Journal of General Internal Medicine

, Volume 15, Issue 3, pp 163–168 | Cite as

Why do physicians vary so widely in their referral rates?

  • Peter Franks
  • Geoffrey C. Williams
  • Jack Zwanziger
  • Cathleen Mooney
  • Melony Sorbero
Original Articles


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 care physician’s practice paterns referral and consultation 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Roland MO, Bartholomew J, Morrell DC, McDermott A, Paul E. Understanding hospital referral rates: a user’s guide. BMJ. 1990;301:98–102.PubMedGoogle Scholar
  2. 2.
    Salem-Schatz S, Moore G, Rucker M, Pearson SD. The case for case-mix adjustment in practice profiling: when good apples look bad. JAMA. 1994;272:871–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Franks P, Zwanziger J, Mooney C, Sorbero M. Variations in primary care physician referral rates. Health Serv Res. 1999;34:323–9.PubMedGoogle Scholar
  4. 4.
    Nutting PA, Franks P, Clancy CM. Referral and consultation in primary care: do we understand what we’re doing? J Fam Pract. 1992;35:21–3.PubMedGoogle Scholar
  5. 5.
    Ludke RL. An examination of the factors that influence patient referral decisions. Med Care. 1982;20:782–96.PubMedCrossRefGoogle Scholar
  6. 6.
    Rothert ML, Rovner DR, Elstein AS, Holzman GB, Holmes MM, Ravitch MM. Differences in medical referral decisions for obesity among family practitioners, general internists, and gynecologists. Med Care. 1984;22:42–55.PubMedCrossRefGoogle Scholar
  7. 7.
    Metcalfe DH, Sischy D. Patterns of referral from family practice. J Fam Pract. 1974;1:34–8.PubMedGoogle Scholar
  8. 8.
    Cherkin DC, Rosenblatt RA, Hart LG, Schneeweiss R, LoGerfo J. The use of medical resources by residency-trained family physicians and general internists. Is there a difference? Med Care. 1987;25:455–69.PubMedCrossRefGoogle Scholar
  9. 9.
    Shortell SM, Vahovich SG. Patient referral differences among specialties. Health Serv Res. 1975;10:146–61.PubMedGoogle Scholar
  10. 10.
    Mayer TR. Family practice referral patterns in a health maintenance organization. J Fam Pract. 1982;14:315–9.PubMedGoogle Scholar
  11. 11.
    Moore AT, Roland MO. How much variation in referral rates among general practitioners is due to chance? BMJ. 1989;298:500–2.PubMedGoogle Scholar
  12. 12.
    Wilkin D, Dornan C. General Practitioner Referrals to Hospital: A Review of Research and Its Implications for Policy and Practice. Manchester, UK: Centre for Primary Care Research, Department of General Practice, University of Manchester; 1990.Google Scholar
  13. 13.
    Clancy CM, Lanier D, Grady ML. Conference Summary Report. Research at the Interface of Primary and Specialty Care. Rockville, Md: Agency for Health Care Policy and Research; 1996. Publication AHCPR 96-0034.Google Scholar
  14. 14.
    Grol R, Whitfield M, De Maeseneer J, Mokkink H. Attitudes to risk taking in medical decision making among British, Dutch and Belgian general practitioners. Br J Gen Pract. 1990;40:134–6.PubMedGoogle Scholar
  15. 15.
    Zaat JOM, van Eijk JTM. General practitioners’ uncertainty, risk preference, and use of laboratory tests. Med Care. 1992;30:846–54.PubMedCrossRefGoogle Scholar
  16. 16.
    Pearson SD, Goldman L, Orav EJ, et al. Triage decisions for emergency department patients with chest pain: do physicians’ risk attitudes make the difference? J Gen Intern Med. 1995;10:557–64.PubMedGoogle Scholar
  17. 17.
    Allison JJ, Kiefe CI, Cook EF, Gerrity MS, Orav EJ, Centor R. The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO. Med Decis Making. 1998;18:320–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Williams GC, Deci EL. Internalization of biopsychosocial values by medical students: a test of self-determination theory. J Pers Soc Psychol 1996;70:767–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Williams GC, Wiener MW, Markakis KM, Reeve J, Deci EL. Medical students’ motivation for internal medicine. J Gen Intern Med. 1994;9:327–33.PubMedCrossRefGoogle Scholar
  20. 20.
    Ryan RM, Connell JP. Perceived locus of causality and internalization: examining reasons for acting in two domains. J Pers Soc Psychol 1989;57:749–61.PubMedCrossRefGoogle Scholar
  21. 21.
    Williams GC, Deci EL. The importance of supporting autonomy in medical education. Ann Intern Med. 1998;129:303–8.PubMedGoogle Scholar
  22. 22.
    Miller ME, Hui SL, Tierney WM, McDonald CJ. Estimating physician costliness: an empirical Bayes approach. Med Care. 1993;31:YS16-YS28.PubMedCrossRefGoogle Scholar
  23. 23.
    Weiner JP, Starfield BH, Steinwachs DM, Mumford LM. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care. 1991;29:452–72.PubMedCrossRefGoogle Scholar
  24. 24.
    Starfield B, Weiner J, Mumford L, Steinwachs D. Ambulatory care groups: a categorization of diagnoses for research and management. Health Serv Res. 1991;26:53–74.PubMedGoogle Scholar
  25. 25.
    Franks P, Clancy CM, Nutting PA. Defining primary care: empirical analyses of the National Ambulatory Medical Care Survey. Med Care. 1997;35:655–68.PubMedCrossRefGoogle Scholar
  26. 26.
    Reynolds GA, Chitnis JG, Roland MO. General practitioner outpatient referrals: do good doctors refer more patients to hospital? BMJ. 1991;302:1250–2.PubMedCrossRefGoogle Scholar
  27. 27.
    Calman NS, Hyman RB, Licht W. Variability in consultation rates and practitioner level of diagnostic certainty. J Fam Pract. 1992;35:31–8.PubMedGoogle Scholar
  28. 28.
    Linn LS, Yager J, Cope D, Leake B. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA. 1986;254:2775–82.CrossRefGoogle Scholar
  29. 29.
    Gerrity MS, DeVellis RF, Earp JA. Physicians’ reactions to uncertainty in patient care: a new measure and new insights. Med Care. 1990;28:724–36.PubMedCrossRefGoogle Scholar
  30. 30.
    Gerrity M, White K. Physicians’ reactions to uncertainty: refining the constructs and scales. Motivation and Emotion. 1995;19: 175–91.CrossRefGoogle Scholar
  31. 31.
    Jackson DN. Jackson Personality Inventory Manual. Goshen, NY: Research Psychologists Press; 1975.Google Scholar
  32. 32.
    Ashworth CD, Williamson PR, Montano D. A scale to measure physician beliefs about psychosocial aspects of patient care. Soc Sci Med. 1984;19:1235–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Levinson W, Roter D. Physicians’ psychosocial beliefs correlate with their patient communication skills. J Gen Intern Med. 1995;10:375–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Liang KY, Zeger SL. Regression analysis for correlated data. Annu Rev Public Health. 1993;14:43–68.PubMedCrossRefGoogle Scholar
  35. 35.
    Fiscella K, Franks P. Risk aversion and costs: comparisons of family physicians and general internists. J Fam Pract. 2000;49:12–6.PubMedGoogle Scholar
  36. 36.
    Franks P, Clancy CM. Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance. J Fam Pract. 1997;45:47–53.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2000

Authors and Affiliations

  • Peter Franks
    • 1
  • Geoffrey C. Williams
    • 2
  • Jack Zwanziger
    • 3
  • Cathleen Mooney
    • 3
  • Melony Sorbero
    • 3
  1. 1.the Primary Institute, Department of Family MedicineUniversity of RochesterRochester
  2. 2.Departments of Medicine and Clinical and Social Sciences in PsychologyUniversity of RochesterRochester
  3. 3.Department of Community and Preventive MedicineUniversity of RochesterRochester
  4. 4.Dept. of Family MedicineUniversity of RochesterRochester

Personalised recommendations