Publishing a hoarseness guideline changed referral behaviour — slightly for the worse

Design

retrospective before-and-after cohort study at a single tertiary academic centre, comparing referral practice across the 2018 guideline update

Population

528 adults referred for a primary complaint of dysphonia between 2015 and 2022; 141 pre-guideline, 387 post-guideline

Primary outcome

adherence to guideline recommendations addressed to referring physicians, individually and combined

Effect

timely referral 80.9% to 71.3% (p = .027); avoidance of imaging 100% to 96.6% (p = .028); avoidance of antibiotics 95.7% to 89.7% (p = .028); all recommendations combined 61.7% to 52.5% (p = .059)

The 2018 hoarseness and dysphonia clinical practice guideline made specific asks of referring physicians: refer in good time, do not image before laryngoscopy, do not give empiric antireflux therapy, steroids or antibiotics, and do not prescribe voice therapy before the larynx has been examined. This study checked whether any of that happened, reviewing 528 adults referred to an academic otolaryngology department for dysphonia between 2015 and 2022 — 141 before the update and 387 after.

Adherence did not improve on any measure, and fell significantly on three. Timely referral dropped from 80.9% to 71.3% (p = 0.027), avoidance of pre-laryngoscopy imaging from 100% to 96.6% (p = 0.028), and avoidance of antibiotics from 95.7% to 89.7% (p = 0.028). Antireflux therapy, corticosteroid use and referral before voice therapy showed no significant change. Overall adherence to all recommendations went from 61.7% to 52.5%, which did not reach significance (p = 0.059).

The authors draw the right conclusion: passive dissemination does not change behaviour. For an ENT department, the practical response is not to publicise the guideline again but to build it into the referral pathway — a structured referral form that asks what has already been tried, an explicit target time for dysphonia referrals, and direct feedback to high-volume referrers. The limits are worth naming: one academic centre, a before-and-after design with no control for secular trends, and post-2018 referrals overlapping a period when access to primary care changed considerably. The direction of change should not be over-read; the absence of improvement is the durable finding.

• Do not rely on guideline publication to change referral behaviour — it did not here
• Build the recommendations into a structured dysphonia referral form rather than a circular
• Set and monitor an explicit target interval for dysphonia referral
• Give named feedback to high-volume referrers; general dissemination did nothing
• Single centre, before-and-after with no control for secular change — read the null, not the apparent worsening

The statistics, in plain English

The three significant declines all sit at p values just under 0.05 across six separate comparisons, so at least one is likely to be chance — which is why the overall composite (61.7% to 52.5%, p = 0.059) is the more informative result, and it shows no significant change. A before-and-after design attributes to the guideline any change that happened over the same seven years, including changes in primary care access and referral systems that had nothing to do with it. The pre-guideline group was small (141 patients), so its baseline percentages are less precisely estimated than the post-guideline ones.

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