Intended for healthcare professionals

Rapid response to:

General Practice

Explaining variation in hospital admission rates between general practices: cross sectional study

BMJ 1999; 319 doi: (Published 10 July 1999) Cite this as: BMJ 1999;319:98

Rapid Response:

Hospital admission rates may be misleading


Rates of general practitioner referrals to hospital outpatients have
been extensively studied, but emergency referrals, which are potentially
far more disruptive to patients, as well as being very expensive, have
Reid et al in their study published 10 July (1) address this issue
indirectly by studying hospital admissions in a large well designed study.
They acknowledge, and the accompanying editorial (2) also highlights, that
admission rates do not necessarily reflect referral rates.
This is not just a theoretical point. In a pilot prospective study of 760
emergency referrals to Northwick Park Hospital, London, in 1993-4 there
was a very wide variation in referral patterns. The highest referring
practice, which referred over 4 times the median number, had under a
quarter of all referrals admitted, the rest being sent home after
assessment. The average practice had two-thirds of their referrals
admitted. This does not necessarily mean that any referrals were
inappropriate, but if emergency admission rates had been studied the
difference in referral rates would have appeared much smaller than it was.
In this small sample 20% of all emergency referrals made to the hospital
were made by 10 GPs, out of over 200 GPs in the hospital catchment area.
Trying to determine emergency referral rates accurately is fraught with
methodological problems, but wide differences in admissions seen in
studies of emergency admissions may well be a significant underestimate of
the differences in true rates of referral.

Yours faithfully

Christopher JM Whitty
Department of Medicine,
College of Medicine,
University of Malawi,
Private Bag 360, Chichiri,
Blantyre 3,

1) Reid FDA, Cook DG, Majeed A. Explaining variation in hospital
admission rates between general practices: cross sectional study. BMJ
1999; 319: 98-103

2) Jankowski R. What do hospital admission rates say about primary
care? BMJ 1999; 319: 67-8.

Competing interests: No competing interests

23 July 1999
Christopher JM Whitty