title: Can guidelines improve referral to elective surgical specialties for adults? A systematic review.
abstract: 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.
authors.affiliation: Warwick Medical School, University of Warwick, Health Sciences Research Institute, Coventry CV4 7AL, UK. aileen.clarke@warwick.ac.uk
authors.forename: Aileen
authors.initials: A
authors.lastname: Clarke
authors.forename: N
authors.initials: N
authors.lastname: Blundell
authors.forename: I
authors.initials: I
authors.lastname: Forde
authors.forename: N
authors.initials: N
authors.lastname: Musila
authors.forename: D
authors.initials: D
authors.lastname: Spitzer
authors.forename: S
authors.initials: S
authors.lastname: Naqvi
authors.forename: J
authors.initials: J
authors.lastname: Browne
mesh_terms: 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