Prevalence of Health Problems and Primary Care Physicians’ Specialty Referral Decisions

,

Original Research

Prevalence of Health Problems and Primary Care Physicians’ Specialty Referral Decisions

J Fam Pract. 2001 May;50(5):427-432

References

1. Forrest CB, Glade GB, Baker AE, Bocian AB, Kang M, Starfield B. The pediatric primary-specialty care interface: how pediatricians refer children and adolescents to specialty care. Arch Pediatr Adolesc Med 1999;153:705-14.

2. 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.

3. Van Suijlekom-Smit LWA, Bruijnzeels MA, Van Der Wouden JC, Van Der Velden J, Visser HKA, Dokter HJ. Children referred for specialist care: a nationwide study in Dutch general practice. Br J Gen Pract 1997;47:19-23.

4. Diller PM, Smucker DR, David B. Comanagement of patients with congestive heart failure by family physicians and cardiologists. J Fam Pract 1999;48:188-95.

5. Hatch RL, Rosenbaum CI. Fracture care by family physicians: a review of 295 cases. J Fam Pract 1994;38:238-44.

6. Horwitz SM, Leaf PJ, Leventhal JM, Forsyth B, Speechley KN. Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices. Pediatrics 1992;89:480-85.

7. McCrindle BW, Shaffer KM, Kan JS, Zahka KG, Rowe SA, Kidd L. Factors prompting referral for cardiology evaluation of heart murmurs in children. Arch Pediatr Adolesc Med 1995;149:1277-79.

8. 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;272:871-74.

9. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA. eds Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.

10. Starfield B. Primary care: balancing health needs, services, and technology. New York, NY: Oxford University Press; 1998.

11. Available at: www.cdc/gov/nchs/about/major/ahcd/ahcd1.htm. Accessed December 5, 2000.

12. Forrest CB, Reid R. Passing the baton: HMOs’ influence on referrals to specialty care. Health Aff 1997;16:157-62.

13. Forrest CB, Whelan E. Primary care safety-net delivery sites in the United States: a comparison of community health centers, hospital outpatient departments, and physicians’ offices. JAMA 2000;284:2077-83.

14. Schneeweiss R, Rosenblatt RA, Cherkin DC, Kirkwood R, Hart G. Diagnosis clusters: a new tool for analyzing the content of ambulatory medical care. Med Care 1983;21:105-22.

15. Johns Hopkins University ACG Case Mix Adjustment System. Baltimore, Md: Johns Hopkins University School of Hygiene and Public Health; 2000. Information available at: acg.jhsph.edu.

16. Hosmer DW, Lemeshow S. Applied logistic regression. New York, NY: John Wiley & Sons; 1989.

17. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika 1986;73:13-27.

18. Luft HS, Garnick DW, Mark DH, McPhee SJ. Hospital volume, physician volume, and patient outcomes. Ann Arbor, Mich: Health Administration Press; 1990.

19. Mathers NJ, Hodgkin P. The gatekeeper and the wizard—a fairytale. BMJ 1989;298:172-74.

20. Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996. Vital Health Stat 13 1998;134:1-37.

Specialist visits can be initiated by primary care physician referral, patient self-referral, or specialist-to-specialist cross-referral. Although our database did not permit us to examine each of these pathways, other research suggests that primary care physician referral is the predominant route, particularly in health maintenance organizations.¹²

Conclusions

Our findings provide evidence that the boundaries between primary care physicians and specialists are defined in part by prevalence of health problems and the overall complexity of patients. Future research should focus on identifying modifiable characteristics of the physician-patient interaction, physicians, their practices, and the health system that influence referral decisions, after accounting for clinical factors. The appreciation of relevant clinical factors is critical to the fair application of administrative and financial constraints on physicians’ abilities to refer. Managed care plans that penalize physicians for high referral behavior, without adjusting for practice prevalence and comorbidity work, are contrary to the goal of providing quality patient care in the most appropriate settings. With more precise definitions of the clinical determinants of referral for populations, health systems can better gauge generalist and specialist workforce requirements.

Acknowledgments

This work was supported by the Agency for Healthcare Research and Quality grants #R01 and #HS09377. Barbara Starfield inspired this work and provided comments on the manuscript. We also thank Barbara Bartman, Norm Smith, MD, MPH, and Jonathan Weiner MD, MPH, for their review and comments on the manuscript. Mia Kang and Sarah von Schrader provided excellent technical assistance.

Related Resources

Agency for Healthcare Research and Quality, Primary Care Subdirectory Page—includes research articles on primary care referral patterns and coordination of care among referring physicians and specialists. http://www.ahrq.gov/research/primarix.htm