Impact of quality of referral letters on the outcome of patient care: cohort study

Abstract Background The high volume of patients presenting with acute chest pain places pressure on the parties that refer and receive them. Referral letters for such patients need immediate evaluation. Hastily prepared referral letters often lack information that is essential for making precise decisions. Our objective was to assess how the quality of acute coronary syndrome (ACS) referral letters influences decision-making. Methods In our cohort study, we examined all consecutive ACS referrals to Helsinki University Hospital (HUS) from January 2021 to April 2022. The study sample comprised 1075 patients. The content of the referrals were gathered on an Excel sheet and analysed in a structured manner. The data were categorized on the basis of the number and the quality of the essential information items: chest pain symptoms, risk factors, electrocardiogram findings, and troponin values. We evaluated references to ischemia (chest pain, release of cardiac troponin or ischemic electrocardiography) and other classified relevant information items (altogether 25 different comorbidities: classical atherosclerosis risk factors, previous myocardial infarction, stroke, cancer, etc.). We cross-tabulated the collected information with all the coronary angiographies performed at HUS during the study period. Results The median number of relevant classified information items in a referral was eight (5–10). The three most important information items–troponin values, electrocardiograms, and patient symptoms–were referred to in 84.5%, 76.6%, and 91.3%, of referrals, respectively, whereas all three were reported in 66.0%. References to ischemia were associated with the odds of undergoing coronary angiography (age- and sex-adjusted OR 2.02 (1.65–2.48), P .001) and with a shorter wait for angiography (adjusted RR 0.83 (0.77–0.89), P .001). The number of classified relevant information items was also associated with the likelihood of undergoing coronary angiography (adjusted OR 1.06 (1.02–1.11), P = .008) but not with the length of the wait for the procedure. A prior percutaneous coronary intervention (PCI), however, was associated with a higher probability of undergoing coronary angiography (univariable OR 3.78 (1.46–11.78), P = .011). Conclusions Although the overall quality of the referrals was satisfactory, the recipient of the referral had to make many decisions on the basis of incomplete information. References to ischemia increased the probability of adequate patient care and decreased the wait for coronary angiography. Other information only had a minor effect on the same measures.