Competency in referral writing skill is needed by doctors for which they are not adequately trained. Although there has been a lot of discussion on improvement of skills for writing consultation letters, still priority is not given to this important task. Ideally there should be a course with assessment for teaching and learning medical referral writing skills for students. Currently, there is no such tool to assess the way communication letters are written. An 18-point assessment scale has been developed through Delphi technique to improve the quality of referral letters. The objective of the present study was to design a structured Proforma for writing referrals, with the consensus of seven participants using Delphi. The place of study was Rawalpindi medical university and allied hospitals. Results were finalised after the acceptance of structured referral by selected participants through Delphi. The response rate was 70%. The validity and interrater reliability were calculated using SPSS25. The Cronbach's alpha was 0.7 and Kappa was 0.3. Both were statistically significant. The designed Proforma for writing referrals, with its interrater reliability calculated, seems effective for writing effective and structured referrals. The study further recommends training junior doctors in making effective referrals.
Keywords: Referral and consultation, Improving quality and referral, Checklists and referrals and consultation.
With the advent of technology, the field of medicine has advanced and is now divided into multiple sub-specialities.1 Patients reporting in the Out Patient Department of any hospital are referred to one or multiple sub-specialities depending on their disease and diagnosis. However, in clinical practice there is usually a communication gap between various specialties regarding proper referral of patients.2 Consultation letters are commonly used between various units of the same hospital or from different hospitals. The primary and secondary healthcare hospitals also send patients with referrals. Consultation letters are, therefore, extremely important ways of communication regarding the patient's condition. The administration of proper treatment depends on a well-structured referral letter. It is an essential requirement for proper care of the patients.3
Better communication has a good impact over patient care. Studies have shown that doctors are not satisfied regarding the quality of referral letters received from various departments and hospitals.4,5 It can affect the care of the patient due to incomplete information and increase the burden by repeating the same investigations and over medication.6 The gaps in communication letters may add to an extra burden both over the healthcare system and the patient. The exact purpose of referral is usually not mentioned in the letter resulting in poor communication between healthcare professionals. There are multiple factors like time constraints and inadequate follow-up which also add to the inadequate referrals.7
A well-written comprehensive consultation has an excellent impact on patient management. Physicians and specialists must have the skill of writing structured referral letters in professional environments. Referral letters must show relevancy. The term relevancy means that only required and precise amount of information is added and a compact document is made. Relevancy comprises clinical information. Furthermore, two other things are required for writing a proper referral letter — a proper referenced opinion and cooperation.8 Both are essential for the purpose of good communication in medicine.
While globally various studies have been done on the quality of referrals, research on the quality and tool validation of referrals has not been adequately conducted in Pakistan. Also, literature shows evidence of a tool which has been developed to write referrals and which can be used both for teaching and assessment purposes to provide valuable feedback to learners in specialty areas.9
The present study seeks to address this research gap by designing a detailed checklist as an effective tool for writing and assessing written referrals and consultation request forms.
Material and Methods
This was a Cross Sectional Quantitative study which was completed in two months, from November till December 2019, through Delphi technique.
The study participants were selected from different departments of public hospitals in Rawalpindi Medical university, Pakistan, so the consultants from major specialties could be included. The participants selected were professors, associate professors or assistant professors with more than five years of teaching and clinical experience.
Among the participants, two were surgeons, two gynaecologists, two medical specialists, one ENT specialist, one eye specialist and two medical educationists. These were major clinical specialities and received most referrals. Out of the 10 participants, seven responded to both the rounds of Delphi.
A thorough search of the literature revealed that no checklist for referral writing had been developed in Pakistan. Utilising the available literature, a checklist of the items, that were most suitable for writing and assessing referral writings, was developed. The guidelines by the College of Physicians and Surgeons of British Columbia10 proved to be particularly helpful in this regard. The proposed checklist was emailed to experts with instructions to mark each item on the check list on a Likert scale of 1 to 5 (1=strongly disagree, 2=disagree, 3= neutral, 4=agree, 5=strongly agree). A predefined consensus criterion was decided and items in the checklists marked as 1 or 2 by 70% of the participants were removed, item marked 3, 4 and 5 by 70% of the participants were included. The initial checklist consisting of 14 items is attached in the annexure.
The referral form developed from literature search was sent to 10 study participants. Three (30%) participants refused to take part in the study, so the response rate was 7(70%). Seven participants marked the tool according to the Likert scale criteria provided. There were 14 points in the tool and 13 of them were accepted by the participants. Percentage agreement was 92%. This tool with 13 points was sent again to the seven participants and the response rate and agreement was 100% in the second round. The data obtained was entered into the SPSS version 25. The reliability of the scale was then calculated which revealed Cronbach's alpha of 0.744.1
Alpha 0.744 is good interclass coefficient which shows how strongly the subheadings in one group resemble each other. It is a type of correlation which measures the strength of the data in structured groups. The kappa checked the interrater reliability, which was 0.31.3 Interrater reliability of the tool was assessed by analysing the variance between raters' scores in both the individual items from the tool and in the total score.4 After the analysis, a final checklist emerged which can be used for making referrals. The final checklist formed after consensus with two rounds of Delphi is attached in annexure.
It is essential to make sure that the referral letter must be written in a structured and coordinated manner while referring the patient to some specialty. This information has its own favourable impact over both the primary and specialist doctors regarding the care of the patient. However, there has been no effective checklist for making referrals in Pakistan, and the patients are typically referred from primary to secondary care hospitals with incomplete information. Moreover, when consultations regarding patients are being made, the patients and their families must be informed about this. A recent study11 explained the role of standardised consultation letters to transfer clinical information about the patient from senior to junior level. In the same way, the present study has developed a standardised checklist for referrals in Pakistan.
Studies have shown that in resource constrained areas where there is minimal communication between doctors, it is improved by the support of staff.12 The checklist made in this study covered most of the significant points needed for making a good referral letter which would be a good communication source between the doctors. However, practically the physicians, their staff, and the whole system working together is a rare finding in a model of chronic care delivery.13 Other studies as the one by Jeffcott et al14 also highlight the importance of coalition and coordination for improvement in the quality of healthcare. Further, it is noted that communication from peripheral areas to specialty care service depends upon the proper referral letters.15
According to the available literature, the amount of information given in consultation letters is incomplete for the receivers.16 Another issue which must be taken care of while shifting the patient from primary healthcare service to specialty is that it is a big clinical handover. There is always a risk that some complication may occur while shifting the patient to specialist healthcare service.17 Hence, making a standard checklist for referrals will improve such communication. As evidenced by Hartveit et al, improving the information given by referral letters while shifting the patients help in reducing the adverse events in such transfers and ensure better care.18
An essential limitation of this study was inclusion of tertiary care hospitals and referral centres only. The primary care hospital could have problems which need to be addressed. The physicians working in smaller centres at the periphery can have different issues regarding the same problem. As the healthcare system needs more interaction between departments and hospitals than before, this referral system should be as best as possible. The second potential limitation is the lack of involvement of medical students and postgraduate students who should learn to use this tool.
Another drawback is that this study only focuses on the content of referrals, while the style of writing should also be included in the assessment of referral letters.
The checklist for referral writing is validated but there must be a way of training primary and secondary care physicians in referral writing which was not considered in this study.
In the light of the existing literature and the practical problems being faced due to inadequate information provided by many referrals, this study designed a checklist for writing referrals. The final checklist, based on feedback provided by the seven participants, is expected to improve the referral writing practice and hence, optimise the quality of referrals. The described tool appears to meet the criteria for writing structured referrals. The content and style of items of the instrument were derived directly from a framework for good practice in written communication. It is further recommended that the impact of writing good referrals on patient care should be appreciated.
Disclaimer: This article was written after profound literature review and final checklist was designed through proper validation. It is not part of thesis and was never presented in any conference.
Conflict of Interest: None to declare.
Funding Resources: None to declare.
1. Cassel CK, Reuben DB. Specialisation, subspecialisation, and subsubspecialisation in Internal medicine. N Engl J Med. 2011;364:1169.
2. Senitan M, Alhaiti AH,Gillespie J. Improving integrated care for chronic non-communicable diseases: A focus on quality referral factors, Intl J Healthcare Management.2019;12:106-115.
3. Tobin-Schnittger P, O’Doherty J, O’Connor R, O’Regan A. Improving quality of referral letters from primary to secondary care: A literature review and discussion paper. Prim Health Care Res Dev . 2018;19:211–22.
4. Vermeir P, Vandijck D, Degroote S, Peleman R, Verhaeghe R, Mortier E, et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Intl J Clin Pract. 2015;69:1257–67.
5. Scaioli G, Schäfer WLA, Boerma WGW, Spreeuwenberg PMM, Schellevis FG, Groenewegen PP. Communication between general practitioners and medical specialists in the referral process : a cross-sectional survey in 34 countries. 2020;1–9.
6. Nabelsi V, Lévesque-Chouinard A, Liddy C, Dumas Pilon M. Improving the Referral Process, Timeliness, Effectiveness, and Equity of Access to Specialist Medical Services Through Electronic Consultation: Pilot Study. JMIR Med Inform. 2019;7:e13354.
7. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intl Med. 2000;15:626–31.
8. Lingard L, Hodges B, MacRae H, Freeman R. Expert and trainee determinations of rhetorical relevance in referral and consultation letters. Med Educ. 2004;38:168–76.
9. François J. Tool to assess the quality of consultation and referral request letters in family medicine. Can Fam Physician. 2011;57: 574–5.
10. The Canadian Medical Protective Association. CMPA Good Practices Guide: Safe care — reducing medical-legal risk. Ottawa, Canada: The Canadian Medical Protective Association, 2016.
11. Kamau KJ, Osuga BO, Njuguna S. Challenges Facing Implementation Of Referral System For Quality Health Care Services In Kiambu County, Kenya. Health Syst Policy Res. 2017;04:1–8.
12. Juliani C, MacPhee M, Spiri W. Brazilian Specialists’ Perspectives on the Patient Referral Process. Healthcare. 2017;5:4.
13. Leppin AL, Montori VM, Gionfriddo MR: Minimally disruptive medicine: a pragmatically comprehensive model for delivering care to patients with multiple chronic conditions. Healthcare 2015;3: 50–63.
14. Jeffcott SA, Evans SM, Cameron PA. Improving measurement in clinical handover. BMJ Qual Saf 2009; 18: 272–7.
15. Durbin J, Barnsley J, Finlayson B, Jaakkimainen L, Lin E, Berta W, et al. Quality of communication between primary health care and mental health care: An examination of referral and discharge letters. J Behav Health Services Res. 2012;39:445–61.
16. Quality of Referrals from Family Medicine to Secondary Care in a University Hospital Communication and Continuity of Care. Ramathibodi Med J. 2015;38.
17. Hartveit M, Vanhaecht K, Thorsen O, Biringer E, Haug K, Aslaksen A. Quality indicators for the referral process from primary to specialised mental health care: an explorative study in accordance with the RAND appropriateness method. Biomedical Central Health Service Research. 2017;17:1–13.
18. Oshikoya KA, Orji MU, Oreagba IA. Medication history documentation in referral letters of children presenting at the emergency unit of a teaching hospital in Lagos, Nigeria.” Ann Ibn Postgrad Med 2016;14:13-20.