Factors influencing general practitioners' referral decisions

Interaction at the primary–secondary care interface: Patients’ and physicians’ perceptions of teleconsultations

Introduction

Previous qualitative research on teleconsultations has focused on synchronous communication between a patient and a clinician. This study aims to explore physicians' and patients' perceptions of the interaction on the interface between primary care and the Cardiology service of a referral hospital through teleconsultations.

Methods

This qualitative study was embedded in an organizational case study concerning the introduction and rollout of a new service model that took place at the point of care. The patients and physicians were recruited for semi-structured interviews until thematic saturation was achieved, between September 2019 - January 2020. The interviews were audiorecorded and anonymized. The transcribed interviews were stored, coded, and analyzed in MAXQDA, following the steps for conventional content analysis.

Results

A total of 29 participants were interviewed. Patients and physicians presented clear views about the role of the GP and the cardiologist and their function in overall structure of healthcare. GPs felt their role was to bring expertise in the patient which could supplement the cardiologists' expertise on the condition. However, GPs had to renegotiate roles in the teleconsultations when they saw themselves in a new situation, together with another physician and the patient.

Conclusions

Our findings suggest that joint teleconsultations can promote continuity of care for patients in the primary/secondary care interface. Active coordination between physicians with delineation of roles throughout primary-secondary care interface is needed to manage selected patients who may benefit the most from shared care.

Documenting surgical triage in rural surgical networks: Formalising existing structures

OBJECTIVE

It is essential that the embedded process of rural case selection be highlighted and documented to provide reassurance of rigour across rural surgical services supported by generalist surgeons, general practitioners with enhanced surgical skills and general practitioner anaesthetists. This enables feedback and improves the triage and case selection process to ensure the highest quality outcomes. Therefore, this research aims to explore participants' rational criteria for decision making around rural case selection.

DESIGN

Participants participated in a series of semi-structured in-depth interviews which were coded and underwent thematic analysis.

SETTING

Six community hospitals in British Columbia, Canada.

PARTICIPANTS

General practitioners with enhanced surgical skills, general practitioner anaesthetists, local maternity care providers, and specialists.

RESULTS

Based on participant accounts, rural surgical and obstetrical decision-making processes for local patient selection or regional referral had five major components: (1) Clinical Factors, (2) Physician Factors, (3) Patient Factors, (4) Consensus Between Providers and (5) the Availability of Local Resources.

CONCLUSION

Decision-making processes around rural surgical and obstetrical patient selection are complex and require comprehensive understanding of local capacity and resources. Current policies and guidelines fail to consider the varying capacities of each rural site and should be hospital specific.

Factors influencing general practitioners decisions to refer Paediatric patients to the emergency department: a systematic review and narrative synthesis

BACKGROUND

Clinical guidelines are integral to a general practitioner's decision to refer a paediatric patient to emergency care. The influence of non-clinical factors must also be considered. This review explores the non-clinical factors that may influence general practitioners (GPs) when deciding whether or not to refer a paediatric patient to the Emergency Department (ED).

METHODS

A systematic review of peer-reviewed literature published from August 1980 to July 2019 was conducted to explore the non-clinical factors that influence GPs' decision-making in referring paediatric patients to the emergency department. The results were synthesised using a narrative approach.

RESULTS

Seven studies met the inclusion criteria. Non-clinical factors relating to patients, GPs and health systems influence GPs decision to refer children to the ED. GPs reported parents/ caregivers influence, including their perception of severity of child's illness, parent's request for onward referral and GPs' appraisal of parents' ability to cope. Socio-economic status, GPs' aversion to risk and system level factors such as access to diagnostics and specialist services also influenced referral decisions.

CONCLUSIONS

A myriad of non-clinical factors influence GP referrals of children to the ED. Further research on the impact of non-clinical factors on clinical decision-making can help to elucidate patterns and trends of paediatric healthcare and identify areas for intervention to utilise resources efficiently and improve healthcare delivery.

Antibiotic prescribing for the older adult: beliefs and practices in primary care

BACKGROUND

Older adults suffer high morbidity and mortality following serious infections, and hospital admissions with these conditions are increasingly common. Antibiotic prescribing in the older adult population, especially in long-term care facilities, has been argued to be inappropriately high. In order to develop the evidence base and provide support to GPs in achieving antimicrobial stewardship in older adults it is important to understand their attitudes and beliefs toward antibiotic prescribing in this population.

OBJECTIVES

To understand the attitudes and beliefs held by GPs regarding antibiotic prescribing in older adults.

METHODS

Semi-structured qualitative interviews were conducted with 28 GPs working in the UK. Data analysis followed a modified framework approach.

RESULTS

GPs described antibiotic prescribing in older adults as differing from prescribing in other age groups in a number of ways, including prescribing broad-spectrum, longer and earlier antibiotics in this population. There were also rationales for situations where antibiotics were prescribed despite there being no clear diagnosis of infection. Trials of antibiotics were used both as diagnostic aids and in an attempt to avoid admission. The risks of antibiotics were understood, but in some cases restrictions on antibiotic use were thought to hamper optimal management of infection in this age group.

CONCLUSIONS

Diagnosing serious infections in older adults is challenging and antibiotic prescribing practices reflect this challenge, but also reflect an absence of clear guidance or evidence. Research that can fill the gaps in the evidence base is required in order to support GPs with their critical antimicrobial stewardship role in this population.

Quality of Referral Letters Written by Family Physicians to Otologists -A Peer Assessment

Introduction

Otolaryngology is a field with a high referral rate; however, there is a dearth of research on the quality of referral letters written in this field. This study was carried out to explicitly assess the quality of referral letters, more specifically in the field of otology.

Materials and Methods

Two otologists assessed referral letters written by general practitioners or primary care physicians working as family physicians. They were asked to make independent assessment on different variables related to the quality of referral letters and their appropriateness. A "qualified referral letter" in the current study is defined as a letter with standard items, including, description of chief complaint, description of associated symptoms, relevant physical findings, past medical history, drug history, family history, and reasons for referral.

Results

A total of 1000 referral letters written by 652 primary care physicians were investigated in the current study. The obtained results indicated that 74% of referral letters to otologists contained inadequate information regarding various items in the referral letters. Symptoms, diagnosis, and signs were only reported in 28.3%, 28.9%, and 3.6% of the letters, respectively. The findings showed that most common reasons for referrals were uncertainty in diagnosis (52.4%), persistence of the patient (32.6%), and failed therapy (32%). With regards to case-specific conditions, the highest referral rates were related to external otitis, otitis media with effusion, and acute otitis media.

Conclusion

According to the obtained results of the current study, the content of referral letters were insufficient or inappropriate. Therefore, it is recommended to improve otolaryngology syllabus and provide suitable courses for undergraduate students in order to become familiar with the importance of referral letter writing.

General practitioners' attitudes and decision making regarding admission for older adults with infection: a UK qualitative interview study

BACKGROUND

The world has an ageing population. Infection is common in older adults; serious infection has a high mortality rate and is associated with unplanned admissions. In the UK, general practitioners (GPs) must identify which older patients require admission to hospital and provide appropriate care and support for those staying at home.

OBJECTIVES

To explore attitudes of UK GPs towards referring older patients with suspected infection to hospital, how they weigh up the decision to admit against the alternatives and how alternatives to admission could be made more effective.Methods. Qualitative study using semi-structured interviews. GPs were purposively sampled from across the UK to achieve maximum variation in terms of GP role, experience and practice population. Interview transcripts were coded and analysed using a modified framework approach.

RESULTS

GPs' key influences on decision making were grouped into patient, GP and system factors. Patient factors included clinical factors, social factors and shared decision making. GP factors included gut instinct, risk management and acknowledging an associated personal emotional burden. System factors involved weighing up the pressure on secondary care beds against increasing GP workload. GPs described that finding an alternative to admission could be more time consuming, complex to arrange or were restricted by lack of capacity.

CONCLUSION

GPs need to be empowered to make safe decisions about place of care for older adults with suspected infection. This may mean developing strategies to support decision making as well as improving the ease of access to, and capacity of, any alternatives to admission.

General practitioner referrals to paediatric specialist outpatient clinics: referral goals and parental influence

INTRODUCTION Previous research on general practitioner (GP) referrals in adult populations demonstrated that patient pressure influenced referral practice. No research has been conducted to investigate how involvement of a parent influences paediatric referrals. AIM To investigate whether GPs who report parental influence on their decision to refer paediatric patients differ in their referral patterns from GPs who do not report parental influence. METHOD A mail survey of 400 GPs who had referred at least two children to paediatric specialist outpatient clinics during 2014 was distributed. RESULTS The response rate was 67% (n = 254). For initial referrals, 27% of GPs stated that parental request frequently or almost always influenced their referral decision. For returning referrals, 63% of GPs experienced parental influence to renew a referral because a paediatrician wanted a child to return; 49% of GPs experienced influence to renew a referral because a parent wanted to continue care with a paediatrician. Experiencing parental influence was associated with increased likelihood for frequent referrals in order for a paediatrician to take over management of a child's condition. DISCUSSION GPs who frequently refer with a goal for a paediatrician to take over management of a child's condition also report that parental request almost always influences their decision to refer.

Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for attending primary care veterinarians

OBJECTIVE To assess the effects of in-person collaborative care by primary care veterinarians (pcDVMs) and board-certified veterinary cardiologists (BCVCs) on survival time of dogs after onset of congestive heart failure (CHF) and on associated revenue for the attending pcDVMs. DESIGN Retrospective cohort study. ANIMALS 26 small-breed dogs treated for naturally occurring CHF secondary to myxomatous mitral valve disease at a multilocation primary care veterinary hospital between 2008 and 2013. PROCEDURES Electronic medical records were reviewed to identify dogs with confirmed CHF secondary to myxomatous mitral valve disease and collect information on patient care, survival time, and pcDVM revenue. Data were compared between dogs that received collaborative care from the pcDVM and a BCVC and dogs that received care from the pcDVM alone. RESULTS Dogs that received collaborative care had a longer median survival time (254 days) than did dogs that received care from the pcDVM alone (146 days). A significant positive correlation was identified between pcDVM revenue and survival time for dogs that received collaborative care (ie, the longer the dog survived, the greater the pcDVM revenue generated from caring for that patient). CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that collaborative care provided to small-breed dogs with CHF by a BCVC and pcDVM could result in survival benefits for affected dogs and increased revenue for pcDVMs, compared with care provided by a pcDVM alone.

The effect of social relationships on the rates of referral to specialists

Purpose

– In order to decrease patient waiting time and improve efficiency, healthcare systems in some countries have recently begun to shift away from decentralized systems of patient referral from general practitioners (GPs) to specialists toward centralized ones. From a queueing theory perspective, centralized referral systems can decrease waiting time by reducing the variation in the referral process. However, from a social psychological perspective, a close relationship between referring physician and specialist, which is characteristic of decentralized referral systems, may safeguard against high referral rates; since GPs refer patients directly to the specialists whom they know, they may be reluctant to damage that relationship with an inappropriate referral. The purpose of this paper is to examine the effect upon referral behavior of a relationship between physicians, as is found in a decentralized referral system, vs a centralized referral system, which is characterized by an anonymous GP-specialist relationship. In a controlled experiment where family practice residents made decisions concerning referral to specialists, physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by the design of the service system and will, in turn, affect system performance.

Design/methodology/approach

– The authors used a controlled experiment to test the research hypotheses.

Findings

– Physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by system attributes and will, in turn, affect system performance.

Research limitations/implications

– The current study has some limitations, however. First, the sample consisted only of family practice residents and did not have the knowledge and experience of GPs regarding the referral process. Second, the authors used hypothetical patient case descriptions instead of real-world patients. Repeating this experiment with primary care physicians in real setting would be beneficial.

Practical implications

– The study indicates that decentralized referral systems may act (rightly or wrongly) as a restraint on the rate of referrals to specialists. Thus, an implementation of a centralized referral system should be expected to produce an increase in referrals simply due to the change in the operational system setup. Even if centralized referral systems are more efficient and can facilitate the referral process by creating a central queue rather than multiple single queues for patients, the removal of social ties such as long-term social relationships that are developed between GPs and specialists in decentralized referral systems may act to counterbalance these theoretical gains.

Social implications

– This study provide support for the idea that non-clinical factors play an important role in referrals to specialists and hence in the quality of provided care, as was suggested by previous studies in this area (Hajjaj et al., 2010; Reid et al., 1999). The design of the service system may inadvertently influence some doctors to refer too many patients to specialists when there is no need for a specialist visit. In high-utilization health systems, this may cause some patients to be delayed (or even denied) in obtaining specialist access. Healthcare systems may be able to implement behavioral-based techniques in order to mitigate the negative consequences of a shift to centralized referral systems. One approach would be to try to create a feeling of close relationship among doctors in centralized referral systems. High communication and frequent interaction among GPs and specialists can boost the feelings of teamwork and personal efficacy through social comparison (Schunk, 1989, 1991) and vicarious learning (Zimmerman, 2000), which can in turn motivate GPs to take control of the patient care process when appropriate, instead of referring patients to specialists.

Originality/value

– The authors’ study is the first examining the effect of social relationships between GPs and specialists on the referral patterns. Considering the significant implications of referral decisions on patients, doctors, and the healthcare systems, the study can shed light into a better understanding of the social and behavioral aspects of the referral process.

The association between general practitioner participation in joint teleconsultations and rates of referral: a discrete choice experiment

Background

Joint consultations – such as teleconsultations – provide opportunities for continuing education of general practitioners (GPs). It has been reported this form of interactive case-based learning may lead to fewer GP referrals, yet these studies have relied on expert opinion and simple frequencies, without accounting for other factors known to influence referrals. We use a survey-based discrete choice experiment of GPs’ referral preferences to estimate how referral rates are associated with participation in joint teleconsultations, explicitly controlling for a number of potentially confounding variables.

Methods

We distributed questionnaires at two meetings of the Portuguese Association of General Practice. GPs were presented with descriptions of patients with dermatological lesions and asked whether they would refer based on the waiting time, the distance to appointment, and pressure from patients for a referral. We analysed GPs’ responses to multiple combinations of these factors, coupled with information on GP and practice characteristics, using a binary logit model. We estimated the probabilities of referral of different lesions using marginal effects.

Results

Questionnaires were returned by 44 GPs, giving a total of 721 referral choices. The average referral rate for the 11 GPs (25%) who had participated in teleconsultations was 68.1% (range 53-88%), compared to 74.4% (range 47-100%) for the remaining physicians. Participation in teleconsultations was associated with reductions in the probabilities of referral of 17.6% for patients presenting with keratosis (p = 0.02), 42.3% for psoriasis (p < 0.001), 8.4% for melanoma (p = 0.14), and 5.4% for naevus (p = 0.19).

Conclusions

The results indicate that GP participation in teleconsultations is associated with overall reductions in referral rates and in variation across GPs, and that these effects are robust to the inclusion of other factors known to influence referrals. The reduction in range, coupled with different effects for different clinical presentations, may suggest an educational effect. However, more research is needed to establish whether there are causal relationships between participation in teleconsultations, continuing education, and referral rates.

Factors influencing veterinarian referral to oncology specialists for treatment of dogs with lymphoma and osteosarcoma in Ontario, Canada

OBJECTIVE

To elucidate factors influencing practitioner decisions to refer dogs with cancer to veterinary oncology specialists.

DESIGN

Cross-sectional study.

SAMPLE

2,724 Ontario primary care companion animal veterinarians.

PROCEDURES

Practitioners were invited to participate in a survey involving clinical scenarios of canine cancer patients, offered online and in paper format from October 2010 through January 2011. Analyses identified factors associated with the decision to refer patients to veterinary oncology specialists.

RESULTS

1,071 (39.3%) veterinarians responded, of which 603 (56.3%) recommended referral for dogs with multicentric lymphoma and appendicular osteosarcoma. Most (893/1,059 [84.3%]) practiced within < 2 hours' drive of a specialty referral center, and most (981/1,047 [93.7%]) were completely confident in the oncology service. Few (230/1,056 [21.8%] to 349/1,056 [33.0%]) were experienced with use of chemotherapeutics, whereas more (627/1,051 [59.7%]) were experienced with amputation. Referral was associated with practitioner perception of patient health status (OR, 1.54; 95% confidence interval [CI], 1.15 to 2.07), the interaction between the client's bond with the dog and the client's financial status, practitioner experience with treating cancer (OR, 2.79; 95% CI, 1.63 to 4.77), how worthwhile practitioners considered treatment to be (OR, 1.66 to 3.09; 95% CI, 1.08 to 4.72), and confidence in the referral center (OR, 2.20; 95% CI, 1. 11 to 4.34).

CONCLUSIONS AND CLINICAL RELEVANCE

Several factors influenced practitioner decisions to refer dogs with lymphoma or osteosarcoma for specialty care. Understanding factors that influence these decisions may enable practitioners to appraise their referral decisions and ensure they act in the best interests of patients, clients, and the veterinary profession.

Competing for Referrals for Cardiac Diagnostic Tests: What Do Family Physicians Really Want?

In recent years, there has been a substantial shift in where many cardiac diagnostic tests are performed. Not-for-profit hospitals now have to compete with for-profit private clinics for referrals from family physicians. This study aims to evaluate the key factors that family physicians consider when deciding where to refer their patients for several cardiac diagnostic services. Ninety-one family physicians were recruited from one of Ontario's 14 regional local health integration networks (LHINs). These physicians reported on 1,262 referrals made in the previous month for echocardiography, cardiac stress testing, cardiac nuclear imaging, and arrhythmia management. Family physician referrals were almost evenly split between not-for-profit hospitals and for-profit private clinics. The primary criteria influencing the location of referrals were: (1) speed of notification of test date; (2) short wait time for patients; and (3) speed of obtaining test results. Study findings also revealed that 23% of participating family physicians referred 25% or more of all patients needing cardiac diagnostic tests outside of their local LHIN, even though 80% of participants indicated that it is "important" or "somewhat important" to have their patients access cardiac diagnostic services within their local LHIN. Knowledge of the criteria that influence family physician decisions on where to refer patients for cardiac diagnostic testing may be used to assist both hospitals and private laboratories in better meeting the needs of physicians and patients. In particular, failure to meet physicians' expectations regarding fast access and communication of results can be expected to have a negative impact on referrals for cardiac diagnostic testing to a particular facility.

[Which criteria affect the cooperation between general practitioners and specialists in ambulatory care? A qualitative study about general practitioners' perception]

BACKGROUND

Good cooperation between physicians is an essential requirement for quality health care. General practitioners (GPs) have a key role in coordinating the various levels of care and physician contacts. Within the scope of the "InteraKtion" study of the Competence Centre of General Practice Baden-Wuerttemberg GPs were interviewed about their experiences and opinions regarding their cooperation with specialists. The aim of this study was to identify criteria and barriers of the referral process.

METHODS

22 semi-structured interviews were conducted among GPs in Heidelberg, Tuebingen and Ulm. Data analysis was carried out using ATLAS.ti according to the qualitative content analysis by P. Mayring.

RESULTS

From the GPs' point of view, the criteria for referral to specialists include: specialists' medical skills, good doctor-patient relationship and patient satisfaction. In addition, the willingness to arrange short-term appointments in urgent cases, timely diagnosis and adequate communication were mentioned. The following barriers were pointed out: long appointment wait times and the specialists' increased provision of Individual Healthcare Services.

CONCLUSION

These results indicate that GPs have clear criteria for referral to specialists. These findings should find their way into future quantitative studies to explore the weighting of the criteria and barriers discussed here. Joint training activities or quality circles could improve the personal contact between GPs and specialists working in the same region.

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.

Decisions about referrals for psychological therapies: a matched-patient qualitative study

BACKGROUND

Psychological therapies are effective treatments for common mental health problems, but access is limited. GPs face difficult decisions as to whom to refer, but little is known about this decision-making process.

AIM

To explore GPs' accounts of decisions to refer, or not refer, patients for psychological therapy.

DESIGN OF STUDY

A qualitative study, using a matched-patient procedure.

SETTING

General practices in two inner London boroughs.

METHOD

In semi-structured interviews, GPs were asked to compare and contrast five matched-patient pairs, consisting of patients who had been referred for psychological therapy paired with patients not referred. The interviews were analysed using a general thematic analysis.

RESULTS

Fourteen GPs discussed 130 matched patients (65 patient pairs). Three main factors distinguished GPs' accounts of the patients they referred compared with the matched patients they did not refer. These factors were: patient initiative in requesting or showing interest in referral; estimated capacity of the patient to benefit from psychological therapy; and the GP's own capacity to help the patient in terms of skills, expertise, and time.

CONCLUSION

GPs gave accounts of themselves acting as rational decision makers, judging how effective they thought a referral would be based on a patient's clinical presentation and motivation, compared with the GPs' own ability to help.

Patient's quality of life and coping style influence general practitioner's management in men with lower urinary tract symptoms: the Krimpen Study

PURPOSE

To identify patient characteristics associated with general practitioner's (GP) initial treatment decision in men with lower urinary tract symptoms (LUTS) and to test the hypothesis that a different coping style of patients results in different GP behaviour regarding treatment.

MATERIALS AND METHODS

A longitudinal, population-based study with a follow-up period of 6.5 years was conducted among 1688 men aged 50-78 years old. Data were collected on quality of life, symptom severity based on the International prostate symptom score (IPSS) and coping. Information on primary care seeking and GP's initial management during 2 years of follow-up of all participants was collected from the general practitioners record.

RESULTS

Data were obtained of 68 men, without a history of LUTS, who had a first GP visit for LUTS during the study period. In 54.4% of the cases the GP prescribed medication, independent of symptom severity. In the group of men with a bad disease-specific QOL those with a high passive-reaction-pattern were treated less frequently than those with a low passive-reaction-pattern.

CONCLUSION

Findings from this quantitative study are consistent with the hypothesis that different coping styles of patients may result in different GP behaviour regarding treatment. The use of the coping style passive-reaction-pattern has a large influence on GP's initial management in men with LUTS.

The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals

Background

Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system.

Methods

Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics.

Results

Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27–0.77, and 0.46, p = 0.002, CI 0.27–0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92–13.48).

Conclusions

Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.

The Surgical Nosology In Primary-care Settings (SNIPS): a simple bridging classification for the interface between primary and specialist care

BACKGROUND

The interface between primary care and specialist medical services is an important domain for health services research and policy. Of particular concern is optimising specialist services and the organisation of the specialist workforce to meet the needs and demands for specialist care, particularly those generated by referral from primary care. However, differences in the disease classification and reporting of the work of primary and specialist surgical sectors hamper such research. This paper describes the development of a bridging classification for use in the study of potential surgical problems in primary care settings, and for classifying referrals to surgical specialties.

METHODS

A three stage process was undertaken, which involved: (1) defining the categories of surgical disorders from a specialist perspective that were relevant to the specialist-primary care interface; (2) classifying the 'terms' in the International Classification of Primary Care Version 2-Plus (ICPC-2 Plus) to the surgical categories; and (3) using referral data from 303,000 patient encounters in the BEACH study of general practice activity in Australia to define a core set of surgical conditions. Inclusion of terms was based on the probability of specialist referral of patients with such problems, and specialists' perception that they constitute part of normal surgical practice.

RESULTS

A four-level hierarchy was developed, containing 8, 27 and 79 categories in the first, second and third levels, respectively. These categories classified 2050 ICPC-2 Plus terms that constituted the fourth level, and which covered the spectrum of problems that were managed in primary care and referred to surgical specialists.

CONCLUSION

Our method of classifying terms from a primary care classification system to categories delineated by specialists should be applicable to research addressing the interface between primary and specialist care. By describing the process and putting the bridging classification system in the public domain, we invite comment and application in other settings where similar problems might be faced.

Where there is no surgeon: the effect of specialist proximity on general practitioners' referral rates

OBJECTIVE

To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?).

DESIGN

A cross-sectional survey of GP-patient encounters.

SETTING

The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia.

PARTICIPANTS

A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters.

MAIN OUTCOME MEASURES

Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments).

RESULTS

Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44-0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49-0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter.

CONCLUSIONS

Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.

Surgery in the absence of pathology the relationship of patients' presentation to gynecologists' decisions for hysterectomy

OBJECTIVE

To test predictions from a theory about patients' influence over doctors' treatment decisions when physical symptoms are presented in the absence of physical pathology.

METHOD

We audiotaped 88 gynecological consultations of consecutive patients who presented menstrual symptoms without pathology. Each consultation was coded according to a scheme, developed from previous qualitative research, which identified specific strategies of patients and gynecologists. The occurrence of each strategy was compared between consultations in which hysterectomy was decided upon (N=15) and those leading to conservative treatment.

RESULTS

Consultations were more likely to lead to hysterectomy if patients deployed specific strategies, including reporting social effects of symptoms, catastrophization, requesting surgery and citing clinical or lay authority in support. Each strategy could account statistically for gynecologists' perceptions that decisions for hysterectomy reflected patients', rather than gynecologists', influence.

CONCLUSION

The findings are consistent with the theory that, in the absence of physical pathology, patients deploy specific strategies that influence gynecologists to offer surgery.

Variation in home-birth rates between midwifery practices in The Netherlands

OBJECTIVE

To examine the reasons for the variation in home-birth rates between midwifery practices.

METHOD

Multi-level analysis of client and midwife associated, case-specific and structural factors in relation to 4420 planned and actual home or hospital births in 42 midwifery practices.

FINDINGS

Women's choice of birth location and the occurrence of complications that lead to referral to specialist care before or during labour, were found to be the main determinants of the home-birth rate. Yet, about 64% of the variation between midwifery practices is explained by midwife and practice characteristics. Higher home-birth rates were associated with a positive attitude to home-birth, a critical attitude to hospital birth for non-medical reasons, and good co-operation between midwifery practices and hospital obstetricians.

CONCLUSIONS

The proportions of planned hospital birth and of referral to specialist care are the most important predictors of the actual hospital-birth rate of women receiving midwifery care. Both can be influenced by the midwife through a positive attitude to home-birth, a critical approach to non-medical reasons for hospital birth, and good co-operation with specialist obstetricians. It is, therefore, important for midwives to be aware of the influence that their own attitudes may have on the choices their clients make about home or hospital birth.

Explaining variation in hospital admission rates between general practices: cross sectional study

OBJECTIVES

To quantify the extent of the variation in hospital admission rates between general practices, and to investigate whether this variation can be explained by factors relating to the patient, the hospital, and the general practice.

DESIGN

Cross sectional analysis of routine data.

SETTING

Merton, Sutton, and Wandsworth Health Authority, which includes areas of inner and outer London.

SUBJECTS

209 136 hospital admissions in 1995-6 in patients registered with 120 general practices in the study area.

MAIN OUTCOME MEASURES

Hospital admission rates for general practices for overall, emergency, and elective admissions.

RESULTS

Crude admission rates for general practices displayed a twofold difference between the 10th and the 90th centile for all, emergency, and elective admissions. This difference was only minimally reduced by standardising for age and sex. Sociodemographic patient factors derived from census data accounted for 42% of the variation in overall admission rates; 45% in emergency admission rates; and 25% in elective admission rates. There was a strong positive correlation between factors related to deprivation and emergency, but not elective, admission rates, raising questions about equity of provision of health care. The percentage of each practice's admissions to different local hospitals added significantly to the explanation of variation, while the general practice characteristics considered added very little.

CONCLUSIONS

Hospital admission rates varied greatly between general practices; this was largely explained by differences in patient populations. The lack of significant factors related to general practice is of little help for the direct management of admission rates, although the effect of sociological rather than organisational practice variables should be explored further. Admission rates should routinely be standardised for differences in patient populations and hospitals used.

Managed care and physician referral

In the era of managed care, fundamental changes are occurring in the American health care system that are altering physician referral patterns. Faced with higher premiums that erode profits and competitiveness, employers, government, and nonprofit agencies are contracting with managed care organizations, which control costs partly by imposing constraints and incentives on physician referral behavior. As more and more Americans are covered by managed care plans, it becomes more important to understand how managed care organizations control access to specialists and how these controls affect health outcomes. The authors present a model defining the expected influence of managed care on physician referral based on social exchange theory and the empirical literature. They conclude with a discussion of the future research implications of the model.

In-house referral: changing general practitioners' roles in the referral of patients to secondary care

Innovative approaches to patient management are needed to ensure that only those patients who would benefit most are referred from primary to secondary care. This report describes an exploratory study in which general practitioners adopted the role of reviewing the management of patients who would otherwise be referred to hospital. Patients in eight general practices in South Wales were referred In-house by general practitioners to a colleague in the practice who reviewed the need for hospital care. Qualitative data from interviews and questionnaires is presented. In-house referral appears to be acceptable, practical and of value to both general practitioners and patients.

Do fee descriptors influence treatment choices in general practice? A multilevel discrete choice model

Before 1990 Australian general practitioners (GPs) were remunerated according to consultation length. This was assumed to encourage GPs to prescribe more, counsel less and provide fewer treatments than were 'appropriate'. In an attempt to change this behaviour, the remuneration system was altered to reflect the content of consultations. This paper analyses, through the use of multilevel modelling, the effect of content-based descriptors on the discrete choice behaviour of GPs while controlling for patient, GP and practice characteristics. GPs who used content-based descriptors were just as likely to prescribe, counsel and treat compared to GPs who used time-based descriptors.

The Patient Requests Form: a way of measuring what patients want from their general practitioner

A consumer-oriented approach to the delivery of health care and an understanding of the processes that influence clinical management decisions require the measurement of what patients seek when they consult their doctor. The present study completed the development of an instrument (the Patient Requests Form) that can quantify the intentions of patients attending their general practitioner. The Patient Requests Form was completed by 410 patients attending two general practices: one in an inner city area, the other in a small town. Principal components analysis revealed that the responses from each sample yielded identical components that described three distinct types of request: (i) for explanation and reassurance, (ii) for emotional support, and (iii) for investigation and treatment. Scales constructed to measure each type of request have high internal consistency while being sufficiently brief to be acceptable to general practice patients. The Patient Requests Form is a novel, convenient method to quantify the intentions of patients when they consult a general practitioner. It permits research into neglected aspects of consultation behaviour, including the factors that influence patients' intentions to seek different kinds of help and GPs' perceptions of these intentions.

Referral pattern to the allergist for hay fever in a health-care system with open access to specialists

Little is known about referral patterns to the allergist for hay fever. In a system with open access to the specialist, we investigated the reasons for consulting an allergist in 126 patients who completed a questionnaire on their first visit. Both sexes were equally represented, the median age was 29 years, the duration of the disease and the duration of seasonal symptoms were 9 years and 10 weeks (median), respectively, and 54% of patients reported a history suggestive of asthma. The symptoms were highly variable; on average, 5.6 on a 10-cm visual analog scale. Most of the patients (94%) had been treated for hay fever before. Only 30% were referred by another physician, the rest being self-referred. The reasons for referral were investigated. The overall motivation to consult was related to symptom severity in 63% of the patients; 37% consulted for other reasons, including an expectation of greater "know-how" on the part of the allergist concerning specific diagnosis, treatment, and advice or counseling. The stimulus triggering the consultation was clearly not related to symptoms or disease in 25% of the cases. We conclude from these data that many patients are clearly interested in benefiting from the professional skill of a fully trained allergist.

Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders

Joint consultation sessions between general practitioners (GPs) and specialists to examine patients for whom decisions about referral are difficult are thought to be helpful, but their effects have not been evaluated. In a randomised, controlled trial we studied the effects of joint sessions of GPs and orthopaedic surgeons on referral and intervention rates. During 1.5 years, 12 GPs (in groups of three) held monthly joint consultation sessions with four participating orthopaedic surgeons: patients were seen by one orthopaedic surgeon in the presence of three GPs. Patients were included in the trial if the GP was uncertain about the diagnostic or therapeutic management and if referral was considered; and excluded if referral was urgently necessary or if there was some other clear indication for referral. By a randomised consent design, patients were assigned to joint consultation sessions (n = 144) or a usual-care control group (n = 128). A year later the patients were examined by an independent orthopaedic surgeon. There were significantly fewer referrals (51/144 [35%] vs 87/128 [68%], p < 0.01) and diagnostic actions in the intervention group than in the control group, without negative effects on health or functional status. More patients in the intervention group were symptom-free at 1 year (35% vs 24%, p < 0.05). Joint consultation sessions of GPs and orthopaedic surgeons within the framework of general practice resulted in more efficient care, with better targeted examination, treatment, and referrals.

How valuable is feedback of information on hospital referral patterns?

OBJECTIVES

To determine general practitioners' responses to and explanations for variation in rates of referral to hospital and how feedback of data on rates of referral could be used to facilitate practices in auditing their own referral behaviour.

DESIGN

Visits by audit facilitators to general practices after feedback of details of rates of referral to hospital derived from annual reports in general practice.

SETTING

92 general practices in East Anglia.

RESULTS

General practitioners judged that access to specialist care, the individual skill of general practitioners, patient demand, and fear of litigation were major determinants of referral behaviour. Because there was widespread scepticism about the accuracy of the data on which the feedback was based and because there is no clear relation between rates of referral and quality of care, it was extremely difficult to encourage doctors to use the feedback as a basis for auditing their own hospital referrals.

CONCLUSION

If general practitioners are to contribute meaningfully to monitoring future changes in referral patterns it will be essential to develop reliable information systems in which doctors have confidence. Furthermore, audits need to be based on analysis of clinical cases rather than on rates of referral.

Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

OBJECTIVES

To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines.

SETTING

Practices within Cambridge Health Authority and Addenbrooke's Hospital, Cambridge.

MAIN OUTCOME MEASURES

Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists. Effect of referral guidelines on referral patterns as judged by general practitioners using the guidelines in clinical practice.

RESULTS

There was 2.5-fold variation in referral rates among general practices. According to the specialists, 9.6% (95% confidence interval 6.4% to 12.9%) of referrals by general practitioners and 8.9% (2.6% to 15.2%) of referrals from other specialists were judged possibly or definitely inappropriate. Against locally determined referral guidelines 15.9% of referrals by general practitioners were judged possibly inappropriate (11.8% to 20.0%). Elimination of all possibly inappropriate referrals could reduce variation in practice referral rates only from 2.5-fold to 2.1-fold. An estimate of the effect of using referral guidelines for 60 common conditions in routine general practice suggested that application of guidelines would have been unlikely to reduce rates of referral in hospital (95% confidence interval -4.5% to 8.6% of consultations resulting in referral).

CONCLUSION

The variation in referral rates among general practitioners in Cambridge could not be explained by inappropriate referrals. Application of referral guidelines would be unlikely to reduce the number of patients referred to hospital.