Improving Outpatient Referrals to Secondary Care

Clinical Question

What is the best way to improve the appropriateness of outpatient referrals from primary to secondary care?

Evidence-Based Answer

The interventions that have the best supporting evidence are the distribution of guidelines with standard referral forms and the involvement of specialist consultants in education. Disseminating guidelines without forms and providing physicians with feedback on referral patterns are not proven to be effective.

Practice Pointers

Improving the referral process is a high priority for family medicine. In 2001, the Institute of Medicine issued a report1 on the state of the health care system that included several goals for overhaul: to make the system safe, effective, patient-centered, timely, efficient, and equitable. Appropriate use of subspecialty care is a key component of these goals.1 In 2004, the Future of Family Medicine Project Leadership Committee developed a template for the transformation of the specialty and the creation of a new model of family medicine.2 A centerpiece of this document is that every patient should have a medical home.2

Grimshaw and colleagues searched for studies of interventions to change or improve outpatient referrals. They found 17 trials with 23 different comparisons. Four out of five studies reported a benefit to dissemination of guidelines with structured referral sheets (checklists to accompany referral letters). These referral sheets prompt primary care physicians to perform prereferral management or tests. In one study, use of a structured referral sheet for infertility consultation yielded absolute increases of 16 percent in the number of primary care physicians who elicited a five-point sexual history, 24 percent in the number of women who received five tests before referral, and 18 percent in the number of men who received two tests before referral.3 All of the studies evaluated referral patterns for only one condition, and only about one half of referrals were accompanied by a completed referral sheet. Overuse of referral checklists for a wider range of conditions could be counterproductive.

Two out of three studies showed involvement of consultants in educational activities to be effective. In a study assessing the impact on referrals of monthly workshops about orthopedic problems, the intervention produced an increase in the use of injections by primary care physicians (30.6 versus 11.7 percent control, P < .001), a reduction in subsequent referrals to orthopedic surgeons (35.4 versus 68.0 percent control, P < .001), and an increase in the number of patients whose symptoms resolved after one year (35.4 versus 23.7 percent control, P < .05).4

Other effective interventions included patient management with a family physician rather than an internist; attachment of a physical therapist to a primary care office; requirement of an in-house second opinion before referral; and changes in the reimbursement scheme, from capitation to a mixed capitation and fee-for-service system and from low-cost fee-for-service to high-cost fee-for-service or capitation. Strategies that were not proven effective included passive dissemination of local consensus referral guidelines, feedback on referral rates, and discussion with an independent medical advisor.

Cyclic vs. Continuous or Extended-Cycle Combined Contraceptives

Clinical Question

Are continuous and extended-cycle combined contraceptives safe and effective?

Evidence-Based Answer

Evidence shows no difference in safety or effectiveness between cyclic and continuous or extended-cycle combined contraceptives. There are fewer menstrual symptoms with extended-cycle contraceptives. Patients’ satisfaction and adherence is similar for all types.

Practice Pointers

American women in the 21st century experience earlier menarche, have fewer babies, breastfeed for shorter periods, and live longer than women in past centuries, and therefore they have many more episodes of bleeding over their lifetimes. Bleeding with contraceptives is caused by pill withdrawal rather than endometrial buildup. There is no biologic reason why monthly cycles are necessary. Because many women prefer fewer days of vaginal bleeding per year, continuous and extended-cycle oral contraceptives have been developed.

To assess the safety and effectiveness of combined oral contraceptives with longer cycle lengths, Edelman and colleagues reviewed the literature for randomized controlled trials comparing 28-day cyclical contraceptives (21 active pills, seven placebos) with continuous combined contraceptives. They found six studies comparing 28-day cycles of combined oral contraceptives with cycles ranging from 49 to 365 days. There was no difference between the regular and extended cycles in satisfaction, adherence, pregnancy rates, or safety. Patients taking continuous oral contraceptives had four to 14 fewer days of bleeding per trimester. In the two studies that included a sonogram or endometrial biopsy, no evidence of endometrial hyperplasia was found after nine cycles.

Although combined oral contraceptive pills also are used to treat conditions such as acne and dysmenorrhea,1,2 there have been no studies on the use of continuous combined oral contraceptives for purposes other than the prevention of pregnancy. Limited data in this review suggest that women taking continuous dosing have fewer headaches and less genital irritation, fatigue, bloating, and menstrual pain.