Download Ear Disease

E.N.T. Referrals
And how to reduce them
Between 2005 and 2009:
GP referrals to outpatients increased by 19%
Consultant to consultant outpatient referrals increased by 40%
New ENT referrals in England
1000000
800000
600000
400000
200000
0
20
03
/4
20
04
/5
20
05
/6
20
06
/7
20
07
/8
20
08
/
20 9
09
/1
0
Number of referrals
1200000
Year
Patient is referred for investigations or admitted for operation
or sent for tertiary opinion
Patient is seen in ENT clinic
---------------------------------------------------------------
Patient is seen by GP
Patient has the symptom
Reasons for a referral
52%
48%
33%
32%
17%
7%
11%
to establish a diagnosis
for treatment or an operation
for a test or investigation which the GP cannot order
for advice on management
for reassurance for the GP / 2nd opinion
for reassurance for the patient or family
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 population
An unhealthier population
NICE / QOF requirements
Defensive practice
Lack of undergraduate training in that specialty
Increase / decrease in consultant to consultant referrals
Early discharge from hospital
Discharges from long term outpatient follow up
Shorter waits – high level of supply gives high referral rate
Not so much private practice
Patient 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, helpseeking 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
20
15
80 or
more
70 to 79
Southampton
Slough
60 to 69
50 to 59
40 to 49
30 to 39
80 or
more
70 to 79
60 to 69
50 to 59
40 to 49
30 to 39
20 to 29
10 to 19
0 to 9
80 or
more
70 to 79
60 to 69
50 to 59
40 to 49
30 to 39
20 to 29
10 to 19
0 to 9
Age
Age
20 to 29
%
%
10 to 19
0 to 9
25
20
15
10
5
0
20
18
16
14
12
10
8
6
4
2
0
% 10
Local Population
5
0
Age
Relative Referral Rate
% of referrals in that age group / % of local population in that age group
Relative referral rate %
All ENT Referrals
n = 3000
200
180
160
140
120
100
80
60
40
20
0
80 or more
70 to 79
60 to 69
50 to 59
40 to 49
30 to 39
20 to 29
10 to 19
0 to 9
Age
Hearing Loss
Hearing Loss
Hearing Loss
n = 1020
300
250
200
150
100
50
0
80 or more
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
Refer to audiology if you want just a hearing test
or a hearing aid opinion
NHS Bournemouth and Poole and NHS Dorset
Grommet / Ventilation Tube Policy Jan 2011
Prior approval not required in the following circumstances:
CHILDREN
1. 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.
2.
3.
4.
Age between 3 and 16 years
Period of watchful waiting for 3 months and the glue ear persists
Child has poor listening skills, indistinct speech or delayed language
development, inattention and behaviour problems
Hearing level in the better ear of 25 dB or worse
NHS Bournemouth and Poole and NHS Dorset
Grommet / Ventilation Tube Policy Jan 2011
Prior approval not required in the following circumstances:
ADULTS
1.
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
Relative Referral Rate / %
Tinnitus
200
Tinnitus
n = 485
100
0
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 / years
Some of these we refer for investigation
or for hearing therapy
Some of these you refer to ENT
(but only about 1 a year)
Some of your patients see you
because of their tinnitus
A lot of your patients
have tinnitus
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)
Vertigo
Relative Referral Rate / %
Vertigo
200
Vertigo
n = 656
100
0
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 / years
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
Relative Referral Rate / %
Ear Wax
500
400
300
Ear Wax
n = 245
200
100
0
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 / years
To syringe or not?
Otitis Externa
Keep dry
Avoid trauma
Remove debris
Swab for MC+S ?
Do not overtreat with topical
antibiotic
Epistaxis
Epistaxis
Epistaxis
n = 497
250
200
150
100
50
0
80 or more
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
Nasal Injury
Nasal Injury
Nasal Trauma
n = 175
500
450
400
350
300
250
200
150
100
50
0
80 or more
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
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 Block
Nasal Block
Relative Referral Rate / %
200
Nasal Block
n = 367
100
0
0 to 9
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79
Age / years
80 or
more
Sinusitis / Facial Pain
Sinusitis / Facial Pain
Relative Referral Rate / %
200
Sinusitis,
Facial Pain
n = 342
100
0
0 to 9
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79
Age / years
80 or
more
Nasal Polyps
Nasal Polyps
Relative Referral Rate / %
200
Nasal Polyp
n = 157
100
0
0 to 9
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79
Age / years
80 or
more
Tonsillitis
Tonsillitis
Tonsillitis
n = 443
450
400
350
300
250
200
150
100
50
0
80 or more
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
NHS Bournemouth and Poole and NHS Dorset
Tonsillectomy Policy Jan 2011
Prior 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
Relative Referral Rate / %
200
Voice
n = 538
100
0
0 to 9
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79
Age / years
80 or
more
Swallowing Problems
Swallowing Problems
Relative Referral Rate / %
300
200
Swallowing
n = 190
100
0
0 to 9
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79
Age / years
High - ENT
Low - Gastroenterology
80 or
more
Lump in Throat Sensation
Lump in Throat Sensation
Relative Referral Rate / %
200
Lump in Throat
n = 124
100
0
0 to 9
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79
Age / years
80 or
more
Sleep Apnoea / Snoring
Sleep Apnoea / Snoring
Snoring / Sleep Apnoea
n = 376
250
200
150
100
50
0
80 or more
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
ENT - Snorers
Respiratory - Sleep Apnoea
Surgery for snoring and laser surgery to the palate not funded by PCT
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
skin lesions / lipomata
NO
Repair of earlobe
NO
Reducing referrals to ENT
How 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 End
The End