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

I agree with Dr. Hon that a larger study of referral completion would provide more insights into the reasons for non-attendance for all patients and important sub-groups. When we completed this study, we felt that following up 776 patients through physicians practices was a major feat! In part, this relates to our methodology--self-administered questionnaires that were mailed to patients. At Children's Hospital of Philadelphia, we have a large pediatric network that has a common electronic health record platform. The EHR is making large scale studies possible, and I hope soon we will have better information about the primary-specialty interface using electronic capture of data via the EHR and the personal health record as well.

Dr. Kuo points out that lack of agreement between doctors and patients and the need for a patient-centered approach when discussing a referral as a management option. I could not agree more. The referral decision is a really a negotiation that can be made more effective with enhanced communication. Patients choose to participate in a referral, and our results indicate that many choose to follow the recommendation of their primary care doctor. Still, I support the need for practice and training modification to enhance the effectiveness of referrals. Measuring outcomes across all referrals is an incredibly difficult, perhaps unattainable task at present. We attempted to do this by assessing patient and physician perceptions of the effectiveness of the referral in terms of addressing the reason for referral and their evaluations. We found no differences in these measures between those with complete and incomplete referrals; nonetheless, I think more work is needed, probably using condition specific designs that permit more complete ascertainment of outcomes, to fully understand when specialty care is needed and for how long.

Competing interests:   None declared

The importance of collaboration and care coordination between primary and specialty care is increasingly being recognized,(1-2) but what if the patient fails to show up? Forrest and colleagues(3) find that 8 of 10 patients do complete a subspecialty referral within 3 months. The authors suggest that referral completion rates may be increased by assisting patients with appointment scheduling and increasing continuity of care by the primary care physician. I am struck by the K of .34 indicating only fair agreement between physician and patient regarding specialty completion and the specificity of 51.5% describing physician report of actual referral completion. It would be one thing if a physician was aware of patient refusal of the specialty referral, but it is another thing for the physician to assume a patient is receiving care when he in fact is not and have an adverse outcome due to delayed assessment and management.

The study findings support the importance of patient-centered care when making subspecialty referrals. The authors report that referral completion was associated with patient requesting referral, increased physician time in practice, and longer continuity of care, which are all issues associated with patient-centered care. The duration of the physician-patient relationship and the years the physician has spent in practice obviously cannot be changed for a given situation, but the authors comments that “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.� There is evidence that training providers to be more patient-centered during clinical consultations improves overall communication and increase patient satisfaction;(4) thus, in addition to practice-level interventions such as scheduling assistance, provider training in communication skills and shared decision making might also impact referral completion rates.

Finally, it would be interesting to examine the outcomes of incomplete versus completed referrals. Reasons patients reported for not completing the referral included resolution of the health problem, lack of time, or disagreement with the physician. If patients who delay or refuse specialty referral do not have worse outcomes, then perhaps such referrals were unnecessary and the patient understood this. The examining physician may have failed to accurately assess the situation, possibly due to suboptimal communication or from liability concerns. Criteria for referrals are complex and vary widely between physicians, and physician training may be able to influence referral rates(5) and, potentially, referral completion.

References:

(1) McManus P, Fox H, Limb S, Carpinelli A, and the Federal Expert Work Group on Pediatric Subspecialty Capacity. Promising approaches for strengthening the interface between primary and specialty pediatric care. Maternal and Child Health Policy Research Center, March 2006. Available at www.mchpolicy.org.

(2) Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv 2001;27:63-80.

(3) Forrest CB, Shadmi E, Nutting PA, Starfield B. Specialty referral completion among primary care patients: results from the ASPN referral study. Ann Fam Med 2007;5:361-7.

(4) Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2001;4:CD003267.

(5) Forrest CB, Nutting PA, von Schrader S, Rohde C, Starfield B. Primary care physician specialty referral decision making: patient, physician, and health care system determinants. Med Decis Making 2006;26:76-85.

Competing interests:   None declared