Family physicians' referral decisions: results from the ASPN referral study - Original Research

Journal of Family Practice, March, 2002 by Christopher B. Forrest, Paul A. Nutting, Barbara Starfield, Sarah Von Schrader

* OBJECTIVE To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer.

* STUDY DESIGN Prospective cohort study.

* POPULATION All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states.

* OUTCOMES MEASURED Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists.

* RESULTS Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician--gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist.

* CONCLUSIONS Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff--patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

* KEYWORDS Referral and consultation; primary health care; family physicians; specialists. (J Fam Pract 2002; 51:215-222)

Conventionally, primary care physicians decided when to refer and to whom a patient should be referred. (1,2) Specialists' assistance was sought for diagnostic or therapeutic dilemmas, (3,4) management of conditions that presented too infrequently to maintain clinical competence, (5) and specialized procedures that fell outside a physician's scope of practice. (3,4) In some cases, physicians referred because patients requested to see a specialist. (1,4)

The reorganization of health care over the past few decades has dramatically altered the interactions between primary care physicians and specialists. The growth in multispecialty group practice arrangements (6) has led to formal, organizationally defined linkages between practitioners. Managed health plans and medical groups (7) encourage primary care physicians' control over the referral process through such mechanisms as specialty referral authorizations, financial disincentives for making a referral, performance assessment of referral patterns, and referral guidelines. These changes have transformed a once-informal process into one rife with administrative restrictions on referral decision making.

The Ambulatory Sentinel Practice Network (ASPN) Referral Study was designed to describe and analyze primary care physicians' referral decisions and their outcomes in the context of a changing health care system in the United States. The study occurred in the ASPN and other regional practice-based research networks. This report examines primary care physicians' referral decisions. We conceptualized the referral decision as occurring in 2 phases: Whether to refer followed by to whom to refer. (2)

METHODS

Physician Sample

Physicians were recruited from March 1997 to May 1998. Recruitment activities were directed to all physician members of ASPN, physicians affiliated with the Medical Group Management Association, local and regional networks (Minnesota Academy of Family Physicians Research Network, the Wisconsin Research Network, the Dartmouth Primary Cooperative Research Network (COOP), and the larger community of primary care physicians. The study was publicized via direct mailings to physicians, articles and notices in practice-based research network newsletters and journals, and presentations at conferences. Contact with physicians expressing interest was made by telephone.

Physicians were included in the study if they practiced in the United States and were not in residency or fellowship training. Of all physicians contacted, 342 expressed interest in the study and 182 completed some aspect of data collection. A total of 141 family physicians, 12 internists, and 1 pediatrician completed all phases of data collection. In this study, the 141 family physicians (41% members of ASPN) formed the physician sample. They delivered health care in 87 practices located in 31 states.