Can guidelines improve referral to elective surgical specialties for adults? A systematic review.
OBJECTIVE
To assess effectiveness of guidelines for referral for elective surgical assessment.


METHODS
Systematic review with descriptive synthesis.


METHODS
Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites.


METHODS
Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults.


METHODS
Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs.


RESULTS
24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex ("one-stop shops") to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change.


CONCLUSIONS
Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.
Clarke
Aileen
A
Warwick Medical School, University of Warwick, Health Sciences Research Institute, Coventry CV4 7AL, UK. aileen.clarke@warwick.ac.uk
Blundell
N
N
Forde
I
I
Musila
N
N
Spitzer
D
D
Naqvi
S
S
Browne
J
J
D000328:Adult; D003365:Costs and Cost Analysis; D016208:Databases, Factual; D017558:Elective Surgical Procedures; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D012017:Referral and Consultation / Q000191:economics / Q000592:standards*; D013043:Specialties, Surgical