Friday, November 30, 2007

Total Recall

At last week's team meeting, we discovered a weakness in how we measure our internal demand.

In the same way that we measure new referrals from family physicians (external demand), we've also been tracking the number of recall appointments requested by our urologists (internal demand). These recall appointments are generated when we want to follow a patient with a chronic or ongoing condition, such as cancer. We receive an average of 150 new referrals, and request about 44 recalls each week.

We can reduce recalls by returning follow-up to the patient's referring physician. This is the true role of a "consultant," that is, provide the service that requires specialty care and then, with appropriate instructions, return care to the primary physician.

Even though all the urologists have agreed that we should try to "repatriate" patients to their referring physicians (where appropriate), we haven't seen a drop in the total number of recall requests. Our project team interpreted this as inadequate implementation of this change by the doctors. However, we now think the lack of change may be an artifact of our data collection.

Our transcriptionists have been tracking the number of recall visits by noting when a recall is requested in the urologist’s letter to the referring physician.  Using this method, we know whether or not a recall is requested, but we don’t know what the recall interval is. Perhaps the doctors have been extending the recall interval instead of completely returning patients to follow-up by their family physician. Changing a recall practice from every 3 months to every 6 months cuts the internal demand by half, yet would still be measured (in our current system) as one discrete recall.

We’ll start recording the recall interval (3, 6, or 12 months) rather than just whether or not a recall is requested. The new data may show us variations in recall practice between urologists. That won’t tell us who’s using the correct practice (very few recall protocols are evidence-based), but it will give us a starting point to discuss the differences in practice. After any future interventions/encouragement aimed at reducing absolute numbers of recalls, and/or extending recall intervals, we’ll be able to measure change in behaviour.

Microhematuria referral guidelines

Someone is reading the letters we send out! 

After we faxed out the guidelines for microhematuria referrals, we received a question from a family physician about how to request a urine cytology. It hadn’t occurred to me that (of course!) urine cytology would be a rare test for a family doctor to order and they may not be familiar with the process. I had been in the habit of adding the test onto a regular lab requisition, but just to be sure, I checked with the lab. They OK’d that, so I updated the guidelines with that information.

Also, I recently received a new microhematuria referral in which the family doctor completed the checklist and faxed it back with the consult.

Thank you, referring colleagues!  (The guidelines are on our practice website.)

I looked back at the 4 weeks prior to having sent out the microhematuria guidelines to see how often certain information (i.e. the information we’re now requesting) had accompanied referral letters. Here’s the raw data. If the referral included the information, or indicated that the test had been ordered, there’s an “x” in that column.




(HPI = History of present illness, PMH = Past medical history, U/A = urinalysis)

Out of 17 cases I reviewed, 8 had no additional information accompanying them.

I’ll review referrals every few weeks to see if there’s an improvement.

P.S. See IHI’s information on Primary Care-Specialist service agreements.

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