E.N.T. ReferralsAnd how to reduce them

New ENT referrals in England

0

200000

400000

600000

800000

1000000

1200000

Year

Nu

mb

er o

f re

ferr

als

Between 2005 and 2009:

GP referrals to outpatients increased by 19%

Consultant to consultant outpatient referrals increased by 40%

Patient is referred for investigations or admitted for operationor sent for tertiary opinion

Patient is seen in ENT clinic---------------------------------------------------------------

Patient is seen by GP

Patient has the symptom

Reasons for a referral52% to establish a diagnosis

48% for treatment or an operation

33% for a test or investigation which the GP cannot order

32% for advice on management

17% for reassurance for the GP / 2nd opinion

7% for reassurance for the patient or family

11% other

Referral rates to a particular specialty within a single area can vary by as much as 10 fold between GPs

Reasons for an increase in referrals

An ageing populationAn unhealthier populationNICE / QOF requirementsDefensive practiceLack of undergraduate training in that specialtyIncrease / decrease in consultant to consultant referralsEarly discharge from hospitalDischarges from long term outpatient follow upShorter waits – high level of supply gives high referral rateNot so much private practicePatient expectation

Factors associated with referral rates

GP Factors GP beliefs or expectations about benefits of referral, gender or age or experience of GP, degree of

training in specialty, GP-patient relationship, congruence between GP and patient’s attitudes, GP relationship with specialist, practice size, fund holding history, services available in practice, GP psychological characteristics

Patient Factors Severity of symptoms, desire for referral, age, gender, social class, diagnosis, co-morbidities, help-

seeking behaviour, perception of the problem, attitudes towards treatment

Structural factors Distance to specialist services, area deprivation, availability or accessibility of specialist care,

alternatives to specialist care, time available for consultation

ENT Referrals

1,150,000 new ENT referrals in 2009/10 in England

Population of England = 51 million

= 22 new ENT referrals per 1000 population per year

Approx 75 % of new ENT outpatient referrals come from G.P.s

= about 16.5 ENT referrals per 1000 population per year

ENT Referrals

Average list size in UK = 1800

About 30 ENT referrals / GP / year

Main presenting complaint

Ear problems 59 %

Nose / sinus problems 16 %

Throat / neck problems 25 %

50 % of all referrals would need audiometry

Ear problems

Hearing loss 34 %

Vertigo 6.3 %

Tinnitus 4.4 %

Otitis externa 3.6 %

Wax 2.4 %

Plus: otalgia, ear discharge, foreign body, lumps and bumps on pinna

Nasal / sinus problems

Epistaxis 4.8 %

Nasal block 3.9 %

Sinusitis / facial pain 2.9 %

Plus: nasal discharge, nasal polyps, rhinitis, anosmia, foreign body, nasal trauma

Throat / neck problems

Voice problems 5.2 %

Tonsillitis 4.3 %

Throat discomfort 4.0 %

Snoring / sleep apnoea 2.9 %

Swallowing problems 1.7 %

Plus: neck lumps, lump in throat sensation, cough, foreign body

West Dorset, South Somerset

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5

10

15

20

0 to 9

10 to 19

20 to 29

30 to 39

40 to 49

50 to 59

60 to 69

70 to 79

80 orm

ore

Age

%

Slough

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101214161820

0 to 9

10 to 19

20 to 29

30 to 39

40 to 49

50 to 59

60 to 69

70 to 79

80 orm

ore

Age

%

Southampton

0

5

10

15

20

25

0 to 9

10 to 19

20 to 29

30 to 39

40 to 49

50 to 59

60 to 69

70 to 79

80 orm

ore

Age

%

Local Population

Relative Referral Rate% of referrals in that age group / % of local population in that age group

All ENT Referralsn = 3000

020406080

100120140160180200

0 to 9

10 to 19

20 to 29

30 to 39

40 to 49

50 to 59

60 to 69

70 to 79

80 or more

Age

Rel

ativ

e re

ferr

al r

ate

%

Hearing Loss

Hearing Loss

Refer to audiology if you want just a hearing test or a hearing aid opinion

Hearing Loss

n = 1020

0

50

100

150

200

250

300

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 or more

NHS Bournemouth and Poole and NHS Dorset

Grommet / Ventilation Tube Policy Jan 2011Prior approval not required in the following circumstances:

CHILDREN1. Disabilities e.g. Turner’s or Down’s Syndrome or cleft palate

where the insertion of ventilation tubes is part of an established pathway of care

2. Clinically significant retraction pocket in pars tensa

3. Frequent episodes (at least 6 in 12 months) of AOM or complications, documented in primary care records

4. Bilateral glue ear when ALL of the following are met:1. Age between 3 and 16 years2. Period of watchful waiting for 3 months and the glue ear persists3. Child has poor listening skills, indistinct speech or delayed language

development, inattention and behaviour problems4. Hearing level in the better ear of 25 dB or worse

NHS Bournemouth and Poole and NHS Dorset

Grommet / Ventilation Tube Policy Jan 2011Prior approval not required in the following circumstances:

ADULTS1. As part of middle ear major surgery

2. Clinically significant retraction pocket in pars tensa

3. Hearing loss post radiotherapy if hearing aids not appropriate

4. As part of postnasal space biopsy for cancer investigation

5. Glue ear (unilateral or bilateral) when all of the following criteria are met:

Watchful waiting period of 3 months and the glue ear persists Hearing level of 30 dB or worse in the better ear Hearing aid use is not appropriate

NHS Bournemouth and Poole and NHS Dorset

Grommet / Ventilation Tube Policy Jan 2011

Reinsertion of Ventilation Tubes

Adults

Prior approval required for second or subsequent procedures

Children

Prior approval required for 4th and subsequent procedures

Tinnitus

Tinnitus

Tinnitus n = 485

0

100

200

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Relat

ive Re

ferral

Rate

/ %

A lot of your patients have tinnitus

Some of your patients see you because of their tinnitus

Some of these you refer to ENT(but only about 1 a year)

Some of these we refer for investigation or for hearing therapy

Tinnitus referrals

When to refer:

Unilateral continuous tinnitus

Severe tinnitus not responding to first line management and especially if causing depression

Tinnitus associated with asymmetrical hearing loss or vertigo

Patients requiring the reassurance of a specialist assessment Tinnitus associated with ear disease e.g. CSOM

Objective tinnitus (usually pulsatile)

VertigoVertigo

Vertigo

Vertigo n = 656

0

100

200

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Relat

ive Re

ferral

Rate

/ %

Vertigo ‘Red Flags’

Persistent, worsening vertigo or dysequilibrium

Atypical ‘non-peripheral’ vertigo such as vertical movement

‘Bizarre’ nystagmus (not simple lateral jerk or rotatory)

Vertigo associated with:

severe headache, especially in the morning diplopia or other cranial nerve palsies

dysarthria, ataxia or other cerebellar signs

papilloedema

Urgent Vertigo Referrals

Should you be referring to:

ENT ?

Neurology ?

Cardiology ?

Elderly Care ?

Vertigo Referrals to ENT

BPPV – should you learn the Epley manoeuvre?

Vestibular Neuronitis (Labyrinthitis) – usually better by the time they are seen

Meniere’s Disease – an over-diagnosed condition

Migrainous Vertigo – an under-diagnosed condition?

Others (especially multisensory, psychological)

Ear Wax

Ear Wax

To syringe or not?

Ear Wax n = 245

0

100

200

300

400

500

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Relat

ive R

efer

ral R

ate /

%

Otitis Externa

Keep dry

Avoid trauma

Remove debris

Swab for MC+S ?

Do not overtreat with topical antibiotic

Epistaxis

Epistaxis

Epistaxis

n = 497

0

50

100

150

200

250

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 or more

Nasal Injury

Nasal Injury

If an acute nasal injury needs to be seen in an ENT clinic, make sure it is within 7 days of the injury so that the MUA can be done within 14 days

Nasal Trauma

n = 175

0

50

100

150

200

250

300

350

400

450

500

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 or more

Nasal Block

Nasal Block

Nasal Block n = 367

0

100

200

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Rel

ativ

e R

efer

ral R

ate

/ %

Sinusitis / Facial Pain

Sinusitis / Facial Pain

Sinusitis,Facial Pain

n = 342

0

100

200

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Rel

ativ

e R

efer

ral R

ate

/ %

Nasal Polyps

Nasal Polyps

Nasal Polyp n = 157

0

100

200

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Rel

ativ

e R

efer

ral R

ate

/ %

Tonsillitis

Tonsillitis

Tonsillitis

n = 443

0

50

100

150

200

250

300

350

400

450

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 or more

NHS Bournemouth and Poole and NHS Dorset

Tonsillectomy Policy Jan 2011Prior approval not required in the following circumstances:

1. Adults or children for cancer or suspected cancer

2. Adults or children with spontaneous tonsillar haemorrhage

3. Adults or children for cases of quinsy

4. Adults with proven obstructive sleep apnoea where other treatments have failed or are inappropriate

5. Adults or children with tonsil crypt debris (tonsilloliths) that are visible and recurrent

6. Adults or children who are immunocompromised or have other medical conditions, e.g. diabetes, cystic fibrosis or guttate psoriasis, which would leave them at risk of severe complications as a result of tonsillitis

NHS Bournemouth and Poole and NHS Dorset

Tonsillectomy Policy Jan 2011

7. In adults and children for tonsillitis if ALL of the following

criteria are met:

i. Sore throats are due to tonsillitis

ii. There are 7 or more episodes of tonsillitis in the last year, or at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years (episodes must be documented in primary care records)

iii. There have been symptoms for at least a year

iv. The episodes of sore throat are disabling and prevent normal functioning

NHS Bournemouth and Poole and NHS Dorset

Tonsillectomy Policy Jan 2011

7. In adults and children for tonsillitis if ALL of the following

criteria are met:

i. Sore throats are due to tonsillitis

ii. There are 7 or more episodes of tonsillitis in the last year, or at least 5 episodes per year for 2 years, or at least 3 episodes per

year for 3 years (episodes must be documented in primary care records)

iii. There have been symptoms for at least a year

iv. The episodes of sore throat are disabling and prevent normal functioning

Voice Problems

Voice Problems

Voice n = 538

0

100

200

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Rel

ativ

e R

efer

ral R

ate

/ %

Swallowing Problems

Swallowing Problems

High - ENT

Low - Gastroenterology

Swallowing n = 190

0

100

200

300

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Rel

ativ

e R

efer

ral R

ate

/ %

Lump in Throat Sensation

Lump in Throat Sensation

Lump in Throat n = 124

0

100

200

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 ormore

Age / years

Rel

ativ

e R

efer

ral R

ate

/ %

Sleep Apnoea / Snoring

Sleep Apnoea / Snoring

ENT - Snorers

Respiratory - Sleep Apnoea

Surgery for snoring and laser surgery to the palate not funded by PCT

Snoring / Sleep Apnoea

n = 376

0

50

100

150

200

250

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 or more

What can we list without prior approval?

Pinnaplasty Children 5-18 only

Rhinoplasty Post-traumatic cases or congenital abnormality

Complications following previous surgery where the airway is obstructed and where treatment would

alleviate the problems

Removal of benign NO

skin lesions / lipomata

Repair of earlobe NO

Reducing referrals to ENTHow to do it

Active Referral Review

Comparative information about GP and practice referral rates by specialty

Routine audits at practice level

Discussion of a sample of referrals to examine referral quality and appropriateness‘right place, right person, right time’

Redesign of elective care pathways

Referral guidelines (but only if combined with feedback from peers or specialists)+/- desktop summaries, structured referral sheets, pro-formas or standardised

letters and risk factor checklists

Closer integration of GPs and specialists

The EndThe EndThe EndThe End