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

Local GP clinics will be randomised to use the referral template or to use standard referral practice. Using a predefined set of quality criteria the investigators will score the process of care in each patient, and compare intervention and control groups. In addition other criteria will be collected and compared between the two groups, e.g.

• time to diagnosis/treatment
• quality of referral
• more appropriate referrals
• patient satisfaction (as measured by a questionnaire)

The investigators hypothesize that the implementation of a referral template will lead to a measurable increase in the quality of health care delivered.

Study Overview

• Status: Completed
• Conditions: Quality of Health Care; Referral
• Intervention / Treatment: Other: Implementation of referral template

Detailed Description

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

• Study Type: Interventional
• Enrollment (Actual): 500
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Norway
  • Harstad, Norway, 9480
    • Medical department - University Hospital of North Norway Harstad

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• referral to medical department of University Hospital of North Norway, Harstad

Exclusion Criteria:

• children (< 18 years of age)
• patients with reduced capacity to consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Referral template; Implementation of the referral templates at the GP office	Other: Implementation of referral template; Implementation of referral template at the GP office
No Intervention: Control; Normal referral pattern

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Collated quality indicator score	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.	The care period for each patient (approx. 3 weeks up to 1 year)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Improved referral quality	The investigators will evaluate each referral against the referral template, and then compare between intervention and control groups.	The care period for each patient (approx. 3 weeks up to 1 year)
Waiting time from referral to appointment		The care period for each patient (approx. 3 weeks up to 1 year)
Time from referral to initiation of treatment	Compare the time from referral to initiation of treatment/"decision no treatment" necessary between intervention and control groups	The care period for each patient (approx. 3 weeks up to 1 year)
Percentage of patients seen within investigation deadline	Compare the number of patients in the two groups seen within the limit set in national prioritisation guidelines	Assessed at end of study - approx 2 years
Number of patients designated with investigation deadline	Compare the number of patients in the intervention vs. control group that were designated with a investigation deadline according to national prioritisation guidelines	Assessed at end of study - approx 2 years
Patient satisfaction	Patient satisfaction as measured by self report questionnaire	The care period for each patient (approx. 3 weeks up to 1 year)
Positive predictive value of referral	Compare the percentage of referrals between the intervention and control groups which have lead to; a diagnostic clarification, or; a histological diagnosis, or; a change in medical management	The care period for each patient (approx. 3 weeks up to 1 year)
Number of appointments needed for diagnostic clarification	Compare the number of appointments needed to clarify diagnosis between intervention and control groups	The care period for each patient (approx. 3 weeks up to 1 year)

Collaborators and Investigators

• Sponsor: University Hospital of North Norway
• Collaborators: University of Tromso
• Investigators: Principal Investigator: Ann Ragnhild Broderstad, Dr. med, University Hospital of North Norway

Publications and helpful links

General Publications

• Wahlberg H, Valle PC, Malm S, Hovde O, Broderstad AR. The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial. BMC Health Serv Res. 2017 Mar 7;17(1):177. doi: 10.1186/s12913-017-2127-1.
• Wahlberg H, Braaten T, Broderstad AR. Impact of referral templates on patient experience of the referral and care process: a cluster randomised trial. BMJ Open. 2016 Oct 24;6(10):e011651. doi: 10.1136/bmjopen-2016-011651.
• Wahlberg H, Valle PC, Malm S, Broderstad AR. Impact of referral templates on the quality of referrals from primary to secondary care: a cluster randomised trial. BMC Health Serv Res. 2015 Aug 29;15:353. doi: 10.1186/s12913-015-1017-7.
• Wahlberg H, Valle PC, Malm S, Broderstad AR. Practical health co-operation - the impact of a referral template on quality of care and health care co-operation: study protocol for a cluster randomized controlled trial. Trials. 2013 Jan 7;14:7. doi: 10.1186/1745-6215-14-7.

Study record dates

Study Major Dates

• Study Start: September 1, 2011
• Primary Completion (Actual): January 1, 2014
• Study Completion (Actual): January 1, 2014

Study Registration Dates

• First Submitted: September 5, 2011
• First Submitted That Met QC Criteria: November 10, 2011
• First Posted (Estimate): November 11, 2011

Study Record Updates

• Last Update Posted (Estimate): July 11, 2014
• Last Update Submitted That Met QC Criteria: July 10, 2014
• Last Verified: July 1, 2014

More Information

Terms related to this study

• Keywords: Quality of Health Care; Referral
• Other Study ID Numbers: HST1026-11