ABSTRACT
BACKGROUND
Subspecialty ambulatory care visits have doubled in the past 10 years and nearly half of all visits are for follow-up care. Could some of this care be provided by primary care providers (PCPs)?
OBJECTIVE
To determine how often PCPs and specialists agree that a mutual patient’s condition could be managed exclusively by the PCP, and to understand PCPs’ perspectives on factors that influence decisions about ‘repatriation,’ or the transfer of patient management to primary care.
DESIGN
A mixed method approach including paired surveys of PCPs and specialists about the necessity for ongoing specialty care of mutual patients, and interviews with PCPs about care coordination practices and reasons for differing opinions with specialists.
PARTICIPANTS
One hundred and eighty-nine PCPs and 59 physicians representing five medicine subspecialties completed paired surveys for 343 patients. Semi-structured interviews were conducted with 16 PCPs.
MEASUREMENTS
For each patient, PCPs and specialists were asked, “Could this diagnosis be managed exclusively by the PCP?”
RESULTS
Specialists and PCPs agreed that transfer to primary care was appropriate for 16 % of patients, whereas 36 % had specialists and PCPs who agreed that ongoing specialty care was appropriate. Specialists were half as likely as PCPs to identify patients as appropriate for transfer to primary care. PCPs identified several factors that influence the likelihood that patients will be transferred to primary care, including perceived patient preferences, limited access to physician appointments, excessive workload, inter-clinician communication norms, and differences in clinical judgment. We group these factors into two domains: ‘push-back’ and ‘pull-back’ to primary care.
CONCLUSIONS
At a large academic medical center, approximately one in six patients receiving ongoing specialty care could potentially be managed exclusively by a PCP. PCPs identified several non-clinical factors to explain continuation of specialty care when patient transfer to PCP is clinically appropriate.
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REFERENCES
Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999–2009. Arch Intern Med. 2012;172:163–70.
Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M. Ambulatory care provided by office-based specialists in the United States. Ann Fam Med. 2009;7:104–11.
Merritt HA. Survey of Physician Appointment Wait Times. Irving, TX: Merritt, Hawkins & Associates; 2004.
Murray MF. Improving access to specialty care. Jt Comm J Qual Patient Saf. 2007;33:125–135.
Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89:39–68.
Pham HH, O’Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. 2009;150:236–42.
Liss DT, Chubak J, Anderson ML, Saunders KW, Tuzzio L, Reid RJ. Patient-reported care coordination: associations with primary care continuity and specialty care use. Ann Fam Med. 2011;9:323–9.
O’Malley AS, Cunningham PJ. Patient experiences with coordination of care: the benefit of continuity and primary care physician as referral source. J Gen Intern Med. 2009;24:170–7.
O’Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med. 2011;171:56–65.
Aubin M, Vezina L, Verreault R, et al. Patient, primary care physician and specialist expectations of primary care physician involvement in cancer care. J Gen Intern Med. 2011;27:8–15.
Bowman BT, Kleiner A, Bolton WK. Comanagement of diabetic kidney disease by the primary care provider and nephrologist. Med Clin N Am. 2013;97:157–73.
Wegner SE, Lathren CR, Humble CG, Mayer ML, Feaganes J, Stiles AD. A medical home for children with insulin-dependent diabetes: comanagement by primary and subspecialty physicians—convergence and divergence of opinions. Pediatrics. 2008;122:383–7.
Starfield B, Forrest CB, Nutting PA, von Schrader S. Variability in physician referral decisions. J Am Board Fam Pract. 2002;15:473–80.
Creswell JW, Clark VLP. Designing and Conducting Mixed Methods Research. Thousand Oaks: SAGE Publications; 2010.
Henry J. Kaiser Family Foundation. California’s ‘Bridge to Reform’ Medicaid Demonstration Waiver - Policy Brief - 8197-R. Oct. 2011. Available at: http://kff.org/health-reform/fact-sheet/californias-bridge-to-reform-medicaid-demonstration-waiver/. Accessed 23 May 2014.
Corbin J, Strauss A. Basics of Qualitative Research. Thousand Oaks: SAGE Publications; 2007.
Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42:1758–72.
Lincoln YS. Naturalistic Inquiry. Thousand Oaks: SAGE Publications; 1985.
Kirschner N, Greenlee MC. The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices. Philadelphia: American College of Physicians; 2010: Policy Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)
Jaén CR, Ferrer RL, Miller WL, et al. Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):S57–S67.
Kirschner N, Barr MS. Specialists/subspecialists and the patient-centered medical home. Chest. 2009;137:200–4.
Chen AH, Kushel MB, Grumbach K, Yee HF. A safety-net system gains efficiencies through “eReferrals” to specialists. Health Aff (Millwood). 2010;29:969–71.
Foy R, Hempel S, Rubenstein L, et al. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Ann Intern Med. 2010;152:247–58.
Diller PM, Smucker DR, David B. Comanagement of patients with congestive heart failure by family physicians and cardiologists: frequency, timing, and patient characteristics. J Fam Pract. 1999;48:188–95.
Stewart MA. Effective physician–patient communication and health outcomes: a review. CMAJ. 1995;152:1423–33.
Acknowledgements
Contributors
We would like to express gratitude to the many clinicians who shared their perspectives with us. We also thank Chartis, Inc. for their assistance with survey administration and Gina Intinarelli for her ongoing support and encouragement.
Funding
Support for this study came through existing clinical operations and evaluation initiatives sponsored by the UCSF Medical Center, the UCSF Department of Medicine Ambulatory Care Operations and Innovations Program, and the Delivery System Reform Incentive Payment (DSRIP) Program. None of these groups were involved in the design, conduct, collection, management, analysis or interpretation of the data. We did not require their approval of the manuscript or decision to submit.
Presentations
Preliminary results of the study reported here were presented at the annual meeting of the Society of General Internal Medicine in Denver, CO in April 2013.
Conflict of Interest
Dr. Gonzales serves as Medical Advisor to Phreesia, Inc. To the best of our knowledge, the authors do not have any additional conflicts of interest, financial or otherwise.
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Ackerman, S.L., Gleason, N., Monacelli, J. et al. When to Repatriate? Clinicians’ Perspectives on the Transfer of Patient Management from Specialty to Primary Care. J GEN INTERN MED 29, 1355–1361 (2014). https://doi.org/10.1007/s11606-014-2920-z
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DOI: https://doi.org/10.1007/s11606-014-2920-z