Introduction

A referral, being a medical document, plays an important role as a carrier of administrative and, above all, medical information. However, in order to provide valuable data for the doctor to whom it is addressed, it must be complete. A referral often replaces direct or telephone contact; therefore, it should be treated both as a means of communication and as a document.

Problems related to improper communication due to poorly prepared referrals have been the subject of many studies.1-5 Attempts have been also made to assess and standardize referrals by introducing assessment questionnaires and providing the referring physicians with training and model referral templates.6-8 The conclusions from the analyses indicate that the referrals often lack important information about patients’ main and accompanying ailments or the course of treatment to date. This may result in incorrect patient prioritization, delays in diagnosis and initiation of treatment, as well as unnecessary duplication of examinations and generating additional costs.

A limited contact with the patient is an unfortunate feature of radiology and diagnostic imaging. Apart from exceptions, such as interventional radiology or ultrasound examinations, the radiologist assesses the patient’s health almost exclusively on the basis of the imaging tests. In contrast to a clinician who performs a physical examination and collects the patient’s medical history, a radiologist, deprived of this knowledge, may fail to detect some pathologies which, often appearing as subtle morphological changes in tissues and organs, can be easily overlooked. Hence, clinical information included in referrals for imaging tests is extremely important, as it facilitates the detection and differential diagnosis of radiological findings.

In Poland, the rules for issuing referrals are set out in the Regulation of the Minister of Health of April 6, 2020 on the types, scope, and models of medical documentation and the method of its processing. On this basis, a referral should include, among others, “designation of the type of examination, consultation, or treatment for which the patient is directed; diagnosis established by the referring person; other information or data to the extent necessary to conduct the examination, consultation or treatment” (article 30, section 1 of the Act of November 6, 2008 on the rights of patients and the Patient’s Rights Ombudsman).9 However, these rules do not indicate the detailed way of formulating a referral. This analysis of computed tomography (CT) referrals is intended to evaluate and improve the long-term communication between doctors and radiologists.

Materials and methods

For the purpose of the study, 336 referrals for CT examinations performed in July 2020 at the Department of Radiodiagnostics and Interventional Radiology of the Medical University of Silesia in Katowice were analyzed. All assessments were performed by the radiologists working in the aforementioned Department.

In the analysis, it was verified whether the referrals contained the following elements: referring entity (hospital department, hospital or external clinic), details on the scope of the study (defined body area, the need for contrast), main diagnosis, the International Statistical Classification of Diseases and Related Health Problems ICD-10 code (and whether it was consistent with the main diagnosis), and information about the patient’s ailments (parameter assessed in justified cases, such as urgent, on-call examinations or the lack of prior diagnosis). We also took into account radiologists’ subjective assessment of the amount and quality of clinical information included in the referral (including concomitant diseases, procedures, and the purpose of the examination) expressed prior to the objectively performed statistical analysis and whether the physician referring for the CT had the title of specialist.

The above parameters were assessed on a scale of 0 to 1. Readability of referrals was assessed according to the following scale: 0, illegible; 1, unclear; 2, clear / computerized. In selected cases, the analysis took into account the radiologist’s comments.

Moreover, the presence of polite expressions, such as “please” and “thank you” was also assessed.

Statistical analysis

Basic statistical analysis was performed using the STATISTICA 13.0 software (TIBCO Software Inc., Palo Alto, California, United States). Statistical significance was set at a P value of less than 0.05. The data in Table 1 were compared with the χ2 test while in Supplementary material, Table S1, the Kolmogorov–Smirnov test was used for data comparison.

Table 1. The complete characteristics of errors and presence of polite expressions on referrals

Variable

All

Specialists

Nonspecialists

Hospital departments

Hospital clinics

External clinics

P value

N (%)

336

219 (65.2)

117 (34.8)

164 (48.8)

124 (36.9)

48 (14.3)

Unspecified CT scope

25 (7.4)

23 (10.5)

2 (1.7)

3 (1.8)

11 (8.9)

11 (22.9)

<⁠0.001

Lack of main diagnosis

49 (14.6)

18 (8.2)

31 (26.5)

37 (22.6)

10 (8.1)

2 (4.2)

<⁠0.001

Lack of ICD-10 code

9 (2.7)

9 (4.1)

0

0

7 (5.6)

2 (4.2)

0.007

Inconsistency of ICD-10 code with the main diagnosis

80 (23.8)

42 (19.2)

38 (32.5)

53 (32.3)

21 (16.9)

6 (12.5)

<⁠0.001

Lack of symptoms

64 (19)

45 (20.5)

19 (16.2)

29 (17.7)

24 (19.3)

11 (22.9)

0.81

Radiologist’s negative opinion

49 (14.6)

30 (13.7)

17 (14.5)

28 (17)

16 (12.9)

5 (10.4)

0.76

Polite expressions

107 (31.8)

80 (36.5)

27 (23)

40 (24.4)

41 (33)

26 (54.2)

<⁠0.001

Data are presented as number (percentage).

Abbreviations: CT, computed tomography; ICD-10, International Statistical Classification of Diseases, Tenth Revision

Ethics

This retrospective analysis of the referrals obtained from medical records did not require an approval of an Ethics Committee. All patients gave informed written consent prior to the CT examination.

Results

The most common error, which occurred in 23.8% of referrals, was an incorrect ICD-10 code, including its absence in 2.7% of cases. Comparatively often (22.1%), referrals did not take into account the patient’s complaints. Every seventh referral (14.6%) did not contain the main diagnosis, and 7.4% of referrals did not specify the type of examination in detail, most often due to the lack of information about the need to perform CT with or without a contrast agent.

In the case of referrals issued by hospitals, the most frequent errors were the inconsistency of the main diagnosis with the ICD-10 code (32.3%) and the lack of the main diagnosis (22.6%), while the referrals from outpatient clinics more often lacked information on symptoms (42.2%) and detailed indications of the scope of the CT examination or the need for contrast (31.8%).

Mistakes were more often made by nonspecialists. Referrals with at least a single error accounted for 76.9% and 62.5% of all referrals from nonspecialists and specialists, respectively. The main difference between the 2 groups was the lack of information about the main diagnosis, which concerned 26.5% of referrals from nonspecialists and 8.2% of referrals from specialists.

According to the radiologists’ subjective assessment, 14% of referrals did not provide an adequate amount of data essential for proper diagnosis.

Since the vast majority of referrals were issued with a computer, a relatively low number of them was not clearly written or illegible, that is, 3% and 0.6%, respectively.

The radiologist’s comments appeared in the case of referrals that contained merely single words in the description of the purpose of the study (such as “diagnostics” or “control”) or those whose contents were copied from the patients medical history and contained a lot of irrelevant and unnecessary information (in some cases up to 2.5 A4 size pages of duplicated data).

Overall, 46.7% of referrals were fully correct and complete, that is, included detailed specification of the type and scope of the examination, the main diagnosis, the ICD-10 code that was consistent with the main diagnosis, and the patient’s complaints (in justified cases). Detailed results are shown in Table 1.

Polite expressions were used in 31.8% of referrals. The most common polite word was “please.” Polite phrases were used more often by specialists (36.5% compared to 23% of doctors without specialization) and doctors referring patients from external clinics (54.2% compared to 33% of doctors from hospital clinics and 24.4% of doctors working in hospital departments). Interestingly, the amount of errors was insignificantly higher in the case of physicians who used polite expressions in referrals, independently of their work experience, as shown in Supplementary material, Table S1.

Discussion

The results of the above analysis indicate that a large proportion of referrals for imaging tests are not prepared correctly, most often due to incorrect diagnosis codes according to ICD-10. The fundamental mistakes concern the lack of information about the diagnosis (main complaints) and symptoms. According to subjective assessment of the radiologists assessing the CT, as many as 1 in 7 referrals did not provide significant data that would facilitate the diagnosis.

In reports on the way of issuing referrals, the dominant belief is that formal referrals are characterized by greater detail than informal referrals.1,3,10 This is because issuing a formal referral is based on standardized formulas and its filling requires greater scrupulousness. Brevity is also recommended.11

The quality of communication between doctors is influenced by the polite nature of referrals. A subjective analysis of the discourtesy of referrals in a study by Westerman et al5 found that approximately 92.8% to 95.5% of referrals issued to general practitioners by specialists did not contain any impoliteness. It does, however, mean than in some cases discourtesy was an issue.

Due to the fact that in referrals issued to specialist clinics or hospitals the present ethical standard is the phrase “I am asking for treatment of the patient” (in Polish, proszę o leczenie), it was considered justified to analyze the presence of courtesies on referrals to diagnostic imaging. The presence of the words “please” or “thank you” was found only in 38.1% of the referrals. Polite words were least frequently used by doctors without specialization, working mainly in hospital departments (23%). No significant association has been demonstrated between the use of polite words and the number of incorrectly issued referrals. This shows that there is no causal link between using courtesies and decreasing the number of errors. The use of polite expressions in referrals remains, however, a matter of impeccable manners.

Conclusions

Proper referral to diagnostic imaging should be treated as a medical letter directed to the radiologist. It should indicate the scope of the examination in detail and include a concise information concerning the main complaints (main diagnosis with ICD-10 code), accompanying diseases, past surgical procedures, present symptoms (in justified cases), and the purpose of the examination. Referrals should be legible and clear.

Effective and detailed communication between doctors fosters better cooperation, and since the patient is the subject of this cooperation, it translates into better and faster results in the diagnostic and therapeutic process.