Journal of General Internal Medicine

, Volume 15, Issue 3, pp 163–168

Why do physicians vary so widely in their referral rates?


    • the Primary Institute, Department of Family MedicineUniversity of Rochester
  • Geoffrey C. Williams
    • Departments of Medicine and Clinical and Social Sciences in PsychologyUniversity of Rochester
  • Jack Zwanziger
    • Department of Community and Preventive MedicineUniversity of Rochester
  • Cathleen Mooney
    • Department of Community and Preventive MedicineUniversity of Rochester
  • Melony Sorbero
    • Department of Community and Preventive MedicineUniversity of Rochester
Original Articles

DOI: 10.1046/j.1525-1497.2000.04079.x

Cite this article as:
Franks, P., Williams, G.C., Zwanziger, J. et al. J GEN INTERN MED (2000) 15: 163. doi:10.1046/j.1525-1497.2000.04079.x


OBJECTIVE: To determine which physician practice and psychological factors contribute to observed variation in primary care physicians’ referral rates.

DESIGN: Cross-sectional questionnaire-based survey and analysis of claims database.

SETTING: A large managed care organization in the Rochester, NY, metropolitan area.

PARTICIPANTS: Internists and family physicians.

MEASUREMENTS AND MAIN RESULTS: Patient referral status (referred or not) was derived from the 1995 claims database of the managed care organization. The claims data were also used to generate a predicted risk of referral based on patient age, gender, and case mix. A physician survey completed by a sample of 182 of the physicians (66% of those eligible) included items on their practice and validated psychological scales on anxiety from uncertainty, risk aversiveness, fear of malpractice, satisfaction with practice, autonomous and controlled motivation for referrals and test ordering, and psychosocial beliefs. The relation between the risk of referral and the physician practice and psychological factors was examined using logistic regression. After adjustment for predicted risk of referral (case mix), patients were more likely to be referred if their physician was female, had more years in practice, was an internist, and used a narrower range of diagnoses (a higher Herfindahl index, also derived from the claims data). Of the psychological factors, only greater psychosocial orientation and malpractice fear was associated with greater likelihood of referral. When the physician practice factors were excluded from the analysis, risk aversion was positively associated with referral likelihood.

CONCLUSIONS: Most of the explainable variation in referral likelihood was accounted for by patient and physician practice factors like case mix, physician gender, years in practice, speciality, and the Herfindahl index. Relatively little variation was explained by any of the examined physician psychological factors.

Key words

Primary health carephysician’s practice paternsreferral and consultation
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© Society of General Internal Medicine 2000