Altering physician referral practices is challenging, but not impossible: spine assessment clinic quality improvement study

INTRODUCTION: Access to medical specialists is a persistent challenge, with neurosurgical spine services reporting some of the longest waits across all fields. Inappropriate and incomplete referrals contribute to delayed access to these providers. Referral guidelines and physician education have been shown to decrease such inefficiencies. Therefore, the goal of this study was to address inappropriate referrals directed to the neurosurgical spine assessment clinic via implementation of a quality improvement initiative. We hypothesised that appropriate referrals, which included patients with potential surgical pathology and fulfilled referral criteria, would increase by 25% following referral guideline distribution. METHODS: A three-phase study was implemented: (1) baseline data were collected from preintervention referrals by noting the reason for consultation and if certain information, deemed relevant for an appropriate referral, was included; (2) a referral guideline, outlining when and how to refer, was distributed to family physicians in the region; and (3) postintervention referrals were collected and analysed as in phase I. RESULTS: A total of 404 referrals were collected (161 pre-intervention and 243 post-intervention). A 36% increase in patients who were deemed appropriate surgical candidates was reported post-intervention (p=0.044), with an escalation in the proportion of patients requiring neurosurgeon assessment observed over time. Limited improvements were appreciated in the presence of the criteria indicated for inclusion in a referral document. CONCLUSION: While challenges remain when attempting to modify the referring behaviours of primary care physicians, this research has demonstrated that guidelines aimed at enhancing specialist directed referrals can lead to improvements in their performance. Nonetheless, translating guidelines into practice is a recognised issue, often requiring time and multiple exposures. Active forms of medical education and multifaceted interventions have been demonstrated to be the most effective means of implementing guidelines into practice, an approach that could further address referral inadequacies in the future.

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