Physician characteristics associated with the referral from general practitioners to dental surgeons and proposal for a referral letter template endorsed by dental surgeons in France: a nationwide cross-sectional survey-based study

Abstract

Background

Interprofessional relationships between general practitioners (GPs) and dental surgeons with a doctorate in dental surgery are essential for the optimal management of the oral health of patients. The objectives of this study were to describe the factors associated with the referral of patients from GPs to dental surgeons in France, and to improve referral practices by establishing a standardized set of items to be included in a referral letter.

Methods

A nationwide, observational, survey-based, cross-sectional study was conducted from 9 February 2023 to 6 April 2023. Two 13-item questionnaires were sent to GPs and dental surgeons. Data on practitioner characteristics, frequency, and perceived usefulness of medical correspondence between the two healthcare professionals were collected. Candidate items selected by expert medical opinion for a standardized referral letter template were appraised by the responding oral surgeons.

Results

A group of 245 dental surgeons (mean age: 38.2 ± 11.1 years, 64.5% female) and 235 GPs (mean age: 36.8 ± 9.8 years, 71.9% female) participated in this study. Medical correspondence between GPs and dental surgeons was reported to be insufficient by most dental surgeons (91.4%). Dental surgeons agreed that GP correspondence could decrease the occurrence of adverse events linked with dental care (mean score: 7.36 ± 2.4, for a maximum of 10). Only 20% of GPs indicated that they had regular communication with dental surgeons. The physician characteristics under study were not statistically associated with initiating referrals. The items most frequently selected by dental surgeons for inclusion in a template referral letter were the presence of diabetes (99.6%), of immunosuppression (98.8%), and medication by anticoagulant or antiplatelet agents (98.3%).

Conclusions

Despite known links between oral and general health, most healthcare professionals did not engage in correspondence or referrals with the other specialty. Standardized referral letters could include the list of items for which interest was confirmed by dental surgeons (including presence of diabetes, immunosuppressants and anticoagulants or antiplatelet agents).

Background

The role of a general practitioner (GP) is to coordinate care and ensure the continuity of care during follow-up. Cooperating and developing collaborations between other healthcare professionals (HCPs), as well as participating in care networks are vital in general practice, particularly when working on complex medical situations.

Oral health promotes general health. Interactions between general medicine and dentistry are necessary to ensure adequate care [1]. Dental physicians with a doctorate in dental surgery work with patients in primary and preventative care settings. In France, as in other countries, the relationship between GPs and dentists have not been as strong as those with internists or other surgeons, because dentists and GPs are members of different professional organizations [2]. Moreover, interactions between these HCPs are very limited, and this lack of collaboration has been considered detrimental for the care of patients [3, 4]. A qualitative study in the form of semi-structured interviews with dentists and GPs in in the Val-d’Oise Department reported a lack of interest on the part of GPs in the dental health concerns of their patients, as well as, a rare and discontinuous relationship between the two professions [3]. The author suggested that better participation in continuous training or membership in care organizations such as the Communautés Professionnelles Territoriales de Santé (CPTS: an association of healthcare professionals that coordinate the healthcare of their patients within a territory) or Maison de Santé Pluridisciplinaire (MSP: a large practice hosting a group of healthcare professionals with various specialties) could promote better communication [3].

Medical correspondence plays a key role in improving communication between HCPs. Referral letters are the most frequently used means of communication [5] and are mostly in paper format and delivered to a patient by hand during a consultation. Imprecise, inaccurate or absent listings of current and previous treatments may be damaging to the patient [6]. Various interventions have been tried to improve the quality of referral letters: electronic referrals, peer feedback, use of letter templates [5, 7]. For example, letter templates have been shown to improve the perceived quality of the referral [7]. However, most of these interventions did not specifically target the referral from GPs to oral surgeons.

Adverse events in oral care can be frequent, and other illnesses can be passed on from the onset and progression of oral diseases [8,9,10]. Better communication between GPs and dental physicians could improve overall patient care. Few studies have been conducted on the medical correspondence and forms of communication used between general and dental practice [3, 11]. The objectives of this study were to describe the factors associated with the referral of patients from GPs to dental surgeons at a national scale in France, and to improve the referral process by establishing a list of items to be included in a standardized referral letter.

Methods

Study design

An observational, cross-sectional study was conducted from February 9, 2023 to April 6, 2023. Two 13-item questionnaires were sent by email to GPs and dental surgeons, with the aim of describing the association of needs and demands of medical correspondence between GPs and dental surgeons as part of their routine clinical practice. The self-declared questionnaires included binary, free form, 10-point Likert scale and multiple-choice questions (see Supplementary Table 1).

The questionnaire was distributed by email, as well to private groups of HCPs on social networks. The questionnaires were accompanied by a leaflet explaining the study. Three reminders were sent at two-week intervals. A link in the email correspondence directed participants to a Google Forms, specifically designed for the study, and adapted for each HCP category (GP or oral surgeon). An information leaflet including a summary of participant rights and data processing characteristics was provided with the questionnaire.

Inclusion/exclusion criteria

Participants were included if they were qualified physicians practicing in France, self-employed GPs, general medical interns with a replacement license, or dentists practicing in France, and had completed the questionnaire. Exclusion criteria were GPs that were not self-employed nor clinically practicing in France.

Variables and data collection

The collected variables included baseline characteristics such as sex, age, years of medical practice, work location type and CPTS membership. Data on the effectiveness, perception and relevance of communication and medical correspondence between the two HCPs was collected. Participants were asked about the medical information they would consider to be of interest in a standardized medical letter used for referral. The candidate items were identified by expert opinion (by two experts within the field of medicine), and included: (i) smoking, (ii) alcohol use, (iii) anticoagulation and antiplatelet agents, (iv) allergies and hypersensitivities, (v) recent antibiotic treatment, (vi) cardiac prosthesis, (vii) osteoporosis, (viii) diabetes, (ix) coagulopathy, (x) immunosuppression, xi) multi-resistant bacteria carrier, xii) list of medical and surgical history, xiii) list of drug treatment, xiv) diagnostic hypotheses and xv) buccal diagram with the identification by a GP.

Statistical analysis

Quantitative variables were described using the mean and standard deviation (SD), and qualitative variables using absolute frequencies and percentages (%). Dental physicians were separated in two groups according to whether or not they had received referral letters. On the other side, GPs were also separated in two groups according to whether or not they had sent referral letters. Chi-squared tests and Student’s t tests were used to compare each pair of groups. A further analysis was conducted according to the self-declared sufficiency of communication between dental surgeons and general practitioners. Results were reported as crude Odds Ratios (OR) with 95% confidence interval (CI). A p-value < 0.05 was considered statistically significant. Analyses were performed with SPSS 27.0 software (Armonk, NY: IBM Corp).

Ethical considerations

This study was not subject to Jardé Law and did not fall within the scope of Article R.1121-1 of the French Public Health Code, therefore, in accordance with French legislation no. 2021 − 300 of March 5, 2012, an ethical committee approval was not required. No personal data were collected. Informed consent was obtained from all participants in the study at the beginning of the questionnaire.

Results

In total, 245 dental surgeons and 235 GPs were included in this study. Most participants were female (dental surgeons: 64.5% and GPs: 71.9%) and the mean age was slightly higher for dental surgeons than for GPs (dental surgeons: 38.2 ± 11.1 years, and GPs: 36.8 ± 9.8 years). More than half of the dental surgeons practiced in an urban setting (51.0%). The mean dental practice duration was 11.8 ± 10.7 years (Table 1). The number of CPTS memberships was low for both HCPs (dental surgeons: 9.8%, and GPs: 21.7%). Very few dental surgeons had a GP within their clinical practice (2.4%), while less than half (44.1%) worked in regular coordination with a GP.

Table 1 Baseline characteristics

Regarding GPs, 42.6% practiced in urban settings, and the mean duration of activity in general practice was 6.1 ± 9.0 years (Table 1). Very few (2.6%) reported that their place of work included a dental surgeon, while 20.0% reported that they had regular medical correspondence. Most dental surgeons (91.4%) reported that the communication between the two medical professions was insufficient, and that improvement in initial oral health training of GPs was required (91.4%). Dental surgeons agreed that GPs play a role in oral health prevention (mean 6.6 ± 2.9 on the 10-point Likert scale), and dental surgeons who had received referral letters had a higher score for this question (p < 0.001) (Table 2).

Table 2 Characteristics of dental surgeons according to whether they received referral letters by general practitioners

Most GPs indicated that they regularly advised their patients to consult dental surgeons (82.6%) and referred their patients to one when needed (91.5%). 14% of GPs stated that medical correspondence between GPs and dental surgeons was poor and 13.6% reported that the initial training in general practice was insufficient for oral pathologies (Table 3). GPs agreed that medical correspondence between dental surgeons and GPs was insufficient (mean score: 8.12 ± 2.33) and there was a soft agreement on the fact that referrals would be easier if letters were in a standardized format mentioning the essential medical information to be transmitted (mean score: 6.21 ± 2.93) (Table 3).

Table 3 Characteristics of general practitioners according to whether or not they sent referrals for their patients to dental surgeons

Dental surgeons reported that medical correspondence with GPs would reduce adverse events related to dental care (mean score: 7.36 ± 2.4), and this opinion was more frequent in dental surgeons who did not consider having sufficient communication with GPs (mean score: 7.51 ± 2.3) versus those who did have communication (mean score: 5.81 ± 3.0) (p = 0.019) (Table 4).

Table 4 Characteristics of dental surgeons according to the self-declared sufficiency of communication between themselves and general practitioners

Regarding candidate information items for a standardized referral letter model, most of the candidate medical terms were confirmed for inclusion by dental surgeons. The items most frequently selected by dental surgeons were the presence of diabetes (99,6%, n = 244), of immunosuppression (98,8%, n = 242), and medication by anticoagulant or antiplatelet agents (98.4%, n = 241). The items least often considered for inclusion were: buccal diagram with lesions identified by the GP (17.1%, n = 42) and diagnostic hypotheses (56,3%, n = 138) (Fig. 1).

Fig. 1

Frequencies of items listed by general practitioners and dental surgeons

Discussion

This study showed that the interaction between dental surgeons and GPs may be limited in real-life settings and that there was a tendency for poor medical correspondence on the part of GPs despite a high overall need expressed by dental surgeons. Similar findings were reported by Holzinger et al. (2016) in an interview based study in which the interactions between GPs and dentists appeared rare and complicated [12]. In another study, Huettig et al. (2018) reported that GPs referred their patients to dental physicians without contacting them [13], which was similar to our study, in which most GPs asked their patients to contact a dental physician directly. Sippli et al. showed that GPs felt that there was no need to collaborate with dentists, whereas dentists were interested in extending medical-dental practice collaborations [2].

Most of the GPs that participated in our study were women, which is consistent with data found in the atlas of medical demography in France [14] where women represented 52.5% of GPs of all ages in general practice in 2022, of which 65.6% were under 40. Our results also matched data from the Observatoire National de la Démographie des Professions de Santé (ONDPS), in which female dental surgeons represented 35% of the total workforce in 2006, growing to 48% in 2021 (59% in the 25 to 29 age group) [15]. It may be worth noting that gender was not a factor influencing medical correspondence.

Age, type of practice, number of years and CPTS membership did not influence the collaboration and communication between the two HCPs. Although Tenenbaum et al. (2008) [4] suggested that the development of joint care organization modes such as CPTS could promote partnerships between dental and general medicine, this was not found in our study. CPTS membership is expected to enable multi-professional care and the decompartmentalization of care [16]. However, it would appear that the number of CPTS members surveyed in our study was low, which may have hindered the potential for uncovering an effect of this variable.

Regarding the low collaboration of GPs and dental surgeons within the same workplace reported in our study, Tenenbaum et al. [4] suggested that multi-professional group practice such as those found in MSP could help increase this collaboration, which may be important to improving overall patient care. Such structures are partly remunerated on the basis of public health and collaboration objectives, and funding can act as an incentive for group practices, motivating HCPs to work together [17, 18].

A 2003 report of the National Institute of Medicine regarding the education of health professionals has indicated that “Work in interdisciplinary teams” is one of the five core competencies that all clinicians should possess [19]. The low referral rate reported by dental surgeons in our study shows that more than 20 years later, this aim has not been achieved yet in industrialized countries.

Improved communication between the two professions could improve medical and dental outcomes by enabling a more comprehensive and accurate exchange of information between HCPs.

Medical referral mail is one way of ensuring quality of care through optimal coordinated management [5, 7]. Since improving oral health care is a public health issue, financial incentives could be a solution to encourage GPs to adopt this approach. Improving coordinated oral health care could be implemented by adding an indicator for referrals to dental surgeons’ remuneration for the public health objectives known in France as Rémunération sur Objectifs de Santé Publique (ROSP). These ROSP indicators could be modified to reinforce their impact on the quality of practices [20].

Medical correspondence by mail plays a role in communication between HCPs. and remains the most widely used means of medical contact [5, 7]. Future studies aiming to develop a standardized referral letter can start with the items listed in our work.

The limitations of this study included a relatively low sample size, and selection bias due to a low response rate. Despite our use of a multi-channel approach, we were only able to reach 245 dental surgeons and 235 GPs among the several thousand practicing in the Grand Est region [14]. This may have been due to the short data collection period and the recruitment methods used to promote the survey. Future research should include larger and more diversified samples in order to gain a better understanding of the communication dynamics between dentists and GPs. Selection bias could also be present since the survey may have been mainly of interest to dental surgeons dissatisfied with their relationship with GPs. Though this study was conducted nationwide and the questionnaires were distributed by the national medical council (Conseil National de l’Ordre des Médecins), respondents mostly came from the Aube Department in France.

Conclusions

Our findings suggest that the inter-professional relationship between GPs and dental surgeons could be improved with better communication, as few dental surgeons indicated that they had received referral letters from GPs. Besides the presence of routine correspondence, we did not find other factors to encourage referral letters. Standardized referral letters could include the list of items for which interest was confirmed by dental surgeons in our study (including the presence of diabetes, immunosuppressants and anticoagulants or antiplatelet agents). Increasing initial and continuous training of GPs relating to oral pathologies could encourage inter-professional work.