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Analysis of referral letters to rheumatology consultation in Tunisia
The Egyptian Rheumatologist xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
The Egyptian Rheumatologist journal homepage: www.elsevier.com/locate/ejr
Original Article
Analysis of referral letters to rheumatology consultation in Tunisia Asma Bachali a,b,⇑, Hana Sahli a,c, Raoudha Tekaya a,d, Ines Mahmoud a,d, Soumaya Hedhili a,d, Leila Abdelmoula a,d a
Faculty of Medicine, University of Tunis El Manar, 1007 Tunis, Tunisia Department of Clinical Laboratory, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia c Department of Internal Medicine, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia d Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia b
a r t i c l e
i n f o
Article history: Received 31 December 2016 Accepted 10 January 2017 Available online xxxx Keywords: Rheumatology Signs and symptoms Referral letter Diagnosis General practitioners
a b s t r a c t Aim of the work: Our objective was to analyze the content and quality of referral letters to rheumatology consultation. Patients and methods: This is a cross-sectional study conducted on the rheumatology consultations in a tertiary hospital over six months (April-October 2014). Patients were interviewed and their rheumatology consultation referral letters analyzed. The relevance of referent reasons, suggested diagnosis and additional tests requested prior to recruitment were studied. Results: We studied 302 referral letters for rheumatology consultation. The average age of patients was 55.34 ± 15 years (13–85). The sex ratio M/F was 0.3. All patients consulted for painful symptoms affecting mainly the lumbar spine (20%) and knees (20%). The current clinical problem was appropriately presented in 43% of the referral letters. Only 6 letters (2%) were illegible, 28 letters did not contain the consultation date (9%). General practitioners represented 59% of referring physicians. The age and patient history were more detailed in the letters written by physician specialists (p = 0.002 and p < 0.001 respectively). The complementary investigations were more requested by private sector physicians (p = 0.04) and physician specialists (p = 0.011). Of the 76 doctors who had proposed a diagnosis, 42 (55%) had proposed a correct one. The relevance of diagnoses showed no significant difference between GPs and specialists. Conclusion: Referral letters deserve more attention in order to improve communication between physicians and rheumatologists. Analysis of the quality of referral letters can be part of initial and continuing medical education. The referral letters have several shortcomings. A model referral letter has been proposed in this study. Ó 2017 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction The referral letter is a device of communication between the referring doctor and the rheumatologist. The referring doctor must ensure that the referral letter has some criteria such as accuracy, clarity and relevance, since it will become a part of the medical record [1]. Otherwise, the referral letter would waste time and can raise risk of errors. Few studies have focused on the analysis of referral letters in rheumatologic consultation [2–6]. This crosssectional study was conducted with the objectives to analyze the different parameters of the referral letter in rheumatologic consultation and to study the adequacy of consultations patterns Peer review under responsibility of Egyptian Society of Rheumatic Diseases. ⇑ Corresponding author at: Mrazgua, 8000 Nabeul, Tunisia. E-mail address: [email protected] (A. Bachali).
described on the referral letter, issued diagnoses and examinations requested in advance by the referring doctor. 2. Patients and methods This cross-sectional study was conducted in the rheumatology clinic of Tunis El Manar University hospital over a 6-month period (April-October 2014). Patients who refused to participate in this study were excluded. All patients had a careful medical history and physical examination, and additional tests if necessary. A complete analysis of referral letter of each patient was carried out: readability, mention of the age, sex and the patient’s medical history, the presence of the doctor’s stamp, the mention of reference pattern or diagnosis issued by the doctor. The prescription of additional examinations was noted. The study conforms to the 1995 Helsinki declaration, was approved by the institutional ethical
http://dx.doi.org/10.1016/j.ejr.2017.01.002 1110-1164/Ó 2017 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Bachali A et al. Analysis of referral letters to rheumatology consultation in Tunisia. The Egyptian Rheumatologist (2017), http://dx.doi.org/10.1016/j.ejr.2017.01.002
2
A. Bachali et al. / The Egyptian Rheumatologist xxx (2017) xxx–xxx
committee and all patients gave their informed consent prior to their inclusion.
Table 2 Distribution of requested diagnostic investigations and reasons for rheumatology consultation.
2.1. Statistical analysis
Variable n (%)
Referrals (n = 302)
The data were collected, tabulated and analyzed by SPSS package version 15 (SPSS corporation, USA). The data were presented as number and frequency and mean ± SD (range). Mann–Whitney tests was used for comparative analysis of 2 quantitative data. Results were considered significant at p value <0.05.
Requested investigation Laboratory test Plain X-ray Bone densitometry Magnetic resonance imaging CT scan Electromyogram Bone scintigraphy No requests
52 140 8 4 2 2 2 144
(17.2) (46.4) (2.6) (1.3) (0.7) (0.7) (0.7) (47.6)
Reason for consultation Low back pain Gonalgia Polyarthralgia Cervicobrachial neuralgia Scapulalgia Cervicalgia Arthritis Heel pain Paresthesia Osteoporosis Others reasons
62 60 60 36 24 20 12 12 8 4 4
(20.5) (19.9) (19.9) (11.9) (7.9) (6.6) (4) (4) (2.6) (1.3) (0.14)
3. Results Five hundred new patients were sent for a rheumatology consultation during the period of this study. Of these, 302 patients (60%) were addressed with a referral letter. All the letters were handwritten. Only 6 referral letters were illegible (2%). The date was specified in 274 referral letters (91%). Patient age was not specified in 48 referral letters (16%). The average age of the patients was 55.34 ± 15 years [13–85] and the sex ratio M/F = 0.3. Patient history were specified in 140 referral letters (47%) and were more noted in the letters from assistants working in university hospital (UHA) (p = 0.016). A stamp was affixed to 288 referral letters (95%). Twenty-eight referring physicians (9.3%) were from private sector and the rest were from the public sector (Table 1). Physicians from university hospitals have specified more often patient’s history (p < 0.001). One hundred seventy-eight letters (58.9%) were from general practitioners (GPs). Distribution of spe-
Table 1 Distribution of referral letters according to the referring establishment, referring physician specialty and their professional ranking. Variable n (%)
Referrals N = 302
Establishment Public sector University hospital Regional hospital District hospital Community health center Hemodialysis center Private sector
108 16 56 92 2 28
(35.8) (5.3) (18.5) (30.5) (6.6) (9.3)
Specialty of referring physician Orthopedic surgery Gastro enterology Emergency medicine Pneumology Cardiology Rheumatology Neurology Endocrinology Internal Medicine General surgery Thoracic surgery Nephrology Otorhinolaryngology Pediatric Ophthalmology General practitioner (GP)
28 28 12 10 10 8 8 4 4 2 2 2 2 2 2 178
(9.3) (9.3) (4) (3.3) (3.3) (2.6) (2.6) (1.3) (1.3) (0.7) (0.7) (0.7) (0.7) (0.7) (0.7) (58.9)
Rank Professor University hospitals assistants Chief physician Senior physician Hospital physician Public health physician Resident Specialist physician Unspecified rank
6 36 18 20 16 72 2 28 104
(2) (11.9) (6) (6.6) (5.3) (23.8) (0.7) (9.3) (34.4)
MRI: Magnetic resonance imaging, CT: computerized tomography.
cialties and professional rank of the referring physicians, being specified in 170 referral letters (56%) are shown in Table 1. The age and patient medical history were more detailed in referral letters written by specialized physicians (p = 0.002 and p < 0.001 respectively). 158 patients (52%) had a prescription of tests to be done before seeing the rheumatologist and plain X-ray was required in 46.6%. Other more specialized tests were requested in 18 patients (Table 2). Most of the tests requested by the referring physicians were incomplete (58%). Specialists asked for more Xray than GPs (26% vs 4%) (p = 0.011). Regarding the relevance of requested investigations, they were comparable between GPs and specialists (60% vs 55%). Laboratory tests prescribed by specialists tended to be more than from GPs (39% vs 27%). The prescription of laboratory tests was most noted in university and district hospitals (p = 0.013). The comparison between letters from the private and public sectors showed a significant difference in specialized complementary tests that were most frequently requested by private physicians (p = 0.04). Pain was the main reason for consultation. Low back pain and knee pain were the most frequent reasons of consultation (Table 2). The reason of consultation was not specified in 2 referral letters (0.7%). The reasons of consultation, specified in 128 referral letters (43%) were consistent with the real reason of consultation reported by patients at the rheumatology consultation, while 104 letters (35%) had issued false patterns and 68 letters (22%) had issued incomplete patterns. The 6 illegible letters were considered as false patterns. 76 referring physicians (25%) had issued a diagnosis in their letter out of which 42 (55%) had issued a correct diagnosis. The percentage of referral letters with suggested diagnosis and relevance of diagnoses were similar between GPs and specialists (22% vs 31%). There was no impact of the physician specialty concerning the relevance of the suggested diagnosis. A model for referral letters for rheumatology consultation is proposed (Appendix 1). 4. Discussion This study showed that the referral letters have several inefficiencies which depend mainly on the referring physician’s profile.
Please cite this article in press as: Bachali A et al. Analysis of referral letters to rheumatology consultation in Tunisia. The Egyptian Rheumatologist (2017), http://dx.doi.org/10.1016/j.ejr.2017.01.002
3
A. Bachali et al. / The Egyptian Rheumatologist xxx (2017) xxx–xxx
The request of additional tests was more prescribed by a specialist or a private sector physician. The date is usually specified in referral letters (88–100%) [2]. Date of consultation allows rheumatologist to assess the time of patient’s management and can even guide the diagnostic and therapeutic approach. Patient’s age is a major information that can save time and build trust between the patient and rheumatologist. Patient’s age was specified in 81.25% of letters studied by Newton et al. [2] and 94.6% of letters studied by Jenkins et al. [3]. Most referring physicians in our study did not miss to specify the age of patient in their referral letters (84%). Moreover, the average age of patients was comparable to the published series [4–6]. The patient’s medical history was rarely specified: 47% in our series and 31% in another study in the oncology department [7]. It is recommended to include the medical history details especially those of relevance to rheumatologic diseases. The typical example is cardiovascular disease with rheumatoid arthritis [8–10], with systemic lupus erythematosus [11] or metabolic syndrome comorbidity with other rheumatic diseases [12,13]. In our study, there was little collaboration between the private sector and the public sector. Indeed, in developing countries, patients who consult in the private sector prefer to stay there. The reasons given by the private sector followers were: improved access, more flexible hours, a shorter wait and greater privacy [14]. In addition, according to a South African study by Lachman et al. [15], the private sector doctors are sending to public hospitals two groups of patients: those who do not have the financial means and those whose pathology cannot be properly supported in private sector. Despite the presence of health establishment in the first line, the patients from university hospitals represented 40% of consultants during the period of our study. Fifty-nine percent of consultants were addressed by GPs. This could be explained by the fact that the GPs is «normally the point of first medical contact within the health care system» and «makes efficient use of health care resources through coordinating care, by managing the interface with other specialities» according to the definition of general practice outlined by WONCA Europe and validated by the European office of the World Health Organization [16]. This role was reinforced by the ‘‘gatekeeping” term, applied in several countries, that describes the process by which a patient is obligatory to consult a primary care professional (usually a GP) before seeing a specialist [17,18]. This model both widespread and controversial did not influence the results of our study in public hospital [18–20]. Few letters contains a diagnostic hypothesis. This is considered a low rate compared to the results of other studies (between 64% and 95%) [7,21]. All patients consulted for painful symptoms especially low back pain and knee pain. It was the same for other studies confirming that the pain of lumbar spine, knee and the cervical spine are the most common musculoskeletal problems [22–24]. Other reasons of consultations were symptoms related to connective tissue disease, arthritis, osteoporosis and neurological disorders [24]. Several studies have shown that 80% of Americans have suffered of back pain at some moment in their lives, and that this pain is the fifth reason for consultation among all specialties [25–27]. In conclusion, we can note that the referral letters deserve more attention in order to improve communication between physicians and rheumatologists. Analysis of the quality of referral letters can be part of initial and continuing medical education. We propose a model type for referral letters for rheumatology consultation.
Conflicts of interest None declared.
Appendix 1. Model of referral letter for rheumatology consultation
Faculty of Medicine, University of Tunis El Manar, Tunisia Referral Letter Date :………………… Name, speciality and grade of referring professional :………………………………………………… Institution or clinic of referring professional :……………………………………………………………..
Dear Dr/Sir/Madam, Patient’s name :…………………………………………………………………….Age :………………………… Reason for referral : ……………………………………………………………………………………………………………………………… Medical history :……………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… Symptoms and signs: ……………………………………………………………………………………………………………………………… Results of complementary exams : ……………………………………………………………………………………………………………………………… Probable diagnosis : ……………………………………………………………………………………………………………………………… Current treatment : ……………………………………………………………………………………………………………………………… Yours Sincerely, Signature and stamp of referring doctor
References [1] Najim H, Singh P. Critical analysis of psychiatrists’ opinion in GP referral letter. Psychiatr Danub 2015;27(Suppl. 1):S429–31. [2] Newton J, Hutchinson A, Hayes V, McColl E, Mackee I, Holland C. Do clinicians tell each other enough? An analysis of referral communications in two specialties. Fam Pract 1994;11:15–20. [3] Jenkins R. Quality of general practitioner referrals to outpatient departments: assessment by specialists and a general practitioner. Br J Gen Pract 1993;43:111–3. [4] Gran J, Nordvåg B. Referrals from general practice to an outpatient rheumatology clinic: disease spectrum and analysis of referral letters. Clin Rheumatol 2000;19:450–4. [5] Gamez-Nava J, Gonzalez-Lopez L, Davis P, Suarez-Almazor ME. Referral and diagnosis of common rheumatic diseases by primary care physicians. Rheumatology 1998;37:1215–9. [6] Cimmino M, Ugolini D, Cauli A, Mannoni A, Macchioni P, Ciocci A, et al. Frequency of musculoskeletal conditions among patients referred to Italian tertiary rheumatological centers. Clin Exp Rheumatol 2006;24:670–6. [7] Graham P. Improving communication with specialists. The case of an oncology clinic. Med J Aust 1994;160:625–7. [8] Mutru O, Laakso M, Isomaki H, Koota K. Cardiovascular mortality in patients with rheumatoid arthritis. Cardiology 1989;76:71–7. [9] Vandenbroucke JP, Hazevoet HM, Cats A. Survival and cause of death in rheumatoid arthritis: a 25-year prospective followup. J Rheumatol 1984;11:158–61. [10] Bacon PA, Townend JN. Nails in the coffin: increasing evidence for the role of rheumatic disease in the cardiovascular mortality of rheumatoid arthritis. Arthritis Rheum 2001;44:2707–10. [11] Khairy N, Ezzat Y, Naeem N, Taha R, Wesam R. Atherosclerosis biomarkers in female systemic lupus erythematosus patients with and without cardiovascular diseases. Egypt Rheumatol 2016. doi: http://dx.doi.org/ 10.1016/j.ejr.2016.03.003. in press. [12] Ghazaly AAH, El-Moez KMA, El-Shorbagy MS, El-Nahrery EM. Angiopoietin-2 as a biomarker for metabolic syndrome and disease activity in rheumatoid arthritis patients. Egypt Rheumatol 2016;38:9–13. [13] El-Gazzar I, El-Dakrony A, Sayed S, El-Fishawy H, Fathi H, Shaaban M, et al. Clinical significance of metabolic syndrome and carotid intima-media
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A. Bachali et al. / The Egyptian Rheumatologist xxx (2017) xxx–xxx thickness in Behҫet’s disease patients: Relation to disease activity. Egypt Rheumatol 2016. doi: http://dx.doi.org/10.1016/j.ejr.2016.11.001. in press. Zwi AB, Brugha R, Smith E. Private health care in developing countries: if it is to work, it must start from what users need. BMJ 2001;323:463–4. Lachman P, Stander I. The referral letter–a problem of communication. S Afr Med J 1991;79:98–100. Allen J, Gay B, Crebolder H, Heyrman J, Svab I, Ram P. The European definitions of the key features of the discipline of general practice: the role of the GP and core competencies. Br J Gen Pract 2002;52:526–7. Loudon I. The principle of referral: the gatekeeping role of the GP. Br J Gen Pract 2008;58:128–30. Willems DL. Balancing rationalities: gatekeeping in health care. J Med Ethics 2001;27:25–9. Halm EA, Causino N, Blumenthal D. Is gatekeeping better than traditional care?: A survey of physicians’ attitudes. JAMA 1997;278:1677–81. Ferris TG, Chang Y, Blumenthal D, Pearson SD. Leaving gatekeeping behind— effects of opening access to specialists for adults in a health maintenance organization. N Engl J Med 2001;345:1312–7. Sverdrup B, Allebeck P, Allander E. Tentative diagnoses among referrals versus diagnoses established at the Department of Rheumatology. Scand J Rheumatol 1983;12:377–8.
[22] Walker D, Griffiths I, Leon C. Referrals to a rheumatology unit: an evaluation of the views of patients, general practitioners, and consultants. Ann Rheum Dis 1991;50:926–9. [23] Chaiamnuay P, Darmawan J, Muirden K, Assawatanabodee P. Epidemiology of rheumatic disease in rural Thailand: a WHO-ILAR COPCORD study. Community Oriented programme for the control of rheumatic disease. J Rheumatol 1998;25:1382–7. [24] Harrington JT, Walsh MB. Pre-appointment management of new patient referrals in rheumatology: a key strategy for improving health care delivery. Arthritis Rheum 2001;45:295–300. [25] Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769–81. [26] Chou R, Qaseem A, Snow V, Casey D, Cross Jr JT, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478–91. [27] Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a US national survey. Spine 1995;20:11–9.
Please cite this article in press as: Bachali A et al. Analysis of referral letters to rheumatology consultation in Tunisia. The Egyptian Rheumatologist (2017), http://dx.doi.org/10.1016/j.ejr.2017.01.002
Contents lists available at ScienceDirect
The Egyptian Rheumatologist journal homepage: www.elsevier.com/locate/ejr
Original Article
Analysis of referral letters to rheumatology consultation in Tunisia Asma Bachali a,b,⇑, Hana Sahli a,c, Raoudha Tekaya a,d, Ines Mahmoud a,d, Soumaya Hedhili a,d, Leila Abdelmoula a,d a
Faculty of Medicine, University of Tunis El Manar, 1007 Tunis, Tunisia Department of Clinical Laboratory, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia c Department of Internal Medicine, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia d Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia b
a r t i c l e
i n f o
Article history: Received 31 December 2016 Accepted 10 January 2017 Available online xxxx Keywords: Rheumatology Signs and symptoms Referral letter Diagnosis General practitioners
a b s t r a c t Aim of the work: Our objective was to analyze the content and quality of referral letters to rheumatology consultation. Patients and methods: This is a cross-sectional study conducted on the rheumatology consultations in a tertiary hospital over six months (April-October 2014). Patients were interviewed and their rheumatology consultation referral letters analyzed. The relevance of referent reasons, suggested diagnosis and additional tests requested prior to recruitment were studied. Results: We studied 302 referral letters for rheumatology consultation. The average age of patients was 55.34 ± 15 years (13–85). The sex ratio M/F was 0.3. All patients consulted for painful symptoms affecting mainly the lumbar spine (20%) and knees (20%). The current clinical problem was appropriately presented in 43% of the referral letters. Only 6 letters (2%) were illegible, 28 letters did not contain the consultation date (9%). General practitioners represented 59% of referring physicians. The age and patient history were more detailed in the letters written by physician specialists (p = 0.002 and p < 0.001 respectively). The complementary investigations were more requested by private sector physicians (p = 0.04) and physician specialists (p = 0.011). Of the 76 doctors who had proposed a diagnosis, 42 (55%) had proposed a correct one. The relevance of diagnoses showed no significant difference between GPs and specialists. Conclusion: Referral letters deserve more attention in order to improve communication between physicians and rheumatologists. Analysis of the quality of referral letters can be part of initial and continuing medical education. The referral letters have several shortcomings. A model referral letter has been proposed in this study. Ó 2017 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction The referral letter is a device of communication between the referring doctor and the rheumatologist. The referring doctor must ensure that the referral letter has some criteria such as accuracy, clarity and relevance, since it will become a part of the medical record [1]. Otherwise, the referral letter would waste time and can raise risk of errors. Few studies have focused on the analysis of referral letters in rheumatologic consultation [2–6]. This crosssectional study was conducted with the objectives to analyze the different parameters of the referral letter in rheumatologic consultation and to study the adequacy of consultations patterns Peer review under responsibility of Egyptian Society of Rheumatic Diseases. ⇑ Corresponding author at: Mrazgua, 8000 Nabeul, Tunisia. E-mail address: [email protected] (A. Bachali).
described on the referral letter, issued diagnoses and examinations requested in advance by the referring doctor. 2. Patients and methods This cross-sectional study was conducted in the rheumatology clinic of Tunis El Manar University hospital over a 6-month period (April-October 2014). Patients who refused to participate in this study were excluded. All patients had a careful medical history and physical examination, and additional tests if necessary. A complete analysis of referral letter of each patient was carried out: readability, mention of the age, sex and the patient’s medical history, the presence of the doctor’s stamp, the mention of reference pattern or diagnosis issued by the doctor. The prescription of additional examinations was noted. The study conforms to the 1995 Helsinki declaration, was approved by the institutional ethical
http://dx.doi.org/10.1016/j.ejr.2017.01.002 1110-1164/Ó 2017 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Bachali A et al. Analysis of referral letters to rheumatology consultation in Tunisia. The Egyptian Rheumatologist (2017), http://dx.doi.org/10.1016/j.ejr.2017.01.002
2
A. Bachali et al. / The Egyptian Rheumatologist xxx (2017) xxx–xxx
committee and all patients gave their informed consent prior to their inclusion.
Table 2 Distribution of requested diagnostic investigations and reasons for rheumatology consultation.
2.1. Statistical analysis
Variable n (%)
Referrals (n = 302)
The data were collected, tabulated and analyzed by SPSS package version 15 (SPSS corporation, USA). The data were presented as number and frequency and mean ± SD (range). Mann–Whitney tests was used for comparative analysis of 2 quantitative data. Results were considered significant at p value <0.05.
Requested investigation Laboratory test Plain X-ray Bone densitometry Magnetic resonance imaging CT scan Electromyogram Bone scintigraphy No requests
52 140 8 4 2 2 2 144
(17.2) (46.4) (2.6) (1.3) (0.7) (0.7) (0.7) (47.6)
Reason for consultation Low back pain Gonalgia Polyarthralgia Cervicobrachial neuralgia Scapulalgia Cervicalgia Arthritis Heel pain Paresthesia Osteoporosis Others reasons
62 60 60 36 24 20 12 12 8 4 4
(20.5) (19.9) (19.9) (11.9) (7.9) (6.6) (4) (4) (2.6) (1.3) (0.14)
3. Results Five hundred new patients were sent for a rheumatology consultation during the period of this study. Of these, 302 patients (60%) were addressed with a referral letter. All the letters were handwritten. Only 6 referral letters were illegible (2%). The date was specified in 274 referral letters (91%). Patient age was not specified in 48 referral letters (16%). The average age of the patients was 55.34 ± 15 years [13–85] and the sex ratio M/F = 0.3. Patient history were specified in 140 referral letters (47%) and were more noted in the letters from assistants working in university hospital (UHA) (p = 0.016). A stamp was affixed to 288 referral letters (95%). Twenty-eight referring physicians (9.3%) were from private sector and the rest were from the public sector (Table 1). Physicians from university hospitals have specified more often patient’s history (p < 0.001). One hundred seventy-eight letters (58.9%) were from general practitioners (GPs). Distribution of spe-
Table 1 Distribution of referral letters according to the referring establishment, referring physician specialty and their professional ranking. Variable n (%)
Referrals N = 302
Establishment Public sector University hospital Regional hospital District hospital Community health center Hemodialysis center Private sector
108 16 56 92 2 28
(35.8) (5.3) (18.5) (30.5) (6.6) (9.3)
Specialty of referring physician Orthopedic surgery Gastro enterology Emergency medicine Pneumology Cardiology Rheumatology Neurology Endocrinology Internal Medicine General surgery Thoracic surgery Nephrology Otorhinolaryngology Pediatric Ophthalmology General practitioner (GP)
28 28 12 10 10 8 8 4 4 2 2 2 2 2 2 178
(9.3) (9.3) (4) (3.3) (3.3) (2.6) (2.6) (1.3) (1.3) (0.7) (0.7) (0.7) (0.7) (0.7) (0.7) (58.9)
Rank Professor University hospitals assistants Chief physician Senior physician Hospital physician Public health physician Resident Specialist physician Unspecified rank
6 36 18 20 16 72 2 28 104
(2) (11.9) (6) (6.6) (5.3) (23.8) (0.7) (9.3) (34.4)
MRI: Magnetic resonance imaging, CT: computerized tomography.
cialties and professional rank of the referring physicians, being specified in 170 referral letters (56%) are shown in Table 1. The age and patient medical history were more detailed in referral letters written by specialized physicians (p = 0.002 and p < 0.001 respectively). 158 patients (52%) had a prescription of tests to be done before seeing the rheumatologist and plain X-ray was required in 46.6%. Other more specialized tests were requested in 18 patients (Table 2). Most of the tests requested by the referring physicians were incomplete (58%). Specialists asked for more Xray than GPs (26% vs 4%) (p = 0.011). Regarding the relevance of requested investigations, they were comparable between GPs and specialists (60% vs 55%). Laboratory tests prescribed by specialists tended to be more than from GPs (39% vs 27%). The prescription of laboratory tests was most noted in university and district hospitals (p = 0.013). The comparison between letters from the private and public sectors showed a significant difference in specialized complementary tests that were most frequently requested by private physicians (p = 0.04). Pain was the main reason for consultation. Low back pain and knee pain were the most frequent reasons of consultation (Table 2). The reason of consultation was not specified in 2 referral letters (0.7%). The reasons of consultation, specified in 128 referral letters (43%) were consistent with the real reason of consultation reported by patients at the rheumatology consultation, while 104 letters (35%) had issued false patterns and 68 letters (22%) had issued incomplete patterns. The 6 illegible letters were considered as false patterns. 76 referring physicians (25%) had issued a diagnosis in their letter out of which 42 (55%) had issued a correct diagnosis. The percentage of referral letters with suggested diagnosis and relevance of diagnoses were similar between GPs and specialists (22% vs 31%). There was no impact of the physician specialty concerning the relevance of the suggested diagnosis. A model for referral letters for rheumatology consultation is proposed (Appendix 1). 4. Discussion This study showed that the referral letters have several inefficiencies which depend mainly on the referring physician’s profile.
Please cite this article in press as: Bachali A et al. Analysis of referral letters to rheumatology consultation in Tunisia. The Egyptian Rheumatologist (2017), http://dx.doi.org/10.1016/j.ejr.2017.01.002
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A. Bachali et al. / The Egyptian Rheumatologist xxx (2017) xxx–xxx
The request of additional tests was more prescribed by a specialist or a private sector physician. The date is usually specified in referral letters (88–100%) [2]. Date of consultation allows rheumatologist to assess the time of patient’s management and can even guide the diagnostic and therapeutic approach. Patient’s age is a major information that can save time and build trust between the patient and rheumatologist. Patient’s age was specified in 81.25% of letters studied by Newton et al. [2] and 94.6% of letters studied by Jenkins et al. [3]. Most referring physicians in our study did not miss to specify the age of patient in their referral letters (84%). Moreover, the average age of patients was comparable to the published series [4–6]. The patient’s medical history was rarely specified: 47% in our series and 31% in another study in the oncology department [7]. It is recommended to include the medical history details especially those of relevance to rheumatologic diseases. The typical example is cardiovascular disease with rheumatoid arthritis [8–10], with systemic lupus erythematosus [11] or metabolic syndrome comorbidity with other rheumatic diseases [12,13]. In our study, there was little collaboration between the private sector and the public sector. Indeed, in developing countries, patients who consult in the private sector prefer to stay there. The reasons given by the private sector followers were: improved access, more flexible hours, a shorter wait and greater privacy [14]. In addition, according to a South African study by Lachman et al. [15], the private sector doctors are sending to public hospitals two groups of patients: those who do not have the financial means and those whose pathology cannot be properly supported in private sector. Despite the presence of health establishment in the first line, the patients from university hospitals represented 40% of consultants during the period of our study. Fifty-nine percent of consultants were addressed by GPs. This could be explained by the fact that the GPs is «normally the point of first medical contact within the health care system» and «makes efficient use of health care resources through coordinating care, by managing the interface with other specialities» according to the definition of general practice outlined by WONCA Europe and validated by the European office of the World Health Organization [16]. This role was reinforced by the ‘‘gatekeeping” term, applied in several countries, that describes the process by which a patient is obligatory to consult a primary care professional (usually a GP) before seeing a specialist [17,18]. This model both widespread and controversial did not influence the results of our study in public hospital [18–20]. Few letters contains a diagnostic hypothesis. This is considered a low rate compared to the results of other studies (between 64% and 95%) [7,21]. All patients consulted for painful symptoms especially low back pain and knee pain. It was the same for other studies confirming that the pain of lumbar spine, knee and the cervical spine are the most common musculoskeletal problems [22–24]. Other reasons of consultations were symptoms related to connective tissue disease, arthritis, osteoporosis and neurological disorders [24]. Several studies have shown that 80% of Americans have suffered of back pain at some moment in their lives, and that this pain is the fifth reason for consultation among all specialties [25–27]. In conclusion, we can note that the referral letters deserve more attention in order to improve communication between physicians and rheumatologists. Analysis of the quality of referral letters can be part of initial and continuing medical education. We propose a model type for referral letters for rheumatology consultation.
Conflicts of interest None declared.
Appendix 1. Model of referral letter for rheumatology consultation
Faculty of Medicine, University of Tunis El Manar, Tunisia Referral Letter Date :………………… Name, speciality and grade of referring professional :………………………………………………… Institution or clinic of referring professional :……………………………………………………………..
Dear Dr/Sir/Madam, Patient’s name :…………………………………………………………………….Age :………………………… Reason for referral : ……………………………………………………………………………………………………………………………… Medical history :……………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… Symptoms and signs: ……………………………………………………………………………………………………………………………… Results of complementary exams : ……………………………………………………………………………………………………………………………… Probable diagnosis : ……………………………………………………………………………………………………………………………… Current treatment : ……………………………………………………………………………………………………………………………… Yours Sincerely, Signature and stamp of referring doctor
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