The effects of audit and feedback and electronic referrals on the quality of primary care referral letters

INTRODUCTION: Appropriate referral from primary care to hospital specialists is a critical component of general practice patient management. This study investigated the quality of such referrals in a group of general practitioners (GPs) and nurses. AIM: To assess whether feedback improves the quality of referral letters from general practice to secondary care and how electronic referrals affect the quality of referral letters. METHODS: All 15 GPs working on the West Coast in New Zealand and the two nurses in this locality who regularly wrote referral letters agreed to participate in the study. For each participant, referral letters to hospital specialists were assessed using a nine-point checklist. Ten consecutive letters were assessed for each participant. Written feedback on referral letter quality was given and a further 10 letters from each participant were assessed five months later. After a further five months, 10 electronic referral letters from each participant were assessed. RESULTS: Feedback to general practitioners and nurses improved the quality of referral letters for participants whose original referral letters were of poorer quality. The average score for referral letters was 81.4% at baseline and this improved to 86.9% after feedback. The introduction of electronic referral letters did not lead to a further improvement in referral letter quality. DISCUSSION: This study demonstrated that feedback to general practitioners and nurses can improve the quality of referral letters to secondary care. The introduction of electronic referral letters as used on the West Coast did not lead to any further improvement in referral quality.