Referral letters and replies from orthopaedic departments: Opportunities missed

Abstract

Objective - To study delays between sending referral letters and the outpatient appointment and to assess the content of referral and reply letters, their educational value, and the extent to which questions asked are answered by reply letters. Design - Retrospective review of referrals to 16 consultant orthopaedic surgeons at five hospitals, comprising 288 referral letters with corresponding replies, by scoring contents of letters. Setting - Orthopaedic teaching hospitals in Nottingham, Derby, and Mansfield. Main outcome measures - Weighted scores of contents of referral and reply letters, assessment of their educational value, and responses to questions in referral letters. Results - Median outpatient delay was 23.4 weeks. There was no significant decrease in waiting time if the referral letter was marked 'urgent' but a significantly greater delay (p < 0.01) if referrals were directed to an unnamed consultant. The content score was generally unsatisfactory for both referrals and replies, and there was no correlation for the content scores of the referral letter and its reply (r = 0.13). Items of education were rare in the referral letters (8/288; 3%) and significantly more common in replies (75/288; 26%) (p << 0.001). Senior registrars were significantly more likely to attempt education than other writers (p < 0.02). Education in replies was significantly related to increased length of the letter (p < 0.05) and was more likely to occur if the referral was addressed to a named consultant (p < 0.03). 48 (17%) Referral letters asked questions, of which 21 (44%) received a reply. No factor was found to influence the asking of or replying to questions. Conclusions - The potential for useful communication in the referral letter and in the reply from orthopaedic surgeons is being missed at a number of levels. The content is often poor, the level of mutual education is low, and the use of referral letter to determine urgency is deficient. Most questions asked by general practitioners are not answered.