Recognition of patient referral desires in an academic managed care plan frequency, determinants, and outcomes

General practitioners referring patients to specialists in tertiary healthcare: a qualitative study

BACKGROUND

There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center.

METHODS

Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results.

RESULTS

Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress.

CONCLUSIONS

General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis

Background

Demand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.

Objective

This research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.

Design

The approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.

Setting

Primary health care.

Main outcome measures

Referral from primary to secondary care.

Review methods

Systematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.

Results

From a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.

Conclusions

The findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.

Study registration

The study is registered as PROSPERO CRD42013004037.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Specialty referral communication and completion in the community health center setting

OBJECTIVE

Parent and provider disagreement about children's care at the time of specialty referral may lead to incomplete referral, ie, not attending a specialty visit when referred. This study's objectives were first to assess parent-provider correlation in perspectives on referral necessity, seriousness of child's health problem, and parental understanding of referral among children referred to pediatric specialists, and second to assess whether these perspectives are associated with incomplete referral.

METHODS

Two months after specialty referral, parents and primary care providers completed a survey rating referral necessity, seriousness of problem, and parental understanding on a 4-part scale ("definitely yes" to "definitely no"). Parents were surveyed by telephone; providers completed one self-administered survey per referral. Using z tests and Pearson correlation coefficients, we summarized parent-provider agreement about referral necessity, seriousness of problem, and parent understanding. We applied logistic regression to test associations of parent and provider ratings for each variable with incomplete referral.

RESULTS

A total of 299 (60.0%) of 498 matched parent and provider surveys were included in the analysis. Parents had low correlation with providers in perspectives of referral necessity and seriousness of problem. Parents reported that referral was necessary more often than providers, and providers underestimated parents' self-reported understanding of the referral. Nearly 1 in 3 children had incomplete referral, and both parent and provider reports of lower necessity were associated with incomplete referral.

CONCLUSIONS

Parents and providers hold divergent perspectives on referral necessity and seriousness of children's health problems; these perspectives may impact rates of incomplete referral. Improving communication around specialty referral might reduce incomplete referral.

Dropping the baton: specialty referrals in the United States

CONTEXT

In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines.

METHODS

This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care.

FINDINGS

PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management).

CONCLUSIONS

There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.

Bridging the care continuum: patient information needs for specialist referrals

BACKGROUND

Information transfer is critical in the primary care to specialist referral process and has been examined extensively in the US and other countries, yet there has been little attention to the patient's perspective of the information transfer process. This cross-sectional study examined the quality of the information received by patients with a chronic condition from the referring and specialist physician in the specialist referral process and the relationship of the quality of information received to trust in the physicians.

METHODS

Structured telephone interviews were conducted with a random sample of 250 patients who had experienced a referral to a specialist for the first visit for a chronic condition within the prior six months. The sample was selected from the patients who visited specialist physicians at any of the 500 hospitals from the National Research Corporation client base.

RESULTS

Most patients (85%) received a good explanation about the reason for the specialist visit from the referring physician yet 26% felt unprepared about what to expect. Trust in the referring physician was highly associated with the preparatory information patients received. Specialists gave good explanations about diagnosis and treatment, but 26% of patients got no information about follow-up. Trust in the specialist correlated highly with good explanations of diagnosis, treatment, and self-management.

CONCLUSION

Preparatory information from referring physicians influences the quality of the referral process, the subsequent coordination of care, and trust in the physician. Changes in the health care system can improve the information transfer process and improve coordination of care for patients.

Has the use of physician gatekeepers declined among HMOs? Evidence from the United States

Since the mid-1980s, health maintenance organizations (HMOs) have grown rapidly in the United States. But despite initial successes in constraining health care costs, they have come under increasing criticism for their restrictive practices. This suggests that, to remain viable, HMOs must change their behavior. Yet few studies offer empirical evidence on the matter. The present study investigates one cost-containment mechanism often associated with HMOs: the assignment of primary care physicians as gatekeepers (who, among other things, monitor patients' use of specialist physicians). In particular, we estimate the effect of physician-HMO involvement on the percentage of HMO patients for whom physicians serve as gatekeepers. We examine this relationship over two time periods: 2000-2001 and 2004-2005. Because physicians can choose whether and to what extent they participate in HMOs, we employ instrumental variables (IV) estimation to correct for the endogeneity of the HMO measure. Although the single-equation estimates suggest that HMO assignment of physician gatekeepers diminished modestly over time, the endogeneity-corrected estimates show no change between the two time periods. Thus, one major tool used by HMOs to constrain health care costs--the physician gatekeeper--has not declined even in a period of backlash against managed care.

[Evaluation of referrals in primary care]

OBJECTIVE

To study the process of referral from primary care in a health area in Madrid. The second objective was to evaluate the trends in the referral process.

DESIGN

Observational, descriptive and cross-sectional study.

SETTING

Three urban health centers in the Area 2.

PARTICIPANTS

All referrals made by 13 doctors during 3 consecutive weeks. The total number of visits attended were 6012. The study was realized between February 2002 and January 2003.

MAIN MEASUREMENTS

Patient, doctor and referral characteristics on every referral.

RESULTS

349 referrals were studied. The rate of referral 5.8% (5.21-6.39). The referred patients, 65.5% women, medium age 50.6+/-21. The specialties that received more referrals are gynecologist, ophthalmology, dermatology, otorhinolaryngology, rehabilitation, orthopedic surgeon and general surgeon. The most common conditions referred, 25.6% of all referrals, are gynecologist check, blindness, other illnesses of subcutaneous cellular tissue, arthrosis, joint pain, diabetes, benign neoplasm of skin, depression and hypoacusis. 92.3% of the referrals were sent to the specialist center. 89.7% were normal (no urgent). The reason for referral was to accede to the patient's request in 18.3% of the referrals.

CONCLUSIONS

The process of referral is similar to previous studies. Although people are more participative, have more information and the defensive medicine is increasing, the process of referral have not changed.

Increasing patient-initiation of cardiac rehabilitation referral in female percutaneous coronary intervention patients

Substantial health risks continue following coronary revascularization, and cardiac rehabilitation (CR) plays a large role in enhancing prognosis. However, fewer women than men are referred to and participate in CR. This study prospectively evaluates a psycho-educational intervention designed to increase patient-initiation of CR referral discussion with their physician, It was hypothesized that an educational brochure along with a motivational interview would facilitate the discussion of CR between physicians and female patients, ultimately resulting in increased referral of women to CR when compared to a control group. Eighty female percutaneous coronary intervention patients were recruited from two acute care sites in Toronto, Ontario. Eight weeks later, a second research assistant blind to condition telephoned participants to assess aftercare and CR referral processes. Results showed that patients in the experimental group more often discussed CR with a health care provider (chi2(1)=5.99, p=.01), and there was a trend toward increased referral when compared to control patients (chi2(1)=2.83, p=.09). Gaps in secondary prevention are noted, and areas for improved referral of women patients to CR are discussed.

From physician to consumer: the effectiveness of strategies to manage health care utilization

Many strategies are commonly used to influence physician behavior in managed care organizations. This review examines the effectiveness of three mechanisms to influence physician behavior: financial incentives directed at providers or patients, policies/procedures for managing care, and the selection/education of both providers and patients. The authors reach three conclusions. First, all health care systems use financial incentives, but these mechanisms are shifting away from financial incentives directed at the physician to those directed at the consumer. Second, heavily procedural strategies such as utilization review and gatekeeping show some evidence of effectiveness but are highly unpopular due to their restrictions on physician and patient choice. Third, a future system built on consumer choice is contradicted by mechanisms that rely solely on narrow networks of providers or the education of physicians. If patients become the new locus of decision making in health care, provider-focused mechanisms to influence physician behavior will not disappear but are likely to decline in importance.