Communication Gaps Persist Between Primary Care and Specialist Physicians

INTRODUCTION

Using 2008 data, O’Malley and Reschovsky found sizeable gaps in communication among physicians caring for mutual patients.¹ Poor communication has been linked to delayed diagnoses, unnecessary testing, and patient and physician dissatisfaction.^2,3 Communication might have improved in the past decade with the proliferation of electronic health records (EHRs), substantial growth in the number and sizes of vertically integrated health systems, and transformation initiatives, such as the Comprehensive Primary Care Plus (CPC₊) model, promoting coordinated care.⁴ We measured the extent to which primary care physicians (PCPs) report sending clinical information to specialists at the time of referral and report receiving information from specialists after consultation, using data collected in 2019 as part of the CPC₊ evaluation. We also aimed to identify characteristics of beneficiaries, physicians, and practice sites that predict the likelihood of communication.

METHODS

This was a cross-sectional study of 4,754 PCPs who responded to the CPC₊ Physician Survey, which assessed PCPs’ experiences in both CPC₊ and comparison (non-participating) practices. The survey was fielded August to December 2019 (2.5-3 years after CPC₊ began).⁵

We included the following 2 previously validated survey questions¹:

Question 1: “When you refer a patient to a specialist, how often do you send the specialist notification of the patient’s history and reason for the consultation?”

Question 2: “How often do you receive useful information about your referred patients from specialists?”

The response options were “Always or most of the time,” “Sometimes,” and “Seldom or never.” We examined the distribution of responses to each question and used logistic regression to predict the likelihood of responding “Always or most of the time” as a function of characteristics of (1) beneficiaries attributed to the PCPs, (2) the PCPs themselves, and (3) the practice site including its market. We supplemented the survey data with Medicare claims, enrollment, and other data sources.

We analyzed data for CPC₊ and comparison practices combined. Because CPC₊ has different entrance requirements for each of its 2 tracks, with more advanced care delivery requirements and payment approaches for Track 2, we analyzed practices (and their comparisons) separately by track. In total, we studied 2,289 PCPs in 1,831 CPC₊ and comparison practice sites in Track 1 and 2,465 PCPs in 1,882 CPC₊ and comparison practice sites in Track 2. Analyses were performed with Stata, version 16.1 (StataCorp LLC) using survey weights, with statistical significance tested at P < .05.

RESULTS

A total of 22% of PCPs in each of the tracks reported that they either “Sometimes” or “Seldom or never” send clinical information to the specialist at the time of a referral (Table 1). Similarly, 35% of Track 1 and 33% of Track 2 PCPs reported that they either “Sometimes” or “Seldom or never” receive information back from the specialist after a consultation.

The explanatory variables (60 total) together explained less than 12% of the variation in the likelihood of a PCP reporting communication “Always or most of the time,” and there were only a handful of individual statistically significant associations, which were small (Table 2).

DISCUSSION

Gaps in communication between PCPs and specialists persist. Because physicians participating in the CPC₊ survey are a highly motivated subset and are in practices with relatively more sophisticated EHR use,⁶ actual communication behaviors nationwide are likely worse than what we found in the present research sample. Because these are physician-level proportions, the number of patients who are potentially affected is large. Further, the presence of any communication between providers does not guarantee that practitioners are sending or receiving the optimal information needed for clinical decision making.

Although our sample is not directly comparable to the national sample of primary care practices examined 11 years ago,¹ the similarity in survey responses suggests that physicians still do not always intentionally engage in communication regarding referrals and consultations despite clinical information being more available. Our findings underscore the need for granular measurements of how communication is changing. It is not enough to assume that putting EHRs in place will improve communication; changes in communication need to be measured. More research is also needed to understand barriers to communication between PCPs and specialists, despite the availability of technology to aid communication and despite incentives to improve care coordination.