Errors in completion of referrals among older urban adults in ambulatory care

Authors

  • Michael Weiner MD MPH,

    Corresponding author
    1. Associate Professor of Medicine, Indiana University Center for Aging Research, Indianapolis, Indiana, USA, Regenstrief Institute, Incorporated, Indianapolis, Indiana, USA and Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
      Dr Michael Weiner
      Indiana University Center for Aging Research
      Regenstrief Institute, Incorporated
      410 West 10th Street, Suite 2000
      Indianapolis
      Indiana 46202-3012
      USA
      E-mail: mw@cogit.net
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  • Anthony J. Perkins MS,

    1. Consulting Analyst, Indiana University Center for Aging Research, Indianapolis, Indiana, USA and Regenstrief Institute, Incorporated, Indianapolis, Indiana, USA
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  • Christopher M. Callahan MD

    1. Professor of Medicine, Indiana University Center for Aging Research, Indianapolis, Indiana, USA, Regenstrief Institute, Incorporated, Indianapolis, Indiana, USA and Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Dr Michael Weiner
Indiana University Center for Aging Research
Regenstrief Institute, Incorporated
410 West 10th Street, Suite 2000
Indianapolis
Indiana 46202-3012
USA
E-mail: mw@cogit.net

Abstract

Rationale, aims and objectives  Clinical care often requires referrals, but many referrals never result in completed evaluations. We determined the extent to which referral-based consultations were completed in a US medical institution. Factors associated with completion were identified.

Method  In a cross-sectional analysis, we analysed billing records and electronic and paper-based medical records for patients aged 65 years or older receiving health care between July 2000 and June 2002 in an integrated, urban, tax-supported medical institution on an academic campus. All referrals in ambulatory care, scheduling of consultation within 180 days, and completion were assessed. We conducted a multivariate survival analysis to identify factors associated with completion.

Results  We identified 6785 patients with encounters. Mean age was 72 years, and, of the participants, 66% were women, 55% were African-American and 32% were Medicaid eligible. Of the 81% with at least one primary-care visit in ambulatory care, 63% had at least one referral. About 8% of referrals required multiple orders before an appointment was scheduled. Among 7819 orders for specialty consultation in ambulatory care, 71% led to appointments, and 70% of appointments were kept (completed = 0.71*0.70 or 50%). Scheduling of consultations varied (12% to 90%) by specialty. Medicare, singular orders, location of referral and lack of hospitalization were independently significantly associated with scheduling of appointments.

Conclusions  Among older adults studied, half of medical specialty referrals were not completed. Multiple process errors, including missing information, misguided referrals and faulty communications, likely contribute to these results. Information systems offer important opportunities to improve the referrals process.

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