The one-stop trial: does electronic referral and booking by the general practitioner (GPs) to outpatient day case surgery reduce waiting time and costs? A randomized controlled trial protocol

Abstract

Background: Waiting time and costs from referral to day case outpatient surgery are at an unacceptably high level. The waiting time in Norway averages 240 days for common surgical conditions. Furthermore, in North Norway the population is scattered throughout a large geographic area, making the cost of travel to a specialist examination before surgery considerable. Electronic standardised referrals and booking of day case outpatient surgery by GPs are possible through the National Health Network, which links all health care providers in an electronic network. New ways of using this network might reduce the waiting time and cost of outpatient day case surgery.

Materials and methods: In a randomised controlled trial, selected patients (inguinal hernia, gallstone disease and pilonidal sinus) referred to the university hospital are either randomised to direct electronic referral and booking for outpatient surgery (one stop), or to the traditional patient pathway where all patients are seen at the outpatient clinic several weeks ahead of surgery. Consultants in gastrointestinal surgery designed standardised referral forms and guidelines. New software has been designed making it possible to implement referral forms, guidelines and patient information in the GP's electronic health record. For "one-stop" referral, GPs must provide mandatory information about the specific condition. Referrals were linked to a booking system, enabling the GPs to book the hospital, day and time for outpatient surgery. The primary endpoints are waiting time and costs. The sample size calculation was based on waiting time. A reduction in waiting time of 60 days (effect size), 25%, is significant, resulting in a sample size of 120 patients in total.

Discussion: Poor communication between primary and secondary care often results in inefficiencies and unsatisfactory outcomes. We hypothesised that standardised referrals would improve the quality of information, making it feasible to use a one-stop approach for all patients undergoing surgery on an outpatient basis for inguinal hernia, pilonidal sinus and gallstones. In this study we wanted to investigate the waiting time and cost-effectiveness of direct electronic referral and booking of outpatient surgery compared to the traditional patient pathway, where the patient is seen at the outpatient clinic prior to surgery.

Trial registration: This trial has been registered at ClinicalTrials.gov. The trial registration number is: NCT00692497.

Figure 1

Trial flow chart.

Figure 2

Beta version of the standardised referral software in the "one-stop" trial. The software is integrated in the GP's electronic patient health records. The referral forms consist of 3 parts: Information needed for anaesthesia (left side of screen), information needed for surgeons (left side of screen) and additional information provided by the GP (right side of screen). When the GP enters an ICPC code (in this example D98 Cholelithiasis) the left side of the screen appears automatically. Booking of surgery is also done from this screen. This referral is fully integrated in the electronic health record (Profdoc Winmed).

Figure 3

Beta version of the guidelines for referral in the "one-stop" trial. Guidelines for referral and information to the patient are integrated in the GP's electronic health record linked to the referral screen. The GP can switch between the referral form and guidelines in the referral process. The guidelines consist of 2 parts: information to the GPs and information to the patient.