Dysphonia referrals got worse after the guideline, not better

Design

retrospective cohort audit comparing pre- and post-guideline referral periods at one academic centre

Population

528 adults referred with dysphonia between January 2015 and December 2022

Primary outcome

adherence to each 2018 hoarseness guideline recommendation relevant to referring physicians

Effect

timely referral 71.3% vs 80.9% (P = 0.027); overall adherence 52.5% vs 61.7% (P = 0.059)

An academic department audited 528 adults referred with dysphonia between 2015 and 2022, 141 before the 2018 hoarseness guideline and 387 after, and scored each referral against the recommendations aimed at referring physicians: refer in good time, do not image before laryngoscopy, do not give empirical antireflux therapy, corticosteroids or antibiotics, and do not start voice therapy before the larynx has been seen.

Adherence did not improve. It fell significantly for three recommendations: timely referral 71.3% after against 80.9% before, avoiding pre-laryngoscopy imaging 96.6% against 100%, and avoiding antibiotics 89.7% against 95.7%. Antireflux therapy, corticosteroid use and laryngoscopy before voice therapy did not change. Overall adherence to every analysed recommendation was 52.5% after against 61.7% before, P = 0.059.

The authors' conclusion is the useful one: passive dissemination of a guideline changes nothing. For the ENT surgeon on the receiving end, roughly half of referrals arrive having had something done that should not have been, and the recurring pattern - a course of antibiotics, a proton pump inhibitor, sometimes a CT - is both a delay and a cost. The fix is local and specific: a one-page referral proforma stating what the ENT department needs before it sees the patient, sent to the referrers who actually refer. For the GP reading this, the single most useful rule is that persistent hoarseness beyond a few weeks needs a look at the larynx before it needs a prescription.

• See the larynx before prescribing for persistent hoarseness - not antibiotics, steroids or antireflux therapy first
• Do not order imaging before laryngoscopy in dysphonia
• Do not start voice therapy before the larynx has been visualised
• Refer persistent dysphonia promptly, especially in a smoker or where there is any red flag
• Send referrers a short proforma rather than assuming they have read the guideline

Why it matters

Publishing a guideline demonstrably did not change referral behaviour, which puts the burden back on the receiving department to specify what it needs.

Don't overread it

A single-centre retrospective audit comparing two time periods cannot show the guideline caused anything, and the overall adherence difference was not statistically significant.

The statistics, in plain English

The apparent worsening is measured across two different time windows, so some of it could reflect who was referring rather than a change in behaviour - the post-guideline group is nearly three times larger and covers four more years. Differences of 3 to 9 percentage points reach significance here because the sample is reasonably large, but they are small in practical terms. The overall adherence figure at P = 0.059 did not reach significance and should be read as no demonstrated change either way.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.