Written feedback on referral behaviour for general practitioners.

Referrals have much impact on the patient and result in relatively high health care costs. Percentages of non-rational referring varying between 25 and 45% are reported. Therefore, changing referral behaviour may be relevant. Attempts to change referral behaviour focused on reducing the number of referrals by giving insight in referral volume data, but no effects could be found. Until now, there have been no publications of studies set up to improve the rationality of referrals. We set up an individual feedback program on GP referrals to outpatient clinics for internal medicine and studied the effects in a randomised controlled trial. Main study question: does feedback lead to fewer non-rational referrals?An expert panel of internists and GPs translated existing (inter)national guidelines/recommendations into 24 regional guidelines on common reasons for referral. A nominal group technique was used to obtain consensus among the experts. The feedback procedure was introduced thereafter.Feedback is set up as structured written reports, provided at least once per year to individual GPs. The feedback reports are based on a critical appraisal of all first referrals in the 6 months preceding the feedback. To that end, clinical information in referral letters are compared with the guidelines. The feedback focuses on the rationality and volume of first referrals to internal medicine. The study is set up as a RCT in which all GPs in the Maastricht region were included. Feedback on first referrals was provided to a random half of all GPs; the rest acting as controls. The intervention should be held during at least 2 years to get sufficient change over time. All GPs are informed but no informed consent is obtained, as all GPs in the Maastricht region have –by contract- agreed to participate in (studies on) implementation strategies.

Repeated feedback reports in which the volume and quality of referrals is discussed will lead to fewer non-rational referrals.

Assembly of guidelines and
assessment of rationality of referrals of one year before and one and two years after the start of the intervention per GP.

Structured written posted feedback reports per GP giving an assessment of the rationality of referrals with recommendations for future changes in referral behaviour. Such reports are to be sent at least once per year. Rationality of referrals is assessed by comparing patient information with previously set guidelines.