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OBJECTIVE: To determine the relative importance of medical and nonmedical factors influencing generalists’ decisions to refer, and of the factors that might avert unnecessary referrals.
DESIGN: Prospective survey of all referrals from generalists to subspecialists over a 5-month period.
SETTING: University hospital outpatient clinics.
PARTICIPANTS: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology.
MEASUREMENTS AND MAIN RESULTS: For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals.
CONCLUSIONS: Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost.
On average, fewer than 5% of office visits to primary care physicians result in referral. 1–7 However, referrals generate significant economic costs for both physician fees and diagnostic tests. 3,8–10 Moreover, referral rates for individual generalists vary widely, suggesting a high level of uncertainty about appropriate referral practices. 1–3,6,11–17 Both underreferral and overreferral can affect quality of care. Underreferral can lead to inappropriate, cost-ineffective, or even dangerous treatment, and may result in costly litigation. 18 Overreferral can lead to fragmented care “by committee”; overtesting and repetitive testing; dangerous polypharmacy; patient confusion and isolation; and complacency on the part of generalists who lose their motivation to continually acquire new knowledge. 19–23
When appropriate, referrals from generalists to specialists can lead to improved patient outcomes, as well as decreased costs through optimal use of physician, hospital, and laboratory services. Studies have suggested benefit for certain patients with severe depression, 24 somatization disorder, 25 AIDS, 26,27 diabetes, 28 rheumatoid arthritis, 29,30 and Parkinson’s disease, 31 among others. Other referrals may be avoidable, poorly timed, or of limited value in guiding diagnosis or treatment and, thus, potentially inappropriate. 32,33
Subspecialty societies, residency programs, and HMOs have paid increasing attention to referrals. 33–36 Although it is unclear how referral rates for HMO patients compare with those for patients in fee-for-service plans, 37 many HMOs and insurance companies have established referral review committees, some of which employ industry-created guidelines for appropriate referrals. 38–40 However, both referral guidelines and referral review committees were created based on a small fund of public knowledge regarding referrals. Thus, it is important to learn more about the referral process so that we can improve its quality and efficiency.
We chose to study the referral process from the perspectives of both generalists and specialists. Our objectives were the following: (1) to determine the perceived importance of a number of medical and nonmedical factors influencing generalist physicians’ decisions to refer; (2) to ascertain generalists’ and specialists’ views regarding the avoidability of referrals and factors that might avert unnecessary referrals; and (3) to determine specialists’ views regarding the appropriateness, timeliness, and complexity of the referrals they receive from generalists.
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The present investigation produced three major findings. First, most referrals to the four specialties studied were made for a combination of medical and nonmedical reasons. This is consistent with Ludke’s work on referrals for possible breast cancer, 4 and with Langley et al.’s data on consultation requests by family physicians. 41 Second, specialists rated the majority of referrals they received as both timely and appropriate. Nevertheless, the appropriateness of a significant minority of referrals was questioned. Third, generalists reported that up to one third of referrals could have been averted. However, generalists and specialists frequently disagreed on which referrals could actually have been avoided.
Many previous studies of referrals have looked at a very small number of physicians or referrals 3,42–44; larger investigations have tended to focus more on rates of referral and less on doctors’ reasons for referral. 1,2,6,15–17,34,45,46 Those studies that did evaluate physicians’ reasons for referral mention the desire for advice on diagnosis or management, performance of a procedure, or a second opinion 4,9; generalist’s workload; practice style (“aggressive” vs “watch and wait”) 17; time constraints; a need to reduce one’s own anxiety over care of the patient; availability of consultants 35; familiarity with the patient 47; patient expectation of or request for referral 41,48; and familiarity of the generalist and patient with the available specialists. 4,19,49 Previous studies have not elicited the perceptions of the consulting specialists regarding specific referrals, nor have they sought to identify the factors that may have allowed some referrals to have been safely delayed or averted.
Our findings that patient request for referral influenced one fifth of referral decisions echoes those of Armstrong et al., 48 who showed a positive correlation between a practitioner’s referral rate and the degree of pressure he or she felt from patients for referral, and Marton et al., 50 who reported that patient expectation for an upper gastrointestinal series played a role in two thirds of ordered procedures. Studying different groups in internal medicine outpatients in managed care settings, Lin et al. found that 54% of patients felt that they either needed or possibly needed subspeciality referral 51; the corresponding figure in Kravitz et al. was 37%. 52 Menken et al. found that in one third of general internists’ referrals to neurologists in an HMO, the neurologists’ advice regarding diagnosis and treatment was of minor or no importance. 32 Rather, such referrals often resulted from patient and family demands, or else were focused on a perceived need for neuroimaging, even when the likely diagnosis and required treatment were already evident. Even so, seeing a specialist can provide many patients with reassurance, 42 and can be considered beneficial and appropriate if, over the long run, specialty contact leads to fewer visits and better outcomes at lower costs.
Our findings of partial agreement or outright disagreement between generalists and specialists over the avoidability of referrals by telephone consult parallel those of Lee et al., 9 who found differences of opinion between generalists and specialists regarding whether or not inpatient consultations were crucial for patient management, as well as those of Kuo et al., 45 who showed disagreements between generalists and subspecialists in perceptions of the quantity and quality of information provided during curbside consultation.
This research has certain limitations, including the limited number of physicians enrolled. However, we were more interested in the referral process than in referral rates, and therefore used referrals as our units of analysis. Second, we evaluated a local, highly capitated managed care population in an academic setting, which may limit the generalizability of our results. Third, we evaluated a local population of physicians at one academic medical center and did not assess differences in referral characteristics based on patients’ insurance status. Fourth, the “no-show” rate of 29% was somewhat higher than the 6% to 26% rates reported by others. 53–58 Reasons for this are not clear, but follow-up was limited to the initially scheduled specialty visit. It is not known how many of the patients who did not arrive for appointments rescheduled their specialty appointments for a later date, visited other specialists outside the university, or failed to appear because their symptoms resolved, they moved out of the area, or they died.