title: Implementing referral guidelines: lessons from a negative outcome cluster randomised factorial trial in general practice.
abstract: BACKGROUND
  Few patients with lower bowel symptoms who consult their general practitioner need a specialist opinion. However data from referred patients suggest that those who are referred would benefit from detailed assessment before referral.
  
  
  METHODS
  A cluster randomised factorial trial. 44 general practices in North Trent, UK. Practices were offered either an electronic interactive referral pro forma, an educational outreach visit by a local colorectal surgeon, both or neither. The main outcome measure was the proportion of cases with severe diverticular disease, cancer or precancerous lesions and inflammatory bowel disease in those referred by each group. A secondary outcome was a referral letter quality score. Semi-structured interviews were conducted to identify key themes relating to the use of the software
  
  
  RESULTS
  From 150 invitations, 44 practices were recruited with a total list size of 265,707. There were 716 consecutive referrals recorded over a six-month period, for which a diagnosis was available for 514. In the combined software arms 14% (37/261) had significant pathology, compared with 19% (49/253) in the non-software arms, relative risk 0.73 (95% CI: 0.46 to 1.15). In the combined educational outreach arms 15% (38/258) had significant pathology compared with 19% (48/256) in the non-educational arms, relative risk 0.79 (95% CI: 0.50 to 1.24). Pro forma practices documented better assessment of patients at referral.
  
  
  CONCLUSIONS
  There was a lack of evidence that either intervention increased the proportion of patients with organic pathology among those referred. The interactive software did improve the amount of information relayed in referral letters although we were unable to confirm if this made a significant difference to patients or their health care providers. The potential value of either intervention may have been diminished by their limited uptake within the context of a cluster randomised clinical trial. A number of lessons were learned in this trial of novel innovations.
authors.affiliation: Curtin University of Technology, GPO Box U1987, Perth, WA 6845, Australia. moyez.jiwa@curtin.edu.au
authors.forename: Moyez
authors.initials: M
authors.lastname: Jiwa
authors.forename: Paul
authors.initials: P
authors.lastname: Skinner
authors.forename: Akinoso Olujimi
authors.initials: AO
authors.lastname: Coker
authors.forename: Lindsey
authors.initials: L
authors.lastname: Shaw
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Campbell
authors.forename: Joanne
authors.initials: J
authors.lastname: Thompson
mesh_terms: D003108:Colonic Diseases / Q000175:diagnosis* / Q000473:pathology; D015179:Colorectal Neoplasms / Q000175:diagnosis; D003107:Colorectal Surgery; D015709:Correspondence as Topic; D004239:Diverticulitis, Colonic / Q000175:diagnosis; D004502:Education, Medical, Continuing; D005194:Family Practice / Q000193:education / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D015212:Inflammatory Bowel Diseases / Q000175:diagnosis*; D033183:Interdisciplinary Communication; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D012002:Rectal Diseases / Q000175:diagnosis* / Q000473:pathology; D012017:Referral and Consultation / Q000592:standards*; D012984:Software; D013997:Time Factors; D006113:United Kingdom