Referral Letter with an Attached Structured Reply Form: Is it A Solution for Not Getting Replies

Abstract

Background:

Communication between primary care doctors and specialists/hospital doctors is vital for smooth functioning of a health care system. In many instances referral and reply letters are the sole means of communication between general practitioners and hospital doctors/specialists. Despite the obvious benefits to patient care, answers to referral letters are the exception worldwide. In Sri Lanka hand written conventional letters are used to refer patients and replies are scarce.

Materials and Methods:

This interventional study was designed to assess if attaching a structured reply form with the referral letter would increase the rate of replies/back-referrals. It was conducted at the Family Medicine Clinic of the Faculty of Medicine, University of Kelaniya. A structured referral letter (form) was designed based on guide lines and literature and it was used for referral of patients for a period of six months. Similarly a structured reply form was also designed and both the referral letter and the reply letter were printed on A4 papers side by side and these were used for the next six months for referrals. Both letters had headings and space underneath to write details pertaining to the patient. A register was maintained to document the number of referrals and replies received during both phases. Patents were asked to return the reply letters if specialists/hospital doctors obliged to reply.

Results:

Total of 90 patients were referred using the structured referral form during 1st phase. 80 letters (with reply form attached) were issued during the next six months. Patients were referred to eight different specialties. Not a single reply during the 1^st phase and there were six 6 (7.5%) replies during the 2^nd phase.

Discussion:

This was an attempt to improve communication between specialists/hospital doctors and primary care doctors. Even though there was some improvement it was not satisfactory. A multicenter island wide study should be conducted to assess the acceptability of the format to primary care doctors and specialists and its impact on reply rate.

Introduction

In the management of patients at primary care settings, referral of patients to better resourced health-care institutions and specialists becomes imperative at times. Primary care doctors refer patients for the number of reasons including diagnosis or investigation, treatment and reassurance (reassurance for themselves as well as reassurance for the patient).[1] In such situations communication link between primary care doctors and specialists/hospital doctors is the referral letter. When these patients are discharged from their care reply letter becomes the vehicle, which carries pertinent information to the primary care doctor.

Good communication between primary and secondary/tertiary care is essential for the smooth running of any health-care system.[2] Poor communication may result in disruptions in continuity of care, delayed diagnosis, increased costs through duplication of services, iatrogenic complications,[3] erroneous prioritization,[4] erosion of patient confidence and patient dissatisfaction.[2] Studies have shown that a comprehensive referral may help to ensure that the right patients are seen by specialists sooner rather than later.[5,6]

Communication between doctors of different experience and expertise is also an important means of education for both.[2]

A referral letter should provide sufficient information to facilitate management of a patient in the hospital. Patient's identity, Information related to the illness, socio psychological factors as well as primary care doctor's details should be included in a referral letter.

Studies world-wide have revealed that recipients (specialists and hospital doctors) are dissatisfied with the content and quality of referral letters.[7,8] Time constraint[9,10] and lack of secretarial support[2] have been identified as possible reasons for poor standard of referral letters.

A reply letter should convey specialist's assessments of patient's current problems and next steps in the care of the patient.[11] A reply letter facilitates comprehensive and continuity of care to the patient at primary care level. It has been revealed that primary care doctors are frustrated by the fact that they do not receive replies to their referrals.[9,12,13] Researches have identified reasons for not replying to referrals. Specialists and hospital doctors are under the impression that patients would not take reply letters back to the primary care doctor.[12] This is a valid reason in a country like Sri Lanka where a patient is not registered with a particular family practice and doctor shopping is the norm. Another reason is the perception among specialists that primary care doctors do not adhere to advice and guidance given in a reply letter. Heavy workload, the way services are structured in the hospitals, no motivation from heads, illegibility of referral letters, unnecessary referrals also could contribute to a tendency not to reply to referrals.[12] Reply letters play a vital role in continued education of primary care doctors, which in turn improves patient care. Pringle once described that reply letter is the most neglected route of continuous medical education.[14]

Attempts have been made to improve communication between primary care doctors and specialists. Introduction of structured form letters have shown improvement in the content of information in both referral[15,16,17,18,19] and reply letters.[15,20] It has been recommended the use of standardized referral templates to improve the effectiveness of electronic health record based referral process[21] and general practitioners have identified the benefits of using templates in the referral process.[22] There is a school of thought that better referral letters will generate more reply letters.[20,23] Kripalani et al. suggested using standardized formats to facilitate more consistent and timely feedback from specialists.[24] General practitioners have favored structured reply letters to conventional letters.[20]

In Sri Lanka, there is no strict referral system and a patient can consult a specialist or get admitted to a hospital without a referral letter from a primary care doctor. For referrals also there is the freedom for primary care doctors to refer patients to whatever institution or specialist they wish to.[9] Patients can be referred to a government or private hospital according to patient preference.

Even when a patient is referred with a referral letter a general practitioner hardly receives a reply from a specialist.[9] Under these circumstances this study was planned to see if introduction of a structured referral letter with an attached reply form would generate more replies. As far as authors are aware attached reply form with the referral letter has not been tried to encourage communication from secondary/tertiary care to primary care.

Materials and Methods

Study setting

This study was conducted at the Family practice center of the department of Family Medicine, Faculty of Medicine, University of Kelaniya, Sri Lanka. This is a non-fee levying, teaching practice where both undergraduates and post graduate trainees undergo training. Apart from the five staff members in the family medicine department who regularly attend to patients post graduate trainees also see patients during their training period. Conventional hand written referral letters were used for referral communications with secondary and tertiary care specialists and for admission of patients to hospitals. Our experience with reply rates was frustrating. Not a single reply letter for so many years. In this back ground, this study was planned to see the impact of structured referral letter attached with a reply form.

Phase 1: A structured referral letter was designed based on guidelines and following extensive literature review.[7,8,9,11,16,25,26] Opinion of experts in family medicine as well as specialists was sought and the content and the format were modified [Figure 1]. It included minimum essential details. Doctors used these referral forms to refer patients for 6 months. A record of the number of letters issued and replies received was maintained.

Figure 1.

Referral form

Phase 2: Similarly, a reply form was designed following extensive Literature review.[13,18,27,28] Taking into account the increased work load and time constraints of specialists only essential information was included. Opinion was sought from specialists as to what information they would like to include in a reply letter and views were obtained from family physicians as to what information they would like to receive and the content and the format were modified. To show the educational significance of a reply to primary care doctors a quote by Pringle[14] was also included in the form [Figure 2]. Both referral form and the reply form were printed side by side on an A4 paper [Figures 1 and 2 together]. This format allowed specialists to keep the referral letter with their records if necessary and detach the reply letter. It facilitated writing their reply directly looking at the referral, which helps to address concerns raised by the primary care doctor.

Figure 2.

Reply form

This format was used for the next 6 months. Patients were requested to bring the reply letter back if the specialists/hospital doctors obliged to reply. Again a record was maintained.

Results

A total of 90 referral letters were issued during the phase 1 of the study. Not a single reply was received during this period.

During the second phase of the study, 80 letters were issued. Letters have been addressed to specialists belonged to eight different specialties including general surgery, ENT, neurology and dermatology. Number of replies received was 6 (7.5%).

Discussion

This was an attempt to improve communication between primary care doctors and specialists/hospital doctors in a country where there is no proper referral system, standard format or guidelines on referral letters and where reply from specialists is scarce. With the introduction of the structured referral there was not a single reply. Couper and Henbest also revealed that there was no improvement in quality or the rate of reply after the introduction of a form letter in their study conducted in South Africa.[17]

There was some improvement in communication following introduction of the referral letter with the attached reply form. We received six reply letters during the study period. Since we used patients as couriers of the reply letters some reply letters may not have reached the family practice. Another drawback of the system is some of the referral letters may not have reached the expected destination since admission officers in hospitals do not send referral letters from primary care doctors with patients to wards always. Sometimes out-patient department (OPD) doctors in some hospitals use their own format to refer the patients from OPD to clinics of specialists. Under these circumstances, we are not sure as how many letters reached the expected destination.

Considering the possible drawbacks and the circumstances even six reply letters is an encouragement. Extensive study involving number of primary care centers should be planned to assess the acceptability of this tool to primary care doctors and specialists and the outcome.