Improving the appropriateness of referrals and waiting times for endoscopic procedures

There is a lack of standard methods for determining the clinical priority of patients referred by general practitioners (GPs) for specialist outpatient consultations. We introduced a system of progressive involvement by general practitioners and specialists with 80 diagnostic procedures. The aim of this study was to evaluate this new method of prioritization of patients suffering from significant gastroenterological disorders needing rapid access to diagnostic procedures.

The study included 438 outpatients who were referred for and underwent a gastroscopy or colonoscopy. GPs used a ranking of waiting times for different levels of clinical priority, called 'homogeneous waiting groups'. Specialists also assigned a priority level for each patient as well as evaluating the appropriateness of the referral and the presence of significant endoscopic disorders. Agreement between GPs' and specialists' priority assessments was evaluated by the kappa statistic.

Most referrals (74.4%) were deemed low priority by GPs, with no maximum waiting time assigned. The level of agreement between GPs and specialists as regards patients' priorities was poor or moderate: for gastroscopy the kappa was 0.31 (weighted kappa 0.47) and for colonoscopy 0.44 (weighted kappa 0.46). There was an association between the proportion of significant disorders identified with endoscopy and the priority assigned to the referral (chi2 = 18.9, 1 df, p < 0.001). The overall proportion of referrals deemed inappropriate by specialists was 22.1%.

There is value in liaison between GPs and specialists for achieving timely referrals and avoiding delayed diagnosis though higher levels of agreement need to be achieved.