Reducing variation in general practitioner referral rates through clinical engagement and peer review of referrals: a service improvement project.

BACKGROUND General practitioner (GP) referral rates to hospital services vary widely, without clearly identified explanatory factors, introducing important quality and patient safety issues. Referrals are rising everywhere year on year; some of these may be more appropriately redirected to lower technology services. AIM To use peer review with consultant engagement to influence GPs to improve the quality and effectiveness of their referrals. DESIGN Service development project. SETTING Ten out of 13 GP practices in Torfaen, Gwent; consultants from seven specialties in Gwent Healthcare NHS Trust; project designed and managed within Torfaen Local Health Board between 2008 and 2009. METHODS GPs discussed the appropriateness of referrals in selected specialties, including referral information and compatibility with local guidelines, usually on a weekly basis and were provided with regular feedback of 'benchmarked' referral rates. Six-weekly 'cluster groups', involving GPs, hospital specialists and community health practitioners discussed referral pathways and appropriate management in community based services. RESULTS Overall there was a reduction in variation in individual GP referral rates (from 2.6-7.7 to 3.0-6.5 per 1000 patients per quarter) and a related reduction in overall referral rate (from 5.5 to 4.3 per 1000 patients per quarter). Both reductions appeared sustainable whilst the intervention continued, and referral rates rose in keeping with local trends once the intervention finished. CONCLUSION This intervention appeared acceptable to GPs because of its emphasis on reviewing appropriateness and quality of referrals and was effective and sustainable while the investment in resources continued. Consultant involvement in discussions appeared important. The intervention's cost-effectiveness requires evaluation for consideration of future referral management strategies.