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Implementing referral guidelines: lessons from a negative outcome cluster randomised factorial trial in general practice

Jiwa, M., Skinner, P., Coker, A., Shaw, L., Campbell, M. and Thompson, J. (2006) Implementing referral guidelines: lessons from a negative outcome cluster randomised factorial trial in general practice. BMC Family Practice, 7 (1). p. 65. ISSN 1471-2296

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Few patients with lower bowel symptoms who consult their general practitioner need a specialist opinion. However data from referred patients suggest that those who are referred would benefit from detailed assessment before referral.


A cluster randomised factorial trial. 44 general practices in North Trent, UK. Practices were offered either an electronic interactive referral pro forma, an educational outreach visit by a local colorectal surgeon, both or neither. The main outcome measure was the proportion of cases with severe diverticular disease, cancer or precancerous lesions and inflammatory bowel disease in those referred by each group. A secondary outcome was a referral letter quality score. Semi-structured interviews were conducted to identify key themes relating to the use of the software


From 150 invitations, 44 practices were recruited with a total list size of 265,707. There were 716 consecutive referrals recorded over a six-month period, for which a diagnosis was available for 514. In the combined software arms 14% (37/261) had significant pathology, compared with 19% (49/253) in the non-software arms, relative risk 0.73 (95% CI: 0.46 to 1.15). In the combined educational outreach arms 15% (38/258) had significant pathology compared with 19% (48/256) in the non-educational arms, relative risk 0.79 (95% CI: 0.50 to 1.24). Pro forma practices documented better assessment of patients at referral.


There was a lack of evidence that either intervention increased the proportion of patients with organic pathology among those referred. The interactive software did improve the amount of information relayed in referral letters although we were unable to confirm if this made a significant difference to patients or their health care providers. The potential value of either intervention may have been diminished by their limited uptake within the context of a cluster randomised clinical trial. A number of lessons were learned in this trial of novel innovations.

Item Type: Article
Copyright, Publisher and Additional Information: © 2006 Jiwa et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Institution: The University of Sheffield
Academic Units: The University of Sheffield > Faculty of Medicine, Dentistry and Health (Sheffield) > School of Health and Related Research (Sheffield) > Institute of General Practice & Primary Care (Sheffield)
Depositing User: Sheffield Import
Date Deposited: 05 Oct 2009 11:36
Last Modified: 08 Oct 2009 10:13
Published Version: http://www.biomedcentral.com/1471-2296/7/65
Status: Published
Publisher: Biomed Central
Identification Number: 10.1186/1471-2296-7-65
URI: http://eprints.whiterose.ac.uk/id/eprint/9678

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