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Assessment of the effect of an Interactive Dynamic Referral Interface (IDRI) on the quality of referral letters from general practitioners to gastroenterologists: a randomised cross-over vignette trial
  1. Sigrun Losada Eskeland1,2,
  2. Cathrine Brunborg3,
  3. Corina Silvia Rueegg3,
  4. Lars Aabakken4,
  5. Thomas de Lange5,6
  1. 1 Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
  2. 2 Faculty of Medicine, University of Oslo, Oslo, Norway
  3. 3 Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
  4. 4 Department of Transplantation Medicine, Section of GI Endoscopy, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
  5. 5 Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
  6. 6 Departement of Bowel Cancer Screening, Cancer Registry of Norway, Majorstuen, Oslo, Norway
  1. Correspondence to Sigrun Losada Eskeland; sigesk{at}


Objectives We evaluated whether interactive, electronic, dynamic, diagnose-specific checklists improve the quality of referral letters in gastroenterology and assessed the general practitioners’ (GPs’) acceptance of the checklists.

Design Randomised cross-over vignette trial.

Setting Primary care in Norway.

Participants 25 GPs.

Intervention The GPs participated in the trial and were asked to refer eight clinical vignettes in an internet-based electronic health record simulator. A referral support, consisting of dynamic diagnose-specific checklists, was created for the generation of referral letters to gastroenterologists. The GPs were randomised to refer the eight vignettes with or without the checklists. After a minimum of 3 months, they repeated the referral process with the alternative method.

Main outcome measures Difference in quality of the referral letters between referrals with and without checklists, measured with an objective Thirty Point Score (TPS).

Difference in variance in the quality of the referral letters and GPs’ acceptance of the electronic dynamic user interface.

Results The mean TPS was 15.2 (95% CI 13.2 to 16.3) and 22.0 (95% CI 20.6 to 22.8) comparing referrals without and with checklist assistance (p<0.001), respectively. The coefficient of variance was 23.3% for the checklist group and 39.6% for the non-checklist group. Two-thirds (16/24) of the GPs thought they had included more relevant information in the referrals with checklists, and considered implementing this type of checklists in their clinical practices, if available.

Conclusions Dynamic, diagnose-specific checklists improved the quality of referral letters significantly and reduced the variance of the TPS, indicating a more uniform quality when checklists were used. The GPs were generally positive to the checklists.

  • referral letters
  • General practice
  • communication
  • Health & safety

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  • Contributors SLE, TdL and LA designed the study. SLE performed the data collection. SLE, CB and CSR performed the power and data analysis. SLE drafted the paper. All authors critically reviewed and improved it. SLE is guarantor. All authors had access to all the data and take responsibility for the integrity of the data and the analysis.

  • Competing interests None declared.

  • Ethics approval The study was reported to and approved by the Data Protection Official for research. The Regional Ethics Committee considered the study outside its mandate, and its approval was not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Full data set and statistical code can be made available from the corresponding author. Participants’ consent was not obtained in accordance with Norwegian Data Protection legislation, but the presented data are anonymised and risk of identification is low.