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.
generalist specialist referral outpatients
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Schaffer WA, Holloman FC Jr. Consultation and referral between physicians in new medical practice environments. Ann Intern Med. 1985;103(4):600–5.PubMedGoogle Scholar
Tenney JB, Brown TC, Rivers K. National ambulatory medical care survey: background and methodology. Vital Health Stat 2. 1974;61:74–1335.Google Scholar
Franks P, Clancy CM, Nutting PA. Defining Primary Care. Empirical analysis of the National Ambulatory Care Survey. Med Care. 1997;35(7):655–68.PubMedCrossRefGoogle Scholar
Schneeweiss R, Ellsbury K, Hart LG, Geyman JP. The economic impact and multiplier effect of a family practice clinic on an academic medical center. JAMA. 1989;262(3):370–5.PubMedCrossRefGoogle Scholar
Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106–12.PubMedCrossRefGoogle Scholar
Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267(12):1624–30.PubMedCrossRefGoogle Scholar
Brock C. Consultation and referral patterns of family physicians. J Fam Pract. 1977;4(6):1129–37.PubMedGoogle Scholar
Calman NS, Hyman RB, Licht W. Variability in consultation rates and practitioner level of diagnostic certainty. J Fam Pract. 1992;35(1):31–8.PubMedGoogle Scholar
Eisenberg L. Treating depression and anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med. 1992;326(16):1080–4.PubMedCrossRefGoogle Scholar
Kashner TM, Rost K, Smith GR, Lewis S. An analysis of panel data: the impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder. Med Care. 1992;30(9):811–21.PubMedCrossRefGoogle Scholar
O’Dell MW. Rehabilitation medicine consultation in persons hospitalized with AIDS: an analysis of thirty cases. Am J Phys Med Rehabil. 1993;72(2):90–6.PubMedCrossRefGoogle Scholar
Turner BJ, McKee L, Fanning T, Markson LE. AIDS specialist versus generalist ambulatory care for advanced HIV infection and impact on hospital use. Med Care. 1994;32(9):902–16.PubMedCrossRefGoogle Scholar
Bloomfield S, Farquhar JW. Is a specialist paediatric diabetic clinic better? Arch Dis Child. 1990;65(1):139–40.PubMedGoogle Scholar
Ward MM, Leigh JP, Fries JF. Progression of functional disability in patients with rheumatoid arthritis: associations with rheumatology subspecialty care. Arch Intern Med. 1993;153(19):2229–37.PubMedCrossRefGoogle Scholar
Sick People in Managed Care Have Difficulty Getting Services and Treatment. New Survey Reports, Robert Wood Johnson Foundation, June 28, 1995.Google Scholar
Doyle RL. Section B—primary care guidelines. In: Healthcare Management Guidelines. Milliman and Robertson; 1991.Google Scholar
Hurley RE, Freund DA, Gage BJ. Gatekeeper effects on patterns of physician use. J Fam Pract. 1991;32(2):167–74.PubMedGoogle Scholar
Cain JM, Jonsen AR. Specialists and generalists in obstetrics and gynecology: conflicts of interest in referral and an ethical alternative. Womens Health Issues. 1992;2(3):137–45.PubMedCrossRefGoogle Scholar
Langley GR, MacLellan AM, Sutherland HJ, Till JE. Effect of nonmedical factors on family physicians’ decisions about referral for consultation. Can Med Assoc J. 1992;147(5):659–66.Google Scholar
Fitzpatrick R, Hopkins A. Referrals to neurologists for headaches not due to structural disease. J Neurol Neurosurg Psychiatry. 1981;44(12):1061–7.PubMedGoogle Scholar
Greenfield S, Linn LS, Purtill N, Young RT. Reverse consultations: the profiles of patients referred from subspecialists to generalists. J Chronic Dis. 1983;36(12):883–9.PubMedCrossRefGoogle Scholar
Leonard I, Babbs C, Creed F. Psychiatric referrals within the hospital—the communication process. J R Soc Med. 1990;83(4):241–4.PubMedGoogle Scholar
Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905–9.PubMedCrossRefGoogle Scholar
Hjortdahl P, Borchgrevnik CF. Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. BMJ. 1991;303(6811):1181–4.PubMedGoogle Scholar
Armstrong D, Fry J, Armstrong P. Doctors’ perceptions of pressure from patients for referral. BMJ. 1991;302(6786):1186–8.PubMedCrossRefGoogle Scholar
Eisenberg JM. Physician utilization: the state of research about physicians’ practice patterns. Med Care. 1985;23(5):461–83.PubMedCrossRefGoogle Scholar
Marton KI, Sox HC Jr, Wasson J, Duisenberg CE. The clinical value of the upper gastrointestinal tract roentgenogram series. Arch Intern Med. 1980;140(2):191–5.PubMedCrossRefGoogle Scholar
Lin CT, Albertson G, Swaney R, Anderson S, Anderson R. Patient expectations for subspecialty referral in an academic managed care system. J Gen Intern Med. 1998;13(suppl):65. Abstract.Google Scholar
Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9(2):75–81.PubMedCrossRefGoogle Scholar
Byrd JC, Moskowitz MA. Outpatient consultation: interaction between the general internist and the specialist. J Gen Intern Med. 1987;2(2):93–8.PubMedCrossRefGoogle Scholar
McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communication between primary care physicians and subspecialty consultants? Arch Intern Med. 1984;144(6):1265–8.PubMedCrossRefGoogle Scholar
Cummins RO, Smith RW, Inui TS. Communication failure in primary care: failure of consultants to provide follow-up information. JAMA. 1980;243(16):1650–2.PubMedCrossRefGoogle Scholar
Lloyd M, Bradford C, Webb S. Non-attendance at outpatient clinics: is it related to the referral process? Fam Pract. 1993;10(2):111–7.PubMedCrossRefGoogle Scholar
Mantyjarvi M. No-show patients in an ophthalmological out-patient department. Acta Ophthalmol (Copenh). 1994;72(3):284–9.Google Scholar
Ross JD, McIver A, Blakely A, Dalrymple J, Peacock W, Wallis C. Why do patients default from follow-up at a genitourinary clinic?: a multivariate analysis. Genitourin Med. 1995;71(6):393–5.PubMedGoogle Scholar