Research | Published:

Modelling clinical decision-making in triage of referrals for extraction

BDJ volume 226, pages 6266 (11 January 2019) | Download Citation

Key points

  • Quantifies the accuracy of assessing referrals for extractions as tier 1 or tier 2 procedures.

  • Presents a model whereby the triage system can be improved without directly affecting quality of patient care.

  • Identifies a signicant propensity to underestimate the complexity of extractions when triaging referrals which could be improved by better quality referral letters.



Oral surgery services are progressively moving out of traditional hospital departments and into primary care. This necessitates accurate methods of triaging referrals, so patients of varying complexity are managed in the most suitable environment. The latest NHS commissioning proposal identifies 'level 1' procedures as simple extractions which do not require referral. We developed a model for quantifying how accurately these simple extractions can be predicted from information in standard referral letters.


Experienced clinicians (N = 10) were independently asked to predict whether extractions (N = 25) were likely to be simple-forceps or surgical procedures, from information provided in specially developed standardised referral letters. One oral surgeon had previously completed all extractions. The triaging clinicians were asked to comment on reasons for each decision and state their level of confidence in their predictions.


Only 67% (range 52–76%) of extractions were correctly predicted as either simple or surgical with a significant propensity to underestimate the complexity of surgical extractions rather than overestimating simple procedures (p <0.05). High levels of confidence reported by the clinicians in their decisions correlated with more accurate predictions (p <0.05).


This is the first attempt to develop a model for clinical decision-making in oral surgery triage services. Our findings suggest there is significant scope for improvement and highlight areas for development.

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We are grateful to colleagues who have assisted with this project and acknowledge the contributions of: Alsheima Osman, Mark Vardon, Mohsin Ali, and Sirisha Duggineni, Barts and the London School of Medicine and Dentistry; Dirk Slabbert, Sussex Implant Centre & Advanced Dentistry. We also acknowledge specific financial support to AL from the Royal College of Surgeons of England, Faculty of Dental Surgery.

Author information


  1. Centre for Oral Immunobiology and Regenerative Medicine, Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Newark Street, London E1 2AT

    • A. Lalli
  2. Centre for Teaching Innovation, Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London Newark Street London E1 2AT

    • W. Slabbert
    • , Z. J. Killick
    • , E. Quartey
    • , P. Marsden
    • , F. Mumford
    •  & J. Jones
  3. Sussex Implant Centre & Advanced Dentistry, Hazel Cottage, Warren Road, Woodingdean, Brighton BN2 6DA

    • W. Slabbert


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Correspondence to A. Lalli.

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