Referral of Patients to Specialists: Factors Affecting Choice of Specialist by Primary Care Physicians

Kraig S. Kinchen; Lisa A. Cooper; David Levine; Nae Yuh Wang; Neil R. Powe

doi:10.1370/afm.68

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Figure 1.
Proportion of patients referred to specialists.

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Table 1.

Characteristics of Primary Care Physician Respondents: Overall and by Race and Sex

	White n = 316	Black n = 242		Male n = 262	Female n = 296
Characteristics	n (%)	n (%)	PValue	n (%)	n (%)	PValue
NA = not applicable; FP = family practice; IM = internal medicine; HMO = health maintenance organization.
Note: numbers for missing values by characteristics were: age (11); board certified (3), international medical graduate (4); location (3); practice setting (21); specialty (38).
Age			<.01			<.01
<40 years	93 (29.7)	99 (42.3)		58 (22.7)	134 (46.1)
40–49 years	125 (39.9)	97 (41.5)		98 (38.3)	124 (42.6)
>49 years	95 (30.4)	38 (16.2)		100 (39.1)	33 (11.3)
Sex, female	163 (51.6)	133 (55.0)	.43	---	---	NA
Race, black	---	---	NA	109 (41.6)	133 (44.9)	.43
Board certified	285 (90.5)	190 (79.2)	<.01	216 (82.8)	259 (88.1)	.07
International medical graduate	20 (6.3)	39 (16.4)	<.01	36 (13.8)	23 (7.9)	.02
Location			<.01			.35
Rural	95 (30.0)	35 (14.6)		67 (25.8)	63 (21.4)
Urban	92 (29.1)	130 (54.4)		103 (39.6)	119 (40.3)
Suburban	127 (40.2)	74 (40.0)		90 (34.6)	111 (37.6)
Other	2 (0.63)	0 (0.0)		0 (0.0)	2 (0.68)
Practice setting			<.01			<.01
Hospital clinic	38 (12.7)	28 (11.8)		27 (10.8)	39 (13.6)
Staff/group HMO	7 (2.3)	26 (11.0)		10 (4.0)	23 (8.0)
Private group	155 (51.7)	80 (33.8)		110 (43.8)	125 (43.7)
Solo	74 (24.7)	69 (29.1)		87 (34.7)	56 (19.6)
Other practice	26 (8.7)	34 (14.4)		17 (6.8)	43 (15.0)
Specialty			.22			.02
Family practice	151 (50.3)	100 (45.5)		103 (43.5)	148 (52.3)
Internal medicine	120 (40.0)	106 (48.2)		107 (45.2)	119 (42.1)
FP/IM with specialty	17 (5.7)	9 (4.1)		19 (8.0)	7 (2.5)
Other	12 (4.0)	5 (2.3)		8 (3.4)	9 (3.2)
Region			<.01			.03
South	82 (26.0)	106 (43.8)		104 (39.7)	84 (28.4)
Northeast	76 (24.1)	54 (22.3)		60 (22.9)	70 (23.7)
Midwest	92 (29.1)	49 (20.3)		58 (22.1)	83 (28.0)
West	66 (20.9)	33 (13.6)		40 (15.3)	59 (19.9)
Almost always knows name of specialist referring to	274 (86.7)	172 (71.1)	<.01	212 (80.9)	234 (79.1)	.35

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Table 2.

Primary Care Physicians’ (N = 553) Ratings of Importance of Different Factors in Choosing a Specialist

	Importance Rating, Percent of Respondents
Factor	No.	No.	Mild	Moderate	Major
Medical skill	545	0.0	0.2	12.3	87.5
Previous experience with specialist	552	0.2	6.2	34.4	59.2
Appointment timeliness	549	0.2	3.6	40.8	55.4
Quality of communication	552	0.0	4.9	42.6	52.5
Likelihood of good patient-physician rapport	553	0.7	5.4	42.5	51.4
Specialist returns to primary physician	550	2.0	12.0	34.9	51.1
Insurance coverage	550	8.2	15.5	26.7	49.6
Patient preference for particular specialist	553	0.9	10.0	48.3	40.9
Primary care physician relationship with specialist	552	3.6	15.8	44.8	35.9
Board certification	549	5.8	20.2	40.1	33.9
Patient convenience	551	1.1	19.1	56.1	23.8
Attitudes of colleagues toward specialist	553	4.7	34.2	46.7	14.5
Hospital affiliation	551	10.9	33.6	41.9	13.6
Office location	551	4.9	34.7	51.0	9.4
Specialist refers patients to primary physician	552	37.3	42.0	16.5	4.2
Medical school	553	47.0	43.8	8.9	0.4
Fellowship training institution	552	40.4	44.4	15.0	0.2

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Table 3.

Percentage of Black and White Primary Care Physicians Who Rated Factors of Major Importance in Choosing a Specialist

	Unadjusted Percent				*Adjusted Percent (95% CI)**
Factors	No.	White	Black	PValue	No.	Black	PValue
CI = conficence interval.
* Adjusted for sex, age, US vs international medical graduate status, board certification, practice setting, whether respondent almost always knows the name of the specialist, practice location, region.
Specialist characteristics
Medical skill	545	90.3	83.9	.03	510	88 (79–93)	.40
Board certification	549	40.5	25.4	>.01	514	29 (20–39)	.03
Practice characteristics
Appointment timeliness	549	51.5	60.4	.04	513	54 (44–64)	.63
Insurance coverage	550	49.8	49.4	.92	514	51 (41–62)	.80
Hospital affiliation	551	13.9	13.3	.84	515	14 (8–23)	.98
Primary care physician-specialist interaction
Primary care physician previous experience with specialist	552	65.0	51.9	<.01	516	55 (44–65)	.05
Specialist returns patient to primary care physician	550	47.3	56.0	.04	515	58 (47–68)	.05
Quality of communication	552	48.7	57.4	.04	516	53 (43–63)	.40
Primary care physician relationship with specialist	552	35.8	36.0	.97	516	35 (26–45)	.84
Attitudes of colleagues toward the specialist	553	16.4	12.0	.14	517	13 (8–21)	.37
Patient-specialist interaction
Likelihood of good patient-physician rapport	553	50.5	52.5	.64	517	54 (44–64)	.46
Patient preference for particular specialist	553	39.9	42.2	.59	517	47 (36–57)	.20
Patient convenience	551	17.4	32.0	<.01	515	26 (17–36)	.06
Office location	551	7.1	12.4	.04	515	12 (6–22)	.14

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Table 4.

Percentage of Male and Female Primary Care Physicians Who Rated Factors of Major Importance in Choosing a Specialist

	Unadjusted Percent				*Adjusted Percent (95% CI)**
Factor	No.	Male	Female	PValue	Female	PValue
CI = confidence interval.
* Adjusted for race, age, US vs international medical graduate status, board certification, practice setting, region, medical specialty.
Specialist characteristics
Medical skill	545	83.6	87.2	.23	90 (83–94)	.09
Board certification	549	30.2	37.1	.09	36 (27–47)	.24
Practice characteristics
Appointment timeliness	549	57.0	53.9	.47	51 (41–61)	.26
Insurance coverage	550	43.6	55.0	<.01	60 (50–70)	<.01
Hospital affiliation	551	13.9	13.4	.85	16 (9–26)	.59
Primary care physician-specialist Interaction
Primary care physician previous experience with specialist	552	59.7	58.8	.84	62 (51–71)	.73
Specialist returns patient to primary care physician	550	59.0	44.2	<.01	46 (36–56)	.01
Quality of communication	552	52.9	52.2	.87	48 (38–58)	.31
Primary care physician relationship with specialist	552	35.1	36.5	.74	35 (26–45)	.95
Attitudes of colleagues toward the specialist	553	12.4	16.3	.19	15 (9–24)	.45
Patient-specialist interaction
Likelihood of good patient-physician rapport	553	52.5	50.3	.61	54 (44–63)	.82
Patient preference for particular specialist	553	42.1	39.8	.59	39 (30–49)	.52
Patient convenience	551	25.9	21.9	.28	19 (13–28)	.11
Office location	551	10.1	8.9	.63	8 (4–14)	.33

The Article in Brief

Primary care physicians consider several factors when choosing a specialist for a patient referral. The specialist's medical skill is the most important factor. Other major considerations include the primary care physician's previous experience with the specialist and the timeliness of the patient's appointment.