The objective of this study was to investigate the degree of consistency between the four Norwegian regional pain management centres in their assessments of the quality of the referrals that they receive and in their conclusions regarding the patients' right to necessary health care. The assessment of the content of the referrals showed that 7 of 16 information categories were to a large degree insufficiently described, and the admission teams deemed the quality of nearly one-half of the referrals to be 'not good'. These findings are consistent with those made by previous studies (7, 8, 10) and confirm the impression that in many cases referrals are of insufficient quality and frequently lack information which is essential to undertake an adequate assessment of the right to treatment in the specialist health service.
Insufficient information was an important reason why a large proportion of the referrals were characterised as 'not good'. Chronic pain is a complex condition, and substantial competence is required to describe the complexity of the illness. Low quality of referrals may reflect a need for competence enhancement on the part of the referrer. Referrals are frequently made by GPs, but the referrals in our study had come from both GPs and the specialist health service, and we were unable to distinguish between them. The list of recommended information items to include is long (3), but most likely, not all recommended information items will be relevant for all patients. The referral needs to communicate adequate information, but selecting the correct information items is a challenge not only for the referrer, but also for the pain management clinics. We found that there was moderate to low agreement between the admission teams in their assessment of quality. This means that the same referral was perceived differently by the various teams, which may reflect differences between them in terms of competence and experience. As a result, the information in the referrals may be weighted differently, signalling a need for harmonisation of the content assessment.
The overall rate of agreement between the admission teams regarding whom to grant the legal right to health care was lower than what is considered acceptable. The primary and secondary assessments granted 63 % the legal right to health care, but the rate of agreement was 69 %. The admission teams had no list of correct answers to consult, and the assessments were made on the basis of information in the referrals, with supplementary information in the patient records if available, as well as recommended guidelines and the experience in the team. What constitutes an acceptable level of agreement is thus debatable. Our results are consistent with findings made by previous studies. Ikezawa and co-authors (2010) investigated whether clinicians who were working in the same rehabilitation centre gave identical back-to-work recommendations. For patients with unambiguous pathologies they found a high degree of agreement (> 94 %) regarding the kind of information that was important in the assessment of the patients' discharge status, but low agreement in cases where the causes of pain and disability were complex (56 %) (22). A Norwegian study of admission teams in 16 district psychiatric centres also found a low rate of agreement in their assessments of the rights to health care for 20 selected referrals (13).
The above findings reflect the challenges that arise when the patient's clinical picture cannot be assessed in a classically medical and pathology-oriented perspective, and this is characteristic of the patient population in our study.
Our results indicate that whether a pain patient will be granted the legal right to health care or not, depends on which centre assesses the referral. The differences between the assessments may reflect varying competence in the centres, but also differences in treatment options within and outside the hospital. As long as competence and treatment options are not explicitly communicated, there is a risk that hidden and undesirable differences may arise between the health regions. The results may also indicate that the Guidelines to Priority Setting: Pain Conditions (4) ought to be reviewed. In addition, it might be considered whether they ought to be adapted for this complex patient group.
It is a recognised fact that the system of referrals needs structuring (23, 24). Standardisation of referral forms and guidelines, as well as involvement of clinicians in training programmes about the referral process, have been shown to produce improvements (9). Rokstad and co-authors (2013) found that the quality of specialist referrals was raised after the introduction of a normative information system. The system was used by 93 (the intervention group) of a total of 210 GPs. The quality of the referrals improved significantly, and less time was used (25). Our findings emphasise the need for a tighter structure that can guide the referrers regarding the information which is necessary.
The weaknesses in our study lie in the relatively small number of referrals that were assessed (40 in total), and that the screening form for the referrals was not validated. The centres that undertook the primary assessments had access to supplementary background information in the patient records, and this weakens the comparison with the secondary assessments. Within their normal time schedule, the admission teams had to undertake secondary assessments of 30 copies of referrals, in addition to the regular referrals. As a result, the reviews may have been less thorough and the assessments of rights may have been affected. The study's strength lies in its realistic nature, since all the assessments were undertaken within the standard clinical framework.