Skip to main content
Article thumbnail
Location of Repository

Can guidelines improve referral to elective surgical specialties for adults? A systematic review

By Aileen Clarke, N. Blundell, I. Forde, N. Musila, D. Spitzer, S. Naqvi and John Browne


Aim To assess effectiveness of guidelines for referral for\ud elective surgical assessment.\ud Method Systematic review with descriptive synthesis.\ud Data sources Medline, EMBASE, CINAHL and Cochrane\ud database up to 2008. Hand searches of journals and\ud websites.\ud Selection of studies Studies evaluated guidelines for\ud referral from primary to secondary care, for elective\ud surgical assessment for adults.\ud Outcome measures Appropriateness of referral (usually\ud measured as guideline compliance) including clinical\ud appropriateness, appropriateness of destination and of\ud pre-referral management (eg, diagnostic investigations),\ud general practitioner knowledge of referral\ud appropriateness, referral rates, health outcomes and\ud costs.\ud Results 24 eligible studies (5 randomised control trials,\ud 6 cohort, 13 case series) included guidelines from UK,\ud Europe, Canada and the USA for referral for\ud musculoskeletal, urological, ENT, gynaecology, general\ud surgical and ophthalmological conditions. Interventions\ud varied from complex (“one-stop shops”) to simple\ud guidelines. Four randomized control trials reported\ud increases in appropriateness of pre-referral care\ud (diagnostic investigations and treatment). No evidence\ud was found for effects on practitioner knowledge. Mixed\ud evidence was reported on rates of referral and costs\ud (rates and costs increased, decreased or stayed the\ud same). Two studies reported on health outcomes finding\ud no change.\ud Conclusions Guidelines for elective surgical referral can\ud improve appropriateness of care by improving prereferral\ud investigation and treatment, but there is no\ud strong evidence in favour of other beneficial effects

Topics: RD
Publisher: BMJ Group
Year: 2010
OAI identifier:

Suggested articles


  1. (2001). [Analysis of a programme of direct referral between primary and specialist care in potential surgery patients]. Aten Primaria
  2. (1998). [Shared care in BPH. First national experience]. Actas Urol Esp.
  3. (2006). A decision aid for GPs for the treatment of elderly male patients with lower urinary tract symptoms (LUTS) Fam Pract. doi
  4. (2003). A systematic review of the effect of primary carebased service innovations on quality and patterns of referral to specialist secondary care.
  5. Adherence of Irish general practitioners to European guidelinesforacutelowbackpain:aprospectivepilotstudy.
  6. (2007). An integrated care pathway for menorrhagia across the primaryesecondary interface: patients’ experience, clinical outcomes, and service utilisation. Qual Saf Health Care doi
  7. (2001). Can evidence change the rate of back surgery? A randomized trial of community-based education. Eff Clin Pract
  8. (2002). Can guidelines impact the ordering of magnetic resonance imaging studies by primary care providers for low back pain?
  9. (2001). Changing provider behavior: an overview of systematic reviews of interventions. Med Care doi
  10. (1999). Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. doi
  11. (1990). Clinical practice guidelines: directions for a new program
  12. (2003). Cluster randomized trial of a guidelinebased open access urological investigation service. Fam Pract
  13. (2003). Compliance with clinical practice guidelines in family physicians managing worker’s compensation board patients with acute lower back pain. doi
  14. (1997). Diagnosis and treatment of benign prostatic hyperplasia. Practice patterns of primary care physicians. doi
  15. (1998). Direct listing’ for tonsillectomy by general practitioners. Clin Otolaryngol Allied Sci doi
  16. (1993). Do clinical guidelines improve general practice management and referral of infertile couples? BMJ doi
  17. (2009). Effects of a shared protocol between urologists and general practitioners on referral patterns and initial diagnostic doi
  18. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. doi
  19. (2001). for the Scottish Intercollegiate Guidelines Network Grading Review Group. A new system for grading recommendations in evidence based guidelines. BMJ doi
  20. (1991). General practitioner outpatient referrals: do good doctors refer more patients to hospital? BMJ doi
  21. Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. doi
  22. (2005). Improving communication between levels of health care: direct referral of patients to a one-stop service for major outpatient surgery. Aten Primaria
  23. (2005). Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev doi
  24. (1995). Management guidelines for improvement of otolaryngology referrals from primary care physicians. Otolaryngol Head Neck Surg doi
  25. (2001). NHS centre for reviews and dissemination. Undertaking systematic reviews of research on effectiveness: CRD’s guidance for those carrying out or commissioning reviews, CRD report number 4 2nd edn.
  26. (2001). of Clinical Excellence. (NICE) Referral advice: a guide to appropriate referral from general to specialist services.
  27. (2001). Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary careesecondary care interface. BMJ doi
  28. (1999). Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia evaluation study. BMJ doi
  29. (2005). Referrals for cataract and action on cataracts, evidence-based guidelines. Br J Gen Pract.
  30. Referrals to hospital based rheumatology and orthopaedic services: seeking direction. doi
  31. (1996). Should the gap be filled between guidelines and actual practice for management of low back pain in primary care? The Quebec experience. Spine doi
  32. (2010). Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. doi
  33. (1997). The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. CMAJ
  34. (1994). The impact of managed care on the diagnosis and treatment of low back pain: a preliminary report. doi
  35. (1997). The south Tyneside FASTRAK service: evaluation of a new model for day surgery. Ambul Surg doi
  36. (1993). Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates? BMJ doi
  37. (1987). Variation in general practitioners’ referral rates to consultants.
  38. (2000). Variation in GP referral rates: what can we learn from the literature? Fam Pract doi

To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.