An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation

Abstract Objective Oral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage. Method A health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination. Results The proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings. Conclusions Implementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.

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Improving Access to Oral Surgery Services in Primary Care

Primary Dental Care ◽

10.1308/135576109789389540 ◽

2009 ◽

Vol os16 (4) ◽

pp. 137-142 ◽

Cited By ~ 20

Author(s):

Nick Kendall

Keyword(s):

Primary Care ◽

Oral Surgery ◽

Waiting Times ◽

Primary Care Trust ◽

Hospital Setting ◽

Substantial Improvement ◽

Dental Services ◽

Collaborative Working ◽

World Class ◽

Further Development

This paper describes the innovative use of National Health Service (NHS) dental commissioning powers to develop specialist primary care based oral surgery services. The outcomes, after one full year of the scheme, have been substantial improvement in access and reduced waiting times for patients, further development of NHS primary care dental services through commissioning processes, increased use and engagement of oral surgery specialists outside of a hospital setting, and considerable ongoing savings to the NHS. Collaborative working between hospital consultants and managers, Primary Care Trust dental commissioners, general dental practice providers, specialist oral surgeons and a dental public health consultant has resulted in sustainable benefits to patients and the NHS within the World Class Commissioning framework.

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Primary care minor oral surgery service: threat to our specialty or opportunity?

British Journal of Oral and Maxillofacial Surgery ◽

10.1016/j.bjoms.2012.04.176 ◽

2012 ◽

Vol 50 ◽

pp. S12

Author(s):

G. Cousin ◽

C.J. Johnston ◽

S.G. Langton ◽

K.N. McAlister ◽

M.E. Morton

Keyword(s):

Primary Care ◽

Oral Surgery ◽

Minor Oral Surgery

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A Baseline Audit of Referral and Treatment Delivered to Patients in the Intermediate Minor Oral Surgery Service in Croydon PCT

Primary Dental Care ◽

10.1308/135576112798990728 ◽

2012 ◽

Vol os19 (1) ◽

pp. 23-28 ◽

Cited By ~ 15

Author(s):

Eunan O'Neill ◽

Jennifer E Gallagher ◽

Nick Kendall

Keyword(s):

Primary Care ◽

Oral Surgery ◽

Descriptive Analysis ◽

Patient Records ◽

Primary Care Settings ◽

The United Kingdom ◽

Referral Management ◽

Minor Oral Surgery ◽

Simple Extraction ◽

Local Pressures

Introduction Patients attending for primary dental care may require oral surgery procedures beyond the capability of a generalist and thus need to be treated by a dentist with greater expertise. In the United Kingdom, it is increasingly accepted that such care may be provided in primary care settings by specialists or dentists with a special interest. In response to local pressures, an intermediate minor oral surgery (IMOS) service has been established in Croydon, south west London, to provide oral surgery treatment for non-urgent patients on referral. Aim To audit the appropriateness and quality of oral surgery referrals after triage to an IMOS service in Croydon and to set standards for future audits on this topic. Methods An audit tool was developed in line with the local referral guidelines and agreed with local stakeholders. Information on 501 (10%) triaged referrals to IMOS practices over a 24-month period was obtained through the referral management centre. A 10% sample of referrals per month to each practice was calculated and IMOS providers randomly selected the relevant patient records. Using an agreed audit pro forma, information on the indications for referral, treatment provided, and dates relating to patient management, in addition to the age and sex of patients, was collected from the IMOS providers by one investigator. Descriptive analysis of the data was performed. Results Of the 501 patient records that were examined, 99% of patients were treated in IMOS practices, with only three (less than 1%) patients being referred on to hospital consultant services. The largest proportion (237; 40%) of referrals was for the extraction of teeth considered to have special difficulty, followed by lower third molars (154; 26%). Almost one-third (159; 32%) of patients were referred for more than one procedure. One in eight (72; 13%) teeth removed by the IMOS providers were recorded as a simple extraction without medical complications. Conclusions • In general, patients were referred appropriately to the primary care oral surgery service in Croydon, with only a minority recorded as receiving simple care that should not have required referral. • The clinician-led triage process using a referral management system worked well in selecting appropriate patients for treatment by IMOS providers in primary care and reduced referrals to hospital. • Suggested standards for future audits of IMOS referrals have been set.

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Guiding local sedation services in dentistry

Bulletin of The Royal College of Surgeons of England ◽

10.1308/147363508x276215 ◽

2008 ◽

Vol 90 (2) ◽

pp. 47-47

Author(s):

Charlotte Worker

Keyword(s):

Primary Care ◽

Oral Surgery ◽

Dental Practice ◽

Special Interests ◽

The Past ◽

Department Of Health ◽

General Dental Practice ◽

Competency Frameworks ◽

Minor Oral Surgery

Over the past three years, the Faculty of General Dental Practice (UK) and the Department of Health (DH) have worked together to develop a series of competency frameworks for dentists with special interests (DwSIs). The frameworks are intended for use by dentists and primary care trusts (PCTs) and set out competencies for the scope of treatment that can be undertaken by dentists who have developed special interests. By the end of 2007, frameworks had been published in minor oral surgery, orthodontics, periodontics, endodontics and prison dentistry.

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The advantages and disadvantages of providing minor oral surgery in primary care

Faculty Dental Journal ◽

10.1308/204268513x13626856629348 ◽

2013 ◽

Vol 4 (2) ◽

pp. 94-98 ◽

Cited By ~ 2

Author(s):

Jayendra Patel

Keyword(s):

Primary Care ◽

Dental Care ◽

Care Setting ◽

Primary Care Setting ◽

Oral Surgery ◽

Healthcare Sector ◽

Fiscal Constraints ◽

Advantages And Disadvantages ◽

Minor Oral Surgery ◽

Spending Cuts

The National Health Service (NHS) has recently been faced with increasing government targets at the same time as increasing spending cuts. Within the current fiscal constraints, the NHS is expected to deliver quality services while at the same time ensuring value for money.1 Since 1995 there have been developments to move the delivery of specialist dental care into the primary healthcare sector. This followed a report by the Chief Dental Officer (CDO) for England, who reviewed the arrangements for specialist training in dentistry.2 To keep in line with Europe, the CDO also recommended an increase in the provision of specialist dental care provided in the primary care setting.

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An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Health Services and Delivery Research ◽

10.3310/hsdr06080 ◽

2018 ◽

Vol 6 (8) ◽

pp. 1-126 ◽

Cited By ~ 7

Author(s):

Joanna Goldthorpe ◽

Tanya Walsh ◽

Martin Tickle ◽

Stephen Birch ◽

Harry Hill ◽

...

Keyword(s):

Primary Care ◽

Diagnostic Test ◽

Oral Surgery ◽

Care Service ◽

Health Economic Evaluation ◽

Diagnostic Test Accuracy ◽

Referral System ◽

Test Accuracy ◽

Referral Management ◽

Electronic Referral

BackgroundOral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.Research questionsCan an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?DesignA mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.SettingThe ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.ParticipantsPatients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.InterventionsA consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.Main outcome measuresDiagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.ResultsIn the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.ConclusionsImplementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.Study limitationsThe geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.Future workThe findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Exploring implementation of an electronic referral management system and enhanced primary care service for oral surgery: perspectives of patients, providers and practitioners

BMC Health Services Research ◽

10.1186/s12913-018-3424-z ◽

2018 ◽

Vol 18 (1) ◽

Cited By ~ 2

Author(s):

Joanna Goldthorpe ◽

Caroline Sanders ◽

Richard Macey ◽

Lesley Gough ◽

Jean Rogers ◽

...

Keyword(s):

Primary Care ◽

Management System ◽

Oral Surgery ◽

Care Service ◽

Primary Care Service ◽

Referral Management ◽

Electronic Referral

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Postgraduate training and educational opportunities for oral surgery in the UK

Faculty Dental Journal ◽

10.1308/204268513x13626856629104 ◽

2013 ◽

Vol 4 (2) ◽

pp. 48-57 ◽

Cited By ~ 2

Author(s):

Tara Renton ◽

Louis McArdle

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Care Setting ◽

Primary Care Setting ◽

Postgraduate Training ◽

Oral Surgery ◽

Local Level ◽

Educational Opportunities ◽

Dental Services ◽

The Uk

The National Health Service globally is currently undergoing significant scrutiny in terms of cost effectiveness, and services in the secondary care sector are being rationalised and, where possible, relocated into a primary care setting. The new commissioning bodies are keen to further develop and continue this trend. Dental services will be commissioned nationally by the NHS Commissioning Board although the implementation will be maintained at a more local level.

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