Specialty Referral Completion Among Primary Care Patients: Results From the ASPN Referral Study

INTRODUCTION

Specialty referrals are one of several management options available to primary care physicians. The effectiveness of specialty referrals as a management tool depends not only on the quality of physician decision making—when and for whom to obtain specialty care—but also on the likelihood that patients referred choose to complete the referral by attending one or more specialist visits.

Although much is published on the determinants of primary care physician referral decision making,^1–3 much less is known about referral completion. Based on chart audits and physician survey, prior studies have found that 63% to 82% of patients referred from primary care settings ultimately attend a consultation with the type of specialist to whom they were referred.^4–6 Beyond these descriptive estimates, there is little information on the associations among patient, referring physician, and health care delivery system characteristics with referral completion.

A necessary step toward improving the quality and outcomes of the specialty referral process is developing a better understanding of the determinants of referral completion. To fill this knowledge gap, we report findings from the ASPN Referral Study, a prospective cohort study that examined the content and results of physicians’ referral decisions.^3,7–9 The study was specifically designed to (1) estimate and contrast rates of referral completion from the perspectives of patients and primary care physicians; (2) identify patient, physician, and delivery system predictors of referral completion; and (3) understand from the perspective of patients why some chose not to or could not complete the referral.

METHODS

RESULTS

The study sample was composed of 776 patients referred by 133 physicians from 81 unique practices located in 30 states. The mean age of patients was 48.2 years (SD, 19.6), and 59.9% were female (Table 1⇓). Only 3.7% of patients were uninsured, and 11.0% had Medicaid financing. Most referrals (64.0%) were expected to be short-term (less than 3 months). The most common reason for a referral was to obtain a therapeutic procedure (eg, a surgery) or diagnostic test (eg, an endoscopy). Almost one-half of the patient sample had a 5-year or longer relationship with their referring physicians. Referring physicians scheduled the specialty appointment for 78.8% of referrals made and sent to the specialist relevant patient information for 85.3%.

Physicians reported that 79.2% (615 of 776) of patients referred had a specialist visit, and 83.0% (644 of 776) of patients reported that they completed the referral (Table 2⇓). According to 132 referred patients who did not see a specialist, the most common, non–mutually exclusive reasons for choosing not to complete the referral were (1) the patient’s belief that the health problem had resolved (47.5%), (2) lack of time (37.3%), and (3) the patient disagreed with the physician on the need for referral (26.5%). Patients who requested the referral were more likely to complete the referral than those who did not (92.4% vs 81.9%; P=.02).

For 2.3% of all referrals made, patients said that their health care insurance plan did not approve the referral. Patients with Medicaid financing were more likely than their insured counterparts to have their referral denied by their health plan (7.1% vs 1.2%; P<.01).

Patients and physicians agreed on referral completion for 79.3% (615 of 776). The κ statistic for patient-physician agreement was 0.34, representing only fair agreement. Using patients’ reports as the reference standard, the sensitivity of physician reports of referral completion was 85.5%, the specificity was 51.5%, the positive predictive value was 89.6%, and the negative predictive value was 42.2%.

All patient, referral decision, health plan, physician, and practice variables, which are listed in Table 1⇑, were tested for statistical association with patient-reported referral completion; only those with a P value of less than .20 are shown in Table 3⇓. Variables not associated with referral completion were (1) patient characteristics—age, sex, education, and income; (2) health plan—gatekeeping arrangements and capitation payment; (3) referral decision—type of specialist referred to, primary expectation of specialist, urgency, referring physician gave name of specialist to patient, and referring physician transferred information to specialist; and (4) physician and practice—sex, census division, and practice size.

A stepwise logistic regression with forward selection was done to select the most parsimonious set of predictors of patient-reported referral completion (Table 4⇓). Patients in Medicaid plans were less likely than all others to complete the referral. On the other hand, a longer duration of relationship with the primary care physician and scheduling of the specialty appointment by the referring physician’s office staff were both positive predictors of referral completion.

DISCUSSION

According to both patients and referring physicians, about 8 in 10 referrals are completed within 3 months. We attempted to minimize the effects of recall bias by using a follow-up period of 3 months; customizing each patient questionnaire with the specific name of the referring physician, the date when the referral was made, and the specific type of specialist referred to; and having referring physicians use patients’ medical records to complete questionnaires.

Physicians in this study volunteered to participate, and many were active in primary care practice-based research networks. Their referral practices may systematically differ from all US physicians because of this self-selection process. Our physician sample has been compared with a nationally representative sample of primary care physicians who participated in the National Ambulatory Medical Care Survey, and results suggested similar rates of referral overall and by age, sex, and disease status between the 2 groups.⁹ Even though all physician participants were interested in research on specialty referrals, the potential direction of any bias on referral completion estimates is unclear.

We believe the effects of nonresponse bias are likely to be minimal, although 22% of patients did not return the follow-up survey. Physician-estimated referral completion for this subgroup was 76%, which is close to the 80% physician-based estimate for the sample who participated in the follow-up survey. Responders and nonresponders to the patient follow-up questionnaire did not differ significantly in terms of payer status or likelihood that physicians or their staff scheduled the specialty appointment. The nonresponders were more likely than responders to report a relationship of less than 5 years with their primary care physician (39% vs 50%, respectively).

Doctor-patient agreement on which patients actually attended a specialty appointment was only fair. Physicians’ perceptions of whether the referral was completed were sensitive, but not specific. In other words, the largest source of disagreement resulted from physicians believing that patients had completed the referral, while the patients reported that they had not. We found that physicians were no better than a chance flip of a coin in reporting on referral completion when patients had, in fact, not seen the specialist. This low level of agreement could result from primary care physicians not following up on all referred patients or incomplete transfer of information from specialists back to primary care practices, leading to a lack of medical record documentation. It should also be noted that we had no source other than patient and physician reports for verifying whether the referral was actually completed, which raises the question of which source is most valid. We elected to use the patient as the criterion in this study, because referral completion is an event that they experience directly, whereas physicians are in effect proxy observers.

Referral completion awareness could be improved with electronic records that automatically update the patient’s primary care records once a specialist appointment has occurred. Such an electronic system could also be used to notify physicians when patients cancel a specialty appointment, perhaps with the reason for the cancellation appended to the notice. Lack of physician knowledge of referral completion could lead to overuse quality problems, resulting from inadvertent duplication of tests, procedures, or prescribing of medications. False-positive physician reports, on the other hand, could result in patients not receiving needed services.

Scheduling the appointment with the specialist at the time the referral was made had a strong positive effect on referral completion. Other researchers have found a similar association between assistance in scheduling the specialist’s appointment and referral completion for youth referred from school-based health centers,⁵ patients referred from an emergency department to outpatient psychiatry,¹⁴ and patients referred for mammograms.¹⁵ Staff or physician scheduling of the specialty referral appointment is low-cost, practical, and, as this study shows, an important determinant of referral completion.

Research from other countries has found that longer waiting times increase the chances of nonattendance for a new referral visit.¹⁶ One reason why specialty appointment waiting times may decrease referral completion is that patients’ health problems can resolve during the wait, which was the case for about one-half of all patients who did not complete the referral in our study. Another study on nonattendance in a pediatric dermatology clinic found similar rates of health problem resolution.¹⁷ It is unclear, however, whether physicians would similarly report that the problem prompting referral had in fact resolved.

Medicaid insurance was associated with reduced chances of completing the referral. The proportion of patients with Medicaid financing (11%) in this study was low, which suggests that practices with higher proportions would experience reduced rates of referral completion. Other research has found that Medicaid beneficiaries are less likely than those with commercial insurance to access specialty care for chronic care management.¹⁸ One explanation for why referral completion rates were so low for Medicaid patients is that their health plans were more likely than their insured counterparts to deny the referral. Another explanation that we did not examine is that Medicaid patients may have more difficulty scheduling a specialist appointment because of low clinician acceptance of Medicaid payment. Nonetheless, Medicaid financing should alert physician organizations to patients who may need special efforts to facilitate referral completion.

A longer relationship between the patient and the referring physician was another important positive predictor of referral completion. Better continuity between doctors and patients has been associated with reduced rates of primary care no-shows.¹⁹ One reason for this association may be that a longer relationship offers greater opportunities for doctors and patients to align their goals regarding health care treatment and outcomes.²⁰ A shared understanding of common goals may increase patients’ trust that their physicians are acting on their behalf, thereby increasing patient’s motivation to follow specialty referral recommendations made by their doctor. Patient motivation to see the specialist, according to our results, is a key reason for attending the appointment: 9 in 10 patients requesting the referral completed it.

Referral completion involves a negotiation process between doctors and patients. This dialogue is influenced by continuity of the doctor-patient relationship. Not all patients choose to participate in their physicians’ management decisions: 1 in 4 patients who did not complete the referral disagreed with their doctor on the need for a specialist, and about 1 in 2 stated the problem prompting the referral had resolved. Findings from this study suggest that referral completion rates may be increased by assisting patients with scheduling their specialty appointments and promoting continuity of care.