Triage of referrals to outpatient hepatology services: an ineffective tool to prioritise patients?
Leigh Horsfall A , Richard Skoien B , Cathy Moss A , Ian Scott C D , Graeme A. Macdonald A D and Elizabeth E. Powell A D EA Department of Gastroenterology and Hepatology, Level 4F, Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD 4102, Australia.
B The Centre for Liver Disease Research, The University of Queensland and Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD 4102, Australia.
C Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD 4102, Australia.
D School of Medicine, The University of Queensland, Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD 4102, Australia.
E Corresponding author. Email: Elizabeth_Powell@health.qld.gov.au
Australian Health Review 36(4) 443-447 https://doi.org/10.1071/AH11111
Submitted: 11 November 2011 Accepted: 26 April 2012 Published: 15 October 2012
Abstract
Background. Appropriate and uniform prioritisation (‘triaging’) of outpatient referrals is critical to good patient outcomes, equity of access to services and efficient use of resources.
Objective. To determine whether there is uniformity in the allocation of triage categories for hepatology outpatient referrals at public hospitals in Queensland.
Methods. A series of 10 recent hepatology referrals were de-identified for both patient and referring clinician details and sent to nine gastroenterology or hepatology centres throughout Queensland. Consultant gastroenterologists and hepatologists (n = 25) were asked to triage the referrals using the process in place in their centre. Responses were de-identified and analysed. Each case was reviewed and allocated an ‘agreed triage category’ based upon the majority view of respondents.
Results. Nineteen responses were received. There was substantial variation amongst consultants in the allocation of triage categories. Although almost two-thirds of respondents agreed with the majority view in 60–80% of cases, none agreed with the majority for every case and some agreed in as few as 50% cases. Disagreement with the majority view of an appropriate triage category was not associated with geography or specialist experience.
Conclusions. Variability in triage categorisation suggests that similar cases may be allocated different priorities by those responsible for determining the urgency of outpatient review. This has implications for equity of access to treatment. The development of triage guidelines and formal training in their implementation, along with periodic audits of triage practices in different centres, may reduce variability.
What is known about the topic? Outpatient clinic appointments are allocated within categories according to ‘agreed’ clinical urgency. The process of triaging referrals seeks to prioritise referrals based on the severity of patients’ conditions and the potential for improving outcomes. At present there are no statewide guidelines or training for the triaging process in hepatology and no recommendations for who should take responsibility for prioritising referrals.
What does the paper add? In Queensland, gastroenterologists (including hepatologists) triage hepatology cases differently and most likely interpret and weight clinical information provided in the referral differently. Disagreement with the majority view of an appropriate triage category is not associated with geography or specialist experience.
What are the implications for practitioners? Variability in triage categorisation suggests that similar cases may be allocated different priorities by those responsible for determining the urgency of outpatient review. This has implications for equity of access to treatment. The development of triage guidelines and formal training in their implementation, along with periodic audits of triage practices in different centres, may reduce variability.
Additional keywords: audit, categories, guidelines, resource allocation, service delivery.
References
[1] Horsfall L, Macdonald G, Scott I, Skoien R, Khatun M, Moss C, Seligman C, Kardash C, Poxon V, Powell EE. The use of standardised assessment forms in referrals to hepatology outpatient services: implications for accurate triaging of patients with hepatitis C. Aust Health Rev [submitted]. 2011.[2] George J, Robotin M. Overview: hepatocellular carcinoma – the future starts now. Cancer Forum 2009; 33
[3] Queensland Health. Outpatient Services Implementation Standard. (Standard QH-IMP-300-1:2010.2010. Available at: http://www.health.qld.gov.au/qhpolicy/docs/imp/qh-imp-300-1.pdf.
[4] Graydon SL, Thompson AE. Triage of referrals to an outpatient rheumatology clinic: analysis of referral information and triage. J Rheumatol 2008; 35 1378–83.
[5] Pothier DD, Repanos C. Referral letters: are we prioritizing consistently? J Laryngol Otol 2005; 119 377–80.
| Referral letters: are we prioritizing consistently?Crossref | GoogleScholarGoogle Scholar |
[6] Patel NN, D’Souza J, Rocker M, Townsend E, Morris-Stiff G, Manimaran M, Magee TR, Galland RB, et al Prioritisation of vascular outpatient appointments cannot be based on referral letters alone. Surgeon 2008; 6 140–3.
| Prioritisation of vascular outpatient appointments cannot be based on referral letters alone.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1cvht12hsg%3D%3D&md5=1e3ffc7f3e5b08d8757188ee875c0674CAS |
[7] Webb JB, Khanna A. Can we rely on a general practitioner’s referral letter to a skin lesion clinic to prioritize appointments and does it make a difference to the patient’s prognosis? Ann R Coll Surg Engl 2006; 88 40–5.
| Can we rely on a general practitioner’s referral letter to a skin lesion clinic to prioritize appointments and does it make a difference to the patient’s prognosis?Crossref | GoogleScholarGoogle Scholar |
[8] Mariotti G, Meggio A, de Pretis G, Gentilini M. Improving the appropriateness of referrals and waiting times for endoscopic procedures. J Health Serv Res Policy 2008; 13 146–51.
| Improving the appropriateness of referrals and waiting times for endoscopic procedures.Crossref | GoogleScholarGoogle Scholar |
[9] Paterson WG, Depew WT, Paré P, Petrunia D, Switzer C, Veldhuyzen van Zanten SJ, Daniels S, Canadian Association of Gastroenterology Wait Time Consensus Group Canadian consensus on medically acceptable wait times for digestive health care. Can J Gastroenterol 2006; 20 411–23.
