Family Practice Vol. 19, No. 3, 297-299
© Oxford University Press 2002
Evaluation of referrals from general practice to a neurological department
Department of Neurology, Tromsø University Hospital, N-9038 Tromsø, Norway.
Bekkelund SI and Albretsen C. Evaluation of referrals from general practice to a neurological department. Family Practice 2002; 19: 297–299.
Received 9 May 2001; Revised 13 September 2001; Accepted 7 January 2002.
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Abstract |
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Background. The presence of neurological deficits as obtained from clinical examination increases the likelihood of detecting serious underlying brain disorders.
Objectives. In this study, we assessed the frequency of reported clinical neurological examination in patients referred to neurology.
Methods. We consecutively evaluated referrals to a neurological centre during a 6-month period.
Results. From a total of 716 patients, 377 (51%) had an examination reported in the referral letter. Clinical examinations were reported more often in patients with musculo-skeletal disorders compared with others, P = 0.0001. Examination was less likely to be reported in those with a history of disturbed consciousness.
Conclusion. By showing that only about half of the patients had an examination reported, the study demonstrates that the process of selecting those with a high priority for a secondary neurological service can be improved.
Keywords. General practice, neurological diagnoses, neurological examination, referral, secondary care.
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Introduction |
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Headache including migraine, faint or collapse, and symptoms involving the musculo-skeletal system are frequently reported disorders among out-patients referred to neurologists by GPs.1,2 Therefore, performing some elements of the clinical examination may be useful to support or refute the tentative diagnosis suggested by the patient's neurological symptoms. Also, the selection patients with high priority for secondary care depends on proper diagnostic information reported in the referrals. The reasons why some patients are referred to the neurological department without information about any clinical neurological examination performed have not been investigated in our country before. To our knowledge, no study evaluating the referral process in a representative population of patients from general practice has been completed before.
In this study, we investigated whether or not GPs performed a clinical neurological examination as a diagnostic work-up in patients who they decide to refer to secondary neurological care.
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Method |
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Subjects
We evaluated consecutively referrals from GPs to the neurological policlinic during a period of 6 months. The defined geographical area included the two northernmost counties in Norway (Tromsø and Finnmark) with a population of ~225 000 people. The Department of Neurology at Tromsø University Hospital serves all patients in the area. There are no private practising neurologists working in this region. The patients referred to the department therefore were as representative as possible. Approximately 225 GPs and 15 neurologists working at hospitals are provided in this area. Additionally, 12 doctors are trained to become neurologists. We selected the following selection criteria: (i) all out-patients referred to the clinic within the study period of 6 months; (ii) only those admitted for the first time; and (iii) only referrals from GPs.
From the hospital databases, we registered 716 referrals to the department from GPs which fulfilled the inclusion criteria. The patients were included from 1 January to 30 June 1999. The tentative diagnoses from GPs were recorded. All patients with evidence of disturbed consciousness, those with headache and patients with symptoms of the musculo-skeletal system were categorized into three different groups. Those patients with a reported history of disturbed consciousness had a tentative diagnosis of either epilepsy, syncope, apoplexy, transitory ischaemic attack or vertigo. Those categorized in the musculo-skeletal group had a tentative diagnosis of low back pain, ischialgia, polyneuropathy, carpal tunnel syndrome, cervicobrachialgia, weakness or paresthesia. The referrals were evaluated according to an agreed questionnaire by two neurologists (CA or SIB).
Analysis
The results are given as both numbers and percentages. Continuous variables such as age are normally distributed and therefore reported as means and standard deviations (SDs). Comparison of subgroups was performed using chi-square analysis for the categorical data. The level of statistical significance was set at P < 0.05.
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Results |
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A total of 716 referral letters from general practice were evaluated. Of these, 295 (41%) were for men and 421 (59%) for women. The mean age was 47.2 years (range 9–89) for the total group. The distributions of diagnoses as suggested by the GPs are displayed in Table 1
. The frequency of patients with reported clinical neurological examination as recorded from the referral letter are displayed in Table 2. Fifty-one per cent of the patients had not had an examination reported (Table 2). Examination was reported more often in patients with symptoms from the musculo-skeletal system than those with disturbed consciousness (Table 2).
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Among this subgroup of patients, 226 (60%) had a normal neurological examination, while 72 patients (19%) had one or more neurological deficits. Seventeen (4%) had more than one neurological deficit, most commonly a combination of sensory and motor deficit, or motor deficit along with reflex changes. Furthermore, 142 patients (20%) had abnormal physical examination regarding the musculo-skeletal system without associated neurological deficits. Evidence of a reflex examination being performed was reported in 191 (27%) of the total group. Among those, 170 (89%) were normal, while 21 (11%) reported abnormal reflex examinations (Table 3
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Discussion |
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In a population of patients referred to be examined at a neurological secondary care unit, fewer than half of the GPs included information to the department about a clinical neurological examination performed. Another main finding from the results in the study is that patients referred because of fainting or seizure disturbances were examined significantly less frequently compared with the other patients. Although the exact number of those with a possible diagnosis of epilepsy is not confirmed in the study, this finding is surprising since those with epileptic seizures have an increased risk of associated organic brain disorders.3,4 Also, epilepsy can be attributed to cerebrovascular diseases, brain tumour, developmental disturbances, infections and other organic brain disorders.4–6 In contrast, patients with headache and disorders related to the musculo-skeletal system may be treated by GPs if there are abnormal clinical findings. As found by others, these patients are common in specialist practice as well as in the general population.7,8
Neurological deficits may not always reflect underlying diseases. In a previous population study of presumably healthy people in Norway, increased frequency of impaired superficial sensation and pyramidal signs was reported.9 Also, impaired motor skills may be due to mechanisms other than brain disorders. We found an association between impaired ability to perform frequent limb movements and reduced cerebellar size in otherwise healthy women evaluated by magnetic resonance imaging.10 Thus, information from both clinical neurological findings and neurological history will be the best guide in the process of selecting those with high priority at the secondary neurological service.
In conclusion, a clinical neurological examination performed in approximately half of the patients referred to the neurological policlinic is less than expected. The reason for this finding was not studied in this report. However, the tendency to report neurological examination in patients with musculo-skeletal diseases more than in those with fainting or seizure disorders needs to be explored. The study demonstrates a potential for better co-operation between GPs and secondary neurological services.
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References |
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1 Cockerell OC, Goodridge DMG, Brodie D, Sander JWAS, Shorvon SD. Neurological disease in a defined population: the results of a pilot study in two general practices. Neuroepidemiology 1996; 15: 73–82.[Web of Science][Medline]
2 Wiles CM, Lindsay M. General practice referrals to a department of neurology. J R Coll Physicians Lond 1996; 5: 426–431.
3 Forsgren L, Bucht G, Eriksson S, Bergmark L. Incidence and clinical characterisation of unprovoked seizures in adults: a prospective population-based study. Epilepsia 1996; 37: 224–229.[Web of Science][Medline]
4 Lhatoo SD, Johnson AL, Goodridge DM, MacDonald BK, Sander JW, Shorvon SD. Mortality in epilepsy in the first 11 to 14 years after diagnosis: multivariate analysis of a long-term, prospective, population-based cohort. Ann Neurol 2001; 48: 336–344.
5 Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935–1984. Epilepsia 1993; 34: 453–468.[Medline]
6 Annegers JF, Rocca WA, Hauser WA. Causes of epilepsy: contributions of the Rochester epidemiology project. Mayo Clin Proc 1996; 71: 571–575.
7 Patterson VH, Esmonde TFG. Comparison of the handling of neurological outpatient referrals by general physicians and a neurologist. J Neurol, Neurosurg, Psychol 1993; 56: 830.
8 Rasmussen BK, Jensen R, Schroll M, Olessen J. Epidemiology of headache in a general population—a prevalence study. J Clin Epidemiol 1991; 44: 1147–1157.[Web of Science][Medline]
9 Skre H. Neurological signs in a normal population. Acta Neurol Scand 1972; 48: 575–606.[Medline]
10 Bekkelund SI, Pierre-Jerome C, Winther J, Mellgren SI. Quantitative MR of the brain and clinical evaluation of velocity limb movements in a healthy population. Eur Neurol 1999; 42: 185–189.[Medline]
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