Family Physicians’ Referral Decisions

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Original Research

Family Physicians’ Referral Decisions

J Fam Pract. 2002 March;51(3):215-222

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References

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Specialist selection

Referrals were made most often to surgical subspecialists (45.4%), followed by medical subspecialists (31.0%), nonphysician clinicians (12.1%), obstetriciangynecologists (ob/gyns) (4.6%), mental health professionals (4.2%), other physicians (2.0%), and generalists (0.8%). The 5 most common specialists to whom patients were referred were orthopedic surgeons (12.1%), general surgeons (9.1%), otolaryngologists (6.9%), gastroenterologists (6.6%), and dermatologists (6.0%). Among male patients, referral to urologists was the second most common type; among female patients, referral to ob/gyns was the third most common type.

Mental health referrals were made predominantly to psychologists (2.1% of all referrals), followed by psychiatrists (1.3%) and social workers (0.4%). The most common types of nonphysician clinicians referred to were physical therapists (4.5%), podiatrists (3.0%), nutritionists (1.5%), and audiologists (1.2%).

Referring physicians recommended a specific specialist to the patient for 86.2% of referrals. In descending rank order according to the mean importance rating (range 1 to 3), the reasons for selecting a particular specialist were personal knowledge of the specialist (2.6), quality of prior feedback (2.5), technical capacity (2.3), appointment availability (2.0), patient’s request (1.6), requirements of patient’s health plan (1.6), and proximity of the specialist to the patient’s home (1.6).

Table 4 shows the 3 most common health problems referred to 10 types of specialists. (An expanded version of this table that includes 29 specialists can be found in Table W2.) The majority of referrals for each type of specialist were for 1 to 3 health problems. Family physicians made 17.1% of all referrals to practitioners within their practices. Intrapractice referrals were significantly higher than the overall average for audiologists (40.0%, P = .031), nutritionists (45.2%, P = .004), and psychologists (46.3%, P < .001) and were lower for gastroenterologists (9.3%, P = .022) and rheumatologists (4.0%, P = .005).

TABLE 4
THREE MOST COMMON CONDITIONS REFERRED TO SELECTED SPECIALISTS*

Type of Specialist (Nos. of Referrals)	Referred Health Problem	No. (Cumulative %)
Cardiologist (n = 94)	Cardiac arrhythmia	20 (21.3)
	Chest pain	17 (39.4)
	Ischemic heart disease	16 (56.4)
Dermatologist (n = 121)	Benign and unspecified neoplasms	36 (29.8)
	Dermatitis and eczema	18 44.6)
	Acne 10	(52.9)
Gastroenterologist (n = 135)	Gastrointestinal signs and symptoms	26 (19.3)
	Gastroesophageal reflux	16 (31.1)
	Abdominal pain	15 (42.2)
General surgeon (n = 185)	Benign and unspecified neoplasms	52 (28.1)
	External abdominal hernias	36 (47.6)
	Cholelithiasis, cholecystitis	23 (60.0)
Ophthalmologist (n = 109)	Diabetes mellitus	32 (29.4)
	Ophthalmic signs and symptoms	17 (45.0)
	Cataract, aphakia	9 (53.2)
Orthopedic surgeon (n = 247)	Musculoskeletal signs and symptoms	78 (31.6)
	Bursitis, synovitis, tenosynovitis	26 (42.1)
	Fractures, excluding digits	22 (51.0)
Otolaryngologist (n = 141)	Otitis media	27 (19.2)
	Sinusitis	13 (28.4)
	Deafness, hearing loss	11 (36.2)
Ob/gyn (n = 93)	Menstrual disorders	17 (18.3)
	Female genital symptoms	10 (29.0)
	Uterovaginal prolapse	9 (38.7)
* An expanded version of this table that includes 29 specialists can be found in Table W1.

Discussion

This study shows that family physicians manage 95% of office visits without specialty referral. About one third of referrals made from primary care practices occur during encounters other than office visits. Referrals made by staff or during telephone conversations may be part of an integrated sequence of contacts between patients and physicians. Nonetheless, assisting patients in selecting a specialist, transferring relevant patient information, and scheduling specialty appointments (referral coordination activities) are more difficult to perform when patients are not seen in the office,¹⁴ because time is limited and integrating care is poorly reimbursed, if at all. When such referral decisions are made appropriately, they provide an efficient mechanism for decreasing workload in a busy primary care practice. Inappropriately made, they can lead to increased expense, unnecessary time spent with specialists, and poorly coordinated care.

We found that the rates of referral were substantially different among the most commonly referred conditions. Prior work has shown that the frequency with which conditions present to primary care physicians explains about 75% of the variation in condition-specific referral rates.⁵ The mix and severity of comorbidities are important determinants of annual patient referral rates^15,16 and the chances of referral during a visit.⁵ Thus, the epidemiology of morbidity among a patient population is a critical factor that defines the boundaries between primary care physicians and specialists. The appreciation of these clinical determinants is crucial for any valid assessment of primary care physicians’ referral patterns.

Limitations

The study’s focus was on new referral decisions made by physicians to other practitioners. No information is provided about ongoing, long-term referrals in which the patient was already under the care of a specialist. The low rates of referral for conditions such as diabetes may be a consequence of this limitation. Patients with diabetes may already have been under the care of a specialist, thereby generating few new referrals. It is also important to note that even in health plans with gatekeeping arrangements, patients self-refer to specialty care¹³; this study did not include any information on self-referral. Patient self-referral appears to be most likely among sick patients, those with established relationships with a specialist, and patients who do not have a good relationship with a primary care physician.¹⁷