Opinions on Referral Guidelines from Audiology to ENT


23 Jan 2018

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A Survey of Opinions on Referral Guidelines, Onward Referral Criteria from Audiology to ENT

Name: Joseph Browne



The Audiologist's primary role in healthcare includes the identification of hearing loss, its management and hearing conservation. Moreover, audiologists also function as ‘gatekeepers’ to secondary medical care. As a result, appropriate audiological referrals can, for some patients, reduce the risk of worsening hearing and other associated medical complications, e.g. otitis media with effusion (OME), cholesteatoma’s etc. In contrast, inappropriate referrals can add to the case workload of an already overburdened health service; can cause anxiety for the patient; and can place increased fiscal pressure on an already over budget HSE.

Audiology in Ireland is a relatively new profession by medical standards. In the future, the current author presupposes that as the profession matures, audiologists will assume a greater degree of responsibility. As a result, this will lead to more clinical and diagnostic decisions being made by the Audiologist. Moreover, many areas of uncertainty abound with respect to referral criteria, care pathways, and guidelines in use for both the adult and paediatric population. As a result, the current author hypothesises varying degrees of opinion exists with respect to referral criteria. Some expressed concern about the number of inappropriate referrals they receive from Audiology, while others were of the opinion that it was manageable, that referrals on the whole were appropriate, and that they did not add significantly to their caseload.

Similarly, with regards the audiologists working in the HSE, whilst many may reference BAA / BSA referral guidelines this may not be the case for the ENT Consultants. Their reference source may be the BSA, BAA TTSA, NICE or ASHA guidelines or indeed a fusion of all three. Interestingly, little has been published with respects to referral criteria from an audiology perspective, this begs the question, do we all agree on the definitions in use in the referral guidelines or is there a variance in meaning between professionals or from hospital to hospital? Identifying the steps to improving a process or policy firstly requires: (i) assessment of current opinions (ii) identification of referral criteria (iii) the identification of the facilitators that can augment policy or process change, (Grimshaw, 2003; Robertson, Baker, & Hearnshaw, 1996). Moreover, the awareness of attitudes and opinions between the associated professionals has the potential to assist in the design of effective and efficient policies and guidelines (Grutters, Van Der Horst, Hans Verschuure, Dreschler, & Anteunis, 2007). The present study focuses on the attitudes and opinions of audiologists and ENT Consultants working within the HSE in Ireland, and the potential facilitators for implementation of referral criterion and care pathways for a client being referred from audiology to ENT.


Having carried out an extensive, indebt literature search on this topic, the current researcher was disappointed with the scarcity of information available on the subject – making it difficult to present a comprehensive literature review of findings. However, it highlighted the gap in research in this area and presented an exciting opportunity for the researcher to gather information and fill this void. As a result, the current researcher focused on research carried out by other professional groups, with similar aims in mind. Accordingly, many of the reviewed papers were of an international nature with their primary focus on physicians referring to secondary care for a variety of reasons.

In 2008, Walshe, Chew-Graham, Todd, & Caress, undertook a qualitative study of 3 primary care trusts in the UK to investigate the referral decisions within community palliative care services. Consequently, the researchers identified that healthcare professionals often made independent decisions on the appropriateness of referrals based on their expertise, workload and relationship with their patients. Similarly, some UK researchers, (Fertig, Roland, King, & Moore, 1993: De Marco, Dain, Lockwood, & Roland, 1993), attemptedto influence GP referral behaviour, namely by audit and local guidelines. However, scepticism on receiving feedback comparative to local norms resulted in the studies being abandoned. More specifically, GP’s cited data accuracy and lack of consensus on the link made between referral rates and quality of care led to the study being abandoned. Subsequently, in a 1994 Delphi study by McColl, Newton & Hutchinson, the researchers set out to understand what influences GP referrals and to identify areas of change. Interestingly, improved access to consultants was identified as an area for improvement. As a result, ‘BoneLine’ was introduced whereby GPs had access to consultants at specified times. However, uptake was poor, however, those who did take advantage of the services found a 22% reduction in their referral rates as a result of having the phone support available to them. No such papers were recovered for Ireland.


Available literature on referral criteria and opinions is dated and deals mainly with the opinions of primary care physicians, particularly in the United Kingdom. The literature review uncovered no evidences from an Irish perspective. It is therefore proposed that such a study be conducted in Ireland. The primary purpose of such a study would be to survey otolaryngologists and audiologists with regard to otology referrals in Ireland.

  1. to ascertain which referral guidelines are in use within the HSE
  2. to assess openness of communication channels between audiology and otolaryngologists
  3. to assess working knowledge of referral guidelines
  4. feasibility study for an ‘expert’ group for the formulation of Irish guidelines


The researcher has designed a short survey to achieve the research aims outlined previously, appendix (i). With CREC approval, this survey will be administered via Survey Monkey, an online surveying tool. In addition, an accompanying e-mail will explain the research question so that the participants can make an informed decision as to whether or not to participate in the study. This will ensure that the participant understands: a) the research in question b) the reason the study is being conducted and c) the potential benefit of the research.

A survey is a research study in which a large number of persons or other units respond to an interview or questionnaire (Mark, 1996). By using this medium, the researcher envisages less susceptibility to information or interviewer bias. However, also acknowledges the possibility of having no responses to questions. Furthermore, by using an online self-administered survey the researcher can reach a larger sample size and cover a wider geographical area. However, by using an electronic questionnaire the researcher has identified that he may inadvertently introduce a potential bias as not all those being surveyed may have access or regular access to e-mail.

For the proposed research question, a quantitative survey with 10 closed statements will be used to assess opinions. The statements have been constructed so as to elicit opinions from Otolaryngologists (Consultant and Non-Consultant) and Audiologists regarding their opinions based on 3 constructs: i) Efficacy of Communication between peers, ii) use of referral guidelines, iii) if a need exists for a feasibility study for Irish guidelines. The survey will be e-mailed to otolaryngologists and audiologists currently listed as working in the HSE with 2 follow-up emails 1 week apart. As the researcher is not employed by the HSE, he acknowledges access to the relevant e-mail addresses is unlikely. As a result, approval will be dependent on the goodwill of decision makers within the HSE to assist in e-mailing the survey to the participants.

Participants will be asked to indicate their level of agreement or disagreement to each statement using a structured interval level response format. The responses will be given a non-forced, balanced ordinal value for statistical purposes: (1) strongly disagree, (2) disagree, (3) no opinion, (4) agree, and (5) strongly agree. The current author acknowledges variants of the Likert scale are commonly used in research, for example 7 and 9 points scales. He has identified these could yield finer discrimination to the research questions. However, the author also believes that a Likert scale larger than 5 points may appear ‘off putting’ for some and as a result could jeopardise his research. In addition, by using the Likert scale of 1 – 5 it will be more straightforward for the current author to construct and administer the scale. Furthermore, it will be easier for the participants to understand, therefore being suitable for the current study.


Once the surveys have been concluded the results will be collated. The responses will be analysed using an Independent Sample t-test to analyse the mean between groups or the Mann-Whitney U test to test the median between the groups. More specifically, variability between the groups will be determined by administering an independent sample t-test to determine if variability exists. This will yield 2 p-values, one will identify if the variance between the groups is significantly different (Levene’s test). Moreover, if a difference is found, statistics should identify if the differences between the groups are significant (Trochim, 2001). Otherwise, the Mann-Whitney U test, which is a non-parametric test, will be used to compare the difference between the groups when the dependent variable is ordinal. This will then be administered assuming the independent sample test cannot find a comparison, (Hollander, Wolfe, & Chisken, 1976). Results will be reported in text and displayed visually for the purpose of clarity using MS Excel.


At present, there are lengthy waiting lists throughout Ireland in both the otolaryngology and audiology setting. Any steps to improve; referral criteria, waiting times and develop better patient care pathways for the professionals involved and the public alike should be taken.


The literature review has highlighted a need for up-to-date research on the topic, a need for audiologists and otolaryngologists to have an Irish input to the research question. Accordingly, ethical approval is being sought by the current author to send out a survey to all

Appendix I:

Appendix II:

Appendix III:


1.I work as a:

Consultant Otolaryngologist

Non-Consultant Otolaryngologist

Community-based Audiologist

Hospital-based Audiologist


2.How long have you been practicing in your hearing related field?

Less than a year

1-5 years

6-10 years

15 years +


3.Please select one option to each statement which best represents your feelings on the following:


Strongly disagree




Strongly agree

Communication between my peers is good

There needs to be more communication between my peers

Communication between my peers needs to be improved

I have supportive correspondence with my peers in an appropriate time scale

Additional comments


4.Which of the following referral guidelines are you aware of? Please tick all that apply.






None of the above

Q 5

5.Which, if any, of the following referral guidelines is your main source of reference?






Additional comments


6.Please select one option to each statement which best describes your use of referral guidelines


Strongly disagree




Disagree strongly

Up-to-date guidelines are easy to locate

I find referral guidelines easy to understand

At times, Audiologists refer inappropriately due to uncertainty


7.Please select one option to each statement which best describes how you USE referral guidelines


Strongly disagree




Strongly agree

I use guidelines in most or all consultations where referral may be necessary

I look at guidelines if I encounter difficult or unfamiliar cases

I rely on memory in order to apply recommendations

I regularly check for updated guidelines

Other (please specify)


8.In order of preference, which of the following options best describes WHY you use guidelines?

To help me make better clinical judgments

They are a requirement of local HSE policy

They will reduce the possibility of legal action against me

I don't use guidelines


9.Which of the following formats would best suit your needs for clinical decision making in the future?

Expert advice on which guidelines are most appropriate

Access to up-to-date paper-based guidelines

E-mail correspondence with a link to electronic guideline

Correspondence when guidelines are updated

Information informing me which guidelines are available


10.In your opinion, which of the following requires onward referral to ENT?





5 year old Pt presenting with OME

15 dB air bone gap between Lt & Rt @ 1 & 2K, 20 dB air bone gap @ 4K

Impacted wax prior to PTA assessment

Pt hearing within normal thresholds but complains s/he is unable to hear in moderate background noise

Asymmetrical tinnitus

Pt who has never had PTA presents with unilateral hearing loss of unexplained origin which s/he has had for 10+ years

Additional comments


11.Briefly, what is your working definition of 'asymmetrical tinnitus’?


12.Would you be willing to participate in an 'expert' group to formulate Irish referral guidelines?



Additional comments

Appendix IV: E-mail requesting participation in a SurveyMonkey survey

Dear Professionals,

My name is Joseph Browne, an MSc. student at University College Cork. As part of my studies in Advanced Audiology, I am currently undertaking a study on ‘A Survey of Opinions on Referral Guidelines, Onward Referral Criteria from Audiology to ENT’

I appreciate that you are very busy but would greatly appreciate it if you would participate in this study.

The online survey is very short consisting of 12 statements requiring that you agree or disagree on a scale of 1-5 and should only take a few minutes to complete.

Please note that participation in this study is completely voluntary. You have the right to decline to participate. You also have the right to abandon the survey at any time before completing it. Should you agree to complete the survey your IP address, name and e-mail address will NOT be recorded. Therefore, I will not know who did or did not complete the survey which will ensure your identity is protected.

After the survey has been submitted however, you will not be able to withdraw from the study. It will be taken that you are providing your informed consent to participate in this online survey if you click on the encrypted link provided below. .

Ethical approval for this study has been received from the Clinical Research Ethics Committee of the Cork Training Hospitals (CREC). Should you require any further information please do not hesitate to contact me at: 5 Commerce House, Flood Street, Galway. T: 091 567 888 or [email protected]

Thank you for taking the time to read this proposal, and I appreciate that you considered taking part.

The closing date for the survey is ?? May, 2014.www.surveymonkey.com (link)

Kind regards

Joseph Browne References

Marco, P., Dain, C., Lockwood, T., & Roland, M. (1993). How valuable is feedback of information on hospital referral patterns? British Medical Journal, 307(6917), 1465-1466. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/

Fertig, A., Roland, M., King, H., & Moore, T. (1993). Understandating variation in rates of referral among general practionners: are inappropriate referrals important and would guidelines help to reduce rates? British Medical Journal, 307(6917), 1467-1470. Retrieved from http://www.ncbi.nlm.nih.gov/pmc

Grimshaw, G. R. (2003). From best evidence to best practice: effectiveimplementation of change in patients’ care. Lancet, 362(3931), 1225-1230.

Grutters, J. P., Van Der Horst, F., Hans Verschuure, M. A., Dreschler, W. A., & Anteunis, L. J. (2007, April 17). Potential barriers and facilitators for implementation of anintegrated care pathway for hearing-impaired persons: anexploratory survey among patients and professionals. BMC Health Services Research. http://dx.doi.org/10.1186/1472-6963-7-57

Hollander, M., Wolfe, D., & Chicken, E. (1973). (3 ed.). New York: Wiley.

Mark, R. (1996). Research Made Simple, A Handbook for Social Workers. London: Sage.

Robertson, N., Baker, R., & Hearnshaw, H. (1996). Changing the clinical behavior of doctors: a psychological framework. Quality Healthcare, 5(1), .

Trochim, W. M. (2001). The Research Methods Knowledge Base. United States: Atomic Dog Publishing.

Walshe, C., Chew-Graham, C., Todd, C., & Caress, A. (2008, July). What influences referrals within community palliative care services? A qualitative case study. Social Science & Medicine, 67(1), 137 - 146. http://dx.doi.org/10.1016/j.socscimed.2008.03.027

Wilkin, D., & Smith, A. (1987). Explaining variation in general practitionerreferrals to hospital. Family Practice, 4(3), 160 - 169. Retrieved from www.oxfordjournals.org


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