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Can guidelines improve referral to elective surgical specialties for adults? A systematic review
  1. A Clarke1,
  2. N Blundell2,
  3. I Forde3,
  4. N Musila4,
  5. D Spitzer5,
  6. S Naqvi1,
  7. J Browne4
  1. 1Health Sciences Research Institute, University of Warwick, Coventry, USA
  2. 2Research in Practice for Adults, Blacklers, Dartington, Totnes, Devon, UK
  3. 3Department of Epidemiology and Public Health, University College, London, UK
  4. 4Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK
  5. 5Centre for Health Sciences, Barts & the London School of Medicine & Dentistry, London, UK
  1. Correspondence to Aileen Clarke, Warwick Medical School, University of Warwick, Health Sciences Research Institute, Coventry CV4 7AL, UK; aileen.clarke{at}


Aim To assess effectiveness of guidelines for referral for elective surgical assessment.

Method Systematic review with descriptive synthesis.

Data sources Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites.

Selection of studies Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults.

Outcome measures Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs.

Results 24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex (“one-stop shops”) to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change.

Conclusions Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.

  • Family practice (MeSH)
  • primary healthcare (MeSH)
  • referral and consultation (MeSH) surgical procedures
  • operative (MeSH)
  • practice guidelines (MeSH)
  • algorithms (MeSH]

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Funding The study was funded by the NIHR SDO research and development programme (grant SDO/08/1310/072). The study funders had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The researchers were independent from the funders.

  • Competing interests Declared. AC, NM and JB are involved in phase II of this work, which involves development and evaluation of referral guidelines for elective surgical assessment in orthopaedics and urology.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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