title: Do referral-management schemes reduce hospital outpatient attendances? Time-series evaluation of primary care referral management.
abstract: BACKGROUND
  Ninety-one per cent of primary care trusts were using some form of referral management in 2009, although evidence for its effectiveness is limited.
  
  
  OBJECTIVE
  To assess the impact of three referral-management centres (RMCs) and two internal peer-review approaches to referral management on hospital outpatient attendance rates.
  
  
  METHODS
  A retrospective time-series analysis of 376 000 outpatient attendances over 3 years from 85 practices divided into five groups, with 714 000 registered patients in one English primary care trust.
  
  
  METHODS
  The age-standardised GP-referred first outpatient monthly attendance rate was calculated for each group from April 2009 to March 2012. This was divided by the equivalent monthly England rate, to derive a rate ratio. Linear regression tested for association between the introduction of referral management and change in the outpatient attendance rate and rate ratio. Annual group budgets for referral management were obtained.
  
  
  RESULTS
  Referral management was not associated with a reduction in the outpatient attendance rate in any group. There was a statistically significant increase in attendance rate in one group (a RMC), which had an increase of 1.05 attendances per 1000 persons per month (95% confidence interval = 0.46 to 1.64; attendance rate ratio increase of 0.07) after adjustment for autocorrelation. Mean annual budgets ranged from £0.55 to £6.23 per registered patient in 2011/2012. RMCs were more expensive (mean annual budget £5.18 per registered patient) than internal peer-review approaches (mean annual budget £0.97 per registered patient).
  
  
  CONCLUSIONS
  Referral-management schemes did not reduce outpatient attendance rates. RMCs were more expensive than internal peer review.
authors.affiliation: Norwich Medical School, University of East Anglia and Public Health Directorate, Norfolk County Council, Norwich, Norfolk. j.cox@nhs.net
authors.forename: Jonathan Ms
authors.initials: JM
authors.lastname: Cox
authors.forename: Nicholas
authors.initials: N
authors.lastname: Steel
authors.forename: Allan B
authors.initials: AB
authors.lastname: Clark
authors.forename: Bharathy
authors.initials: B
authors.lastname: Kumaravel
authors.forename: Max O
authors.initials: MO
authors.lastname: Bachmann
mesh_terms: D000554:Ambulatory Care Facilities / Q000191:economics / Q000458:organization & administration*; D001071:Appointments and Schedules; D003362:Cost-Benefit Analysis; D017598:Efficiency, Organizational / Q000191:economics*; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D010044:Outpatient Clinics, Hospital / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D010045:Outpatients; D010352:Patient Dropouts / Q000706:statistics & numerical data; D011320:Primary Health Care; D011785:Quality Assurance, Health Care / Q000458:organization & administration; D012017:Referral and Consultation; D012189:Retrospective Studies; D013222:State Medicine / Q000191:economics / Q000458:organization & administration*