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Retrospective data analysis of referral letters for orofacial vascular anomalies to a tertiary center
Zaridah Zainal Abidin1, Juanna Bahadun1
1Department of Pediatric Dentistry, Hospital Tunku Azizah, Kuala Lumpur, Malaysia.
Insights
Referral letters for vascular anomalies often lack critical clinical details, leading to misdiagnosis. Implementing a standardized proforma can improve documentation for better patient care.
Area of Science:
- Vascular Surgery
- Pediatric Surgery
- Dermatology
Background:
- Vascular anomalies encompass a range of disorders, including vascular tumors and malformations.
- Accurate diagnosis and classification are essential for appropriate management.
- Referrals to tertiary centers often lack comprehensive clinical information.
Purpose of the Study:
- To analyze referral patterns for vascular anomalies at a tertiary center.
- To identify common omissions and patterns of misdiagnosis in referral letters.
- To develop a standardized proforma to enhance clinical information capture.
Main Methods:
- Retrospective analysis of 47 vascular anomaly referral letters from 2018-2023.
- Descriptive analysis of documented patient demographics, clinical findings, and vascular anomaly characteristics.
- Development of a redesigned proforma based on identified information gaps.
Main Results:
- Demographic data were well-documented, but medical history and pre-referral investigations were frequently omitted.
- Key vascular anomaly characteristics like compressibility, pulsation, associated conditions, and involution were often overlooked.
- Over half of the letters detailed presenting problems, clinical findings, and some characteristics (e.g., appearance, growth, color).
Conclusions:
- Incomplete documentation in referral letters hinders accurate diagnosis and treatment planning for vascular anomalies.
- Critical information regarding specific vascular anomaly features is frequently missing.
- A standardized proforma is necessary to ensure comprehensive data collection and improve patient management.
Background:
Vascular anomalies are disorders of the vascular system. These anomalies are classified as either vascular tumors or vascular malformations, with each possessing distinct characteristics. This study was performed to analyze vascular anomaly referrals to a tertiary center, identify patterns of misdiagnosis, and create a proforma to ensure the comprehensiveness of clinical information.
Methods:
We retrospectively analyzed vascular anomaly referral letters received by Hospital Tunku Azizah from 2018 to 2023. Specifically, we descriptively analyzed the inclusion of vascular anomaly characteristics, the demographic profiles of referrers and patients, and basic clinical findings. Subsequently, we developed a redesigned proforma.
Results:
Overall, 47 referral letters were analyzed. The patients comprised 25 boys and 22 girls, with ages ranging from birth to 14 years. Patient name, sex, and date of birth, along with the referrer's name and address, were satisfactorily documented. The review revealed that 44 (93.6%) of the letters included the patient's presenting problem, 43 (91.5%) contained clinical findings, 37 (78.7%) reported diagnostic investigations, and 29 (61%) referenced medical history. Regarding characteristics of vascular conditions, over half of the letters detailed time of appearance (n= 40, 85%), growth (n= 24, 66%), complications (n= 25, 53.2%), color (n= 32, 68%), and shape (n= 34, 72%). However, fewer than half mentioned compressibility (n= 7, 14.8%), pulsation (n= 7, 14.7%), and associated conditions (n= 2, 4.3%), and none referenced involution.
Conclusion:
Although demographic data were generally well-documented, critical medical history information was frequently omitted, including a lack of adequate pre-referral investigations. Key characteristics of vascular anomalies, namely compressibility, pulsation, associated conditions, and involution, were frequently overlooked. Accurate documentation of these features is crucial for determining treatment urgency. A standardized proforma must be implemented to ensure that vital information is captured, thus facilitating diagnosis and optimizing patient care.
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