The impact of psoriasis guidelines on appropriateness of referral from primary to secondary care: a randomized controlled trial.
BACKGROUND
Most patients with psoriasis have limited disease which can be managed effectively in primary care. There is a marked variation in the frequency of referrals between practices reflecting, in part, inadequate training of general practitioners (GPs) in the management of psoriasis.


OBJECTIVE
To assess the effectiveness of guidelines and training sessions on the management of psoriasis in reducing inappropriate referrals from primary care.


METHODS
Patients aged 18 years or over with psoriasis were eligible for the cluster-randomized, randomized controlled trial if they were referred by their GP between 9 September 2002 and 31 December 2003 to one of four hospital dermatology departments in Greater Manchester, North-West England. All GPs from 165 health centres were invited to a lecture by a local dermatologist on the diagnosis and management of psoriasis. Health centres in the intervention arm received guidelines on the management of psoriasis in primary care, developed by local dermatologists, supplemented by the offer of a practice-based nurse-led training session; those in the control arm received neither guidelines nor training sessions.


RESULTS
Eighty-two health centres were randomized to the intervention arm and 83 to the control arm. Outcome data were available for 188 of the 196 eligible patients referred during the study period. Patients in the intervention arm were significantly more likely to be appropriately referred in comparison with patients in the control arm [difference = 19.1%; odds ratio (OR) 2.47; 95% confidence interval (CI) 1.31-4.68; intracluster correlation coefficient (ICC) = 0]. Only 25 (30%) health centres in the intervention arm took up the offer of training sessions. There was no significant difference in outcome between health centres in the intervention arm that received a training session and those that did not (OR 1.28, 95% CI 0.50-3.29, ICC = 0).


CONCLUSIONS
Dissemination of guidelines on the management of psoriasis in primary care can significantly enhance the appropriateness of referral of patients to secondary care.
Griffiths
C E M
CE
Cancer Research UK Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. christopher.griffiths@manchester.ac.uk
Taylor
H
H
Collins
S I
SI
Hobson
J E
JE
Collier
P A
PA
Chalmers
R J G
RJ
Stewart
E J C
EJ
Dey
P
P
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence; D004502:Education, Medical, Continuing / Q000379:methods; D004739:England; D005194:Family Practice / Q000193:education / Q000592:standards; D005260:Female; D006302:Health Services Research / Q000379:methods; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D010808:Physical Examination / Q000379:methods / Q000592:standards; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards*; D011565:Psoriasis / Q000175:diagnosis / Q000628:therapy*; D012017:Referral and Consultation / Q000592:standards*