|Year : 2007 | Volume
| Issue : 3 | Page : 113-117
Quality of primary care referral letters and feedback reports in buraidah, Qassim region, Saudi Arabia
Mohammed A Al-Alfi1, Abdullah M Al-Saigul1, Ashraf M Abed-Elbast1, Atef M Sourour2, Hasnin A Ramzy1
1 Primary Health Care, Qassim Region, Saudi Arabia
2 King Fahad Specialist Hospital, Buraidah, Saudi Arabia
|Date of Web Publication||28-Jun-2012|
Mohammed A Al-Alfi
Consultant Family Physician, PHC Qassim Region, P.O. Box 1036, Buraidah 81999
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To evaluate the quality of referral letters and feedback reports written according to the standards of Quality Assurance Manual of Ministry of Health from primary health care centers (PHCC's) in Buraidah.
Methodology: This study was conducted during October and November 2004. A total of 330 referral letters and feedback reports were randomly selected from six PHCCs (20% from PHCCs in Buraidah City). About 55 referral and feedback letters were selected from each PHCC by systematic sampling method. The referral letters and feedback reports were reviewed thoroughly for the main items required in ideal referral letters and feedback reports according to the standard of Quality Assurance Manual of Ministry of Health, and a scoring system was used
Result: Many of the referral letters lacked such important information as the history in 36%, vital signs in 30%, results of clinical examination in 45%, results of basic investigations in 52%, provisional diagnosis in 50%, and treatment given in PHCCs in 47%. The legibility of referral letters and feedback reports was good in 75%, and 63% respectively, and the quality of referral letters and feedback reports was good in 63% and 39% respectively. The rate of feedback reports received by PHCCs was 30% of total number of referrals to the hospitals. The referral rate was (4%) from total number of patients seen in PHCCs. The most frequent reasons for referrals were for general treatment 36.7%, for general diagnostic evaluation 28%, and for laboratory investigation 18.8%.
Conclusion: The referral rate from PHCCs in Buraidah fell within the standard set in Quality Assurance Manual. However, the quality of referral letters and feedback reports was poor in 17.6% and 29.7% respectively. The quality of both referral letters and feedback reports should improve to guarantee the quality of patient care..
Keywords: Referral letters, Feedback reports, Quality, Buraidah, Qassim Region
|How to cite this article:|
Al-Alfi MA, Al-Saigul AM, Abed-Elbast AM, Sourour AM, Ramzy HA. Quality of primary care referral letters and feedback reports in buraidah, Qassim region, Saudi Arabia. J Fam Community Med 2007;14:113-7
|How to cite this URL:|
Al-Alfi MA, Al-Saigul AM, Abed-Elbast AM, Sourour AM, Ramzy HA. Quality of primary care referral letters and feedback reports in buraidah, Qassim region, Saudi Arabia. J Fam Community Med [serial online] 2007 [cited 2020 Oct 22];14:113-7. Available from: https://www.jfcmonline.com/text.asp?2007/14/3/113/97099
| Introduction|| |
The referral system is a means of communication between physicians at three levels of health care and it is one of the indicators of the quality of health care services. . Good communication between primary, secondary, and tertiary care is essential for the smooth running of any health system. Referral is the process by which one physician requests another physician to examine a patient and give advice or manage.  The referral system helps to avoid an overload, limits over-medication, over-investigation and over-treatment.  Communication between two doctors with different experiences and expertise is also an important tool of education for both of them.  The referral process includes communication of the need and purpose of referral to the consultant, communication of the consultant's findings and recommendation to the referring physician, and mutual decision on continuing care. , Failure in communication can occur at any stage of the referral process, if the referring physician fails to phrase a question appropriately or provide adequate information. The consultant may not address the referring physician's question, ,, fail to communicate his findings to the referring physician, , and make recommendations that may be unclear, or even inappropriate. , The implementation of the referral system from the primary health care centers to hospitals in all regions of the Kingdom started in 1988.  To our knowledge, no attempt has been made to evaluate the system in the Qassim Region. The aim of this paper is to evaluate the quality of referral letters from PHCCs and feedback reports from referral hospitals in Buraidah.
| Methodology|| |
The city of Buraidah is the capital of the Qassim region. The total population of the Qassim region is around one million, one third of which is in Buraidah. There are 27 government PHCCs in Buraidah, six of which were selected randomly (20% from PHCCs in Buraidah City). These PHCCs were Fayziah, Muntazah, Hay Alamn, Rafeah, Shamal Buraidah, and Khaleg. A total of 330 referral letters and feedback reports were randomly selected. The referral records were reviewed during October and November 2004, and about 55 referral and feedback letters were selected from each PHCC by systematic sampling method. Every fourth referral letter and feedback report was selected from the referral registry in the PHCC. The referral letters were reviewed thoroughly for the components of an ideal referral letter according to the standard of Quality Assurance Manual of Ministry of Health.  Sixteen items demanded by the standards include general information such as name, age, sex, nationality, address, complaint, past medical history, vital signs, examination findings, investigation, diagnosis, treatment given, cause and place of referral. Data was collected on other important items including patient file number, type of referral, date of referral, name & signature of referring physician, and legibility of hand writing. The quality of referral letters was estimated by giving a score of one to each of the required items present amounting to a score range of 0 to16. Similarly the presence or absence of 11 components in the feedback reports was noted. It included any additional significant history, result of physical examination, result of investigations, final diagnosis, management plan, clear recommendation, arrangement for follow-up, patient hospital number, clear hand writing, date of feedback, and name & signature of the consultant. Each feedback report was also graded on a score of one to each item presenting a score range of 0 to 11. The data were analyzed using Statistical Package for Social Science (SPSS) Version 11.5.
| Result|| |
The referral rate was 4% from total number of patients seen in PHCCs. [Table 1] shows the frequency of recording the necessary standard components of an ideal referral letter. The best was for general information, and the worst was the result of investigation. [Table 2] shows frequency of recording the necessary standard components in ideal feedback reports, the best of which was for final diagnosis, and the worst the hospital file number. [Figure 1] shows the reason for referral. The most frequent, 37%, was for general treatment and 28% for general diagnostic evaluation. The patients were referred to different specialties, the most frequent being dermatology, 25.5%, obstetrics & gynecology, 11.2%, and ophthalmology, 10%. The legibility of referral letters and feedback reports was also evaluated. The legibility of referral letter was good in 75% and the legibility of feedback reports was good in 63%. The quality of referral letters was good in 63%, fair in 19.4%, and poor in 17.6% [Figure 2]. The quality of feedback reports was good in 38.8%, fair in 31.5%, and poor in 29.7% [Figure 3]. Most patients (73.4%) were seen by the consultant within three weeks of referral, 15% within one week and 27% after three weeks. The rate of response of sending the feedback reports to the PHCCs was about 30%, 69% of which reached the PHCCs within three months from the date of referral and 31% reaching the PHCCs more than three months after the referral.
| Discussion|| |
There is a variety of reasons for incompleteness and the inferior quality of referral letters. Two local references and a British study, ,, show that our overall assessment was good. However, there should be no complacency since this might be the result of the difference in the standards set and indicators set or the difference in health system compared with the global study, or perhaps the time difference between our study and other studies. Although only 17.6% of referral letters was poor, many indicators on the performance scale were low. Those related to relevant history and vital signs were found in about one third of referrals; result of clinical examination, result of basic investigations, provisional diagnosis and treatment given in about half of referral letters. This assessment agreed with the Al Jarallah study in Riyadh.  Without this information from the primary health care doctors, the hospital consultants glean very little information which in turn affects the quality of patient care.  Our study of legibility of referral letters showed that 25% of the referral letters had illegible handwriting. This was similar to the Al Amoud study, in which one third of referral letters were illegible.  The main reason for sending letters of referral from PHCCs was to help arrive at a proper diagnosis and to provide management that the facilities and expertise of the PHC cannot provide. This result was similar to the result of the Dafallah study in Sudan.  Although doctors in hospitals usually complain about the quality of referral from primary health care, the study also indicated that the quality of feedback reports was below standard. About 30% of the feedback reports which is less than the result reported by the Al Jarallah study in Riyadh were of poor quality.  The legibility of feedback reports was 63%, and the rate of response in sending the feedback reports to the PHCCs was about 30%. This result was less than the results from other published studies that indicated consultation feedback rate ranging from 40 to 88%. ,,,, The majority of patients were referred for management. Despite this, the final diagnosis was not specified in 22% of feedback reports; also lacking in 33% of feedback reports were physical examination findings, and result of investigations in 48% of feedback reports. This is similar to the result of the previous study done by Aljarallah in Riyadh. 
The consultant may deem this information of little importance, but the primary care physician needs this information on the patient's condition, to assist in resolving the problem. Besides, without these details the educational purpose of the referral process is impeded. There is evidence that serious consideration, if provided, is given to consultants' recommendations,  and are more likely to be followed if they are concise, clear, specific, and focus on issues central to current patient care. ,, In 34% of the feedback reports there were no clear recommendations from the consultant. This was less than the result reported by Al Jarallah study in Riyadh.  Poor referral letter from primary health care physician yield poor consultant feedback report.  The possible reasons for the poor quality of referral and feedback letters were: unclear handwriting, lack of appropriate means of communication between primary health care centers and hospitals, high turnover of the staff and lack of resources. We recommend that primary health care doctors should be trained to write proper referral letters; adequate staff should be provided in central office to type referral and feedback letters, electronic media e.g. e-mail and internet should be used for the exchange of referral letters and feedback reports.
| References|| |
|1.||Al - Amoud Mayson. Analysis of poor referral letters. Saudi Medical Journal 1994; 15 (5): 354-7. |
|2.||Lawler FH. Referral rates of senior family practice residents in an ambulatory care clinic. J Med Educ 1987; 62: 177-82. |
|3.||Westerman RF. A study of communication between general practitioners and specialist. Br J Gen Pract 1990; 40: 445-9. |
|4.||Hansen JP, Brown SE, Sullivan RJ, Muhlabaier LH. Factors related to an effective referral and consultation process. J Fam Pract 1982; 15(4):651-6. |
|5.||Mc Phee SJ, Lo B, Saika GY, Meltzer R. How good communication between primary care physicians and subspeciality consultants. Arch Intern Med 1984; 144:1265-8. |
|6.||Cummins RO, Smith RW, Inui TS. Communication failure in primary care, failure of consultants to provide follow up information. JAMA 1980;243(16):1650-2. |
|7.||Lee T, Pappius EM, Goldman L. Impact on inter physician communication on effectiveness of medical consultation. Am J Med 1983;74;106-12. |
|8.||Byrd JC, Moskowitz MA. Outpatient consultation interaction between the general internist and specialist. J Gen Intern Med 1987;2(2):93-8. |
|9.||9- Sears CL, Charlson ME. The effectiveness of a consultation, compliance with initial recommendations. Am J Med 1983;74: 870-6. |
|10.||Al-Soweilem LS, Mangoud AM. Evaluation of antenatal referrals from health centers to maternity and children's hospital in Damam City, Saudi Arabia. Journal of Family and Community Medicine 1996; 3(1):22-8. |
|11.||Quality Assurance in Primary Health Care Manual. MOH G.D. of health centers, WHO / EMRO. Riyadh, Saudi Arabia 1994:129-42. |
|12.||Jarallah JS. The Quality of Referral Letters in Two Heath Centers in Riyadh. Annals of Saudi Medicine 1991;11(6):658-62. |
|13.||Dafallah SE, Yousif EM. Analysis of documents used in referral system in Wad Medani, Sudan. Saudi Med J 2005;26(1):148-50. |
|14.||Mackenzie TB, Popkin MK, Callies AL. The effectiveness of cardiology consultation: concordance with diagnostic and drug recommendations. Chest J 1981;79:16-22. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]