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Research ArticleOriginal Research

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

Christopher B. Forrest, Efrat Shadmi, Paul A. Nutting and Barbara Starfield
The Annals of Family Medicine July 2007, 5 (4) 361-367; DOI: https://doi.org/10.1370/afm.703
Christopher B. Forrest
MD, PhD
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Efrat Shadmi
PhD, RN
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Paul A. Nutting
MD, MSPH
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Barbara Starfield
MD, MPH
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Tables

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    Table 1.

    Characteristics of Study Sample

    CharacteristicsNo.%
    * Numbers may not sum to 776 for each variable because of missing data.
    Patient characteristics (n = 776 referred patients)*
    Age
        0–19 y709.0
        20–39 y17923.1
        40–49 y14618.8
        50–59 y13317.2
        60–69 y12015.5
        ≥ 70 y12716.4
    Sex
        Male31140.1
        Female46559.9
    Patient/parent education
        Less than high school degree12115.6
        High school or some college37448.2
        College or technical school graduate20726.7
        Graduate or professional degree749.5
    Annual family income
        <$20,00021530.7
        $20,000–$40,00021831.1
        $40,000–$60,00012317.5
        >$60,00014520.7
    Patient race
        White69391.8
        Nonwhite628.2
    Health plan characteristics
    Health plan payer (n = 648)
        Private40863.0
        Medicaid7111.0
        Medicare14522.3
        Uninsured243.7
    Gatekeeping and primary care payment type (n=630)
        No gatekeeping29446.7
        Gatekeeping with fee-for-service payment17728.1
        Gatekeeping with capitated payment15925.2
    Referral decision characteristics (n = 776 referrals)
    Type of specialist referred to
        Medical subspecialist25933.4
        Surgical subspecialist36246.6
        Obstetrician/gynecologist344.4
        Nonphysician clinician8911.5
        Mental health professional324.1
    Primary expectation of specialist
        Consultation for advice8110.6
        Perform a test or procedure38550.3
        Shared responsibility for ongoing management22028.7
        Transferred responsibility for ongoing management8010.4
    Expected duration of specialist involvement
        <3 mo49364.0
        3–12 mo17322.5
        >12 mo10413.5
    Urgency of referral—how soon patient should see specialist
        <1 wk26534.6
        1 wk – 1 mo40652.9
        At the patient’s discretion9612.5
    Duration of relationship with referring physician
        <3 mo9212.0
        3 mo – 5 y29538.5
        ≥5 y37949.5
    Referring physician/staff scheduled specialist appointment
        No16321.2
        Yes60578.8
    Referring physician gave patient the name of a specialist
        No8711.3
        Yes68688.7
    Referring physician transferred patient information to specialist
        No11314.7
        Yes65585.3
    Referring physician characteristics (n = 133 physicians)
    Years in practice
        <5 y2821.1
        6–14 y3828.6
        ≥15 y6750.4
    Sex
        Male10679.7
        Female2720.3
    Specialty
        Family physician12392.5
        General internist107.5
    Referring practice characteristics (n = 81)
    Location
        Urban6784.8
        Rural1215.2
    US census division
        Northeast1214.8
        Midwest2834.6
        South2429.6
        West1721.0
    Size
        Solo, 2- to 3-physician practice3037.0
        Large practice (>3 physicians)5163.0
    • View popup
    Table 2.

    Patient-Physician Agreement on Referral Completion

    Patient-Reported Referral Completion
    Referring Physician-Reported Referral CompletionYes No. (%)No No. (%)Totals
    Yes551 (85.6)64 (48.5)615
    No93 (14.4)68 (51.5)161
    Totals644 (100.0)132 (100.0)776
    • View popup
    Table 3.

    Associations Between Patient-Reported Referral Completion and Patient, Referral Decision, Physician, Practice, and Health Plan Characteristics: Univariate Analyses

    PredictorCompleted/Total Referrals* No.Referral Completion %P Value
    Note: Associations with P <.20 only are shown in this table.
    * For each bivariate association, denominators may vary because of missing values.
    Overall644/77683.0
    Patient race
        White581/69383.8
        Nonwhite46/6274.2.06
    Medicaid health plan
        Yes53/7174.6
        No591/70583.8.07
    Expected duration of specialist involvement
        <3 mo418/49384.8
        3–12 mo141/17381.5
        >12 mo80/10476.9.13
    Duration of patient-physician relationship
        <3 mo69/9275.0
        3 mo – 5 y240/29581.4
        ≥5 y325/37985.8.04
    Referring physician/staff scheduled appointment
        No122/16374.8
        Yes515/60585.1<.01
    Referring physician years in practice
        <5 y95/12576.0
        6–14 y191/22983.4
        ≥15 y358/42284.8.07
    Referring physician specialty
        Internist41/5673.2
        Family physician603/72083.8.04
    Referring physician practice location
        Urban555/67482.3
        Rural72/8090.0.08
    • View popup
    Table 4.

    Predictors of Referral Completion: Logistic Regression Analysis

    Predictors of Referral CompletionAdjusted Odds Ratio95% Confidence Interval
    Note: Predictor variables were retained in the final model only if they significantly improved model fit (P <.05 for the likelihood ratio test). Logistic regression with the generalized estimating equation was used to estimate odds ratios and their 95% confidence intervals.
    Medicaid health plan
        Yes0.510.28–0.92
        NoReferent
    Duration of patient-physician relationship
        <3 moReferent
        3 mo – 5 y1.650.87–3.13
        ≥5 y2.141.14–4.00
    Referring physician/staff scheduled appointment
        NoReferent
        Yes1.911.19–3.06

Additional Files

  • Tables
  • The Article in Brief

    Specialty Referral Completion Among Patients: Results from the ASPN Referral Study

    Christopher B. Forrest, MD, PhD, and colleagues

    Background When primary care doctors refer patients to specialists, they may not be aware of whether the visit takes place. This lack of information could result in patients receiving duplicate medical services or not receiving needed services at all. This study set out to understand more about referrals of patients to specialists from the viewpoints of both patients and doctors.

    What This Study Found About 8 in 10 patients visit a specialist within 3 months of being referred by their primary care doctor. The most common reasons for not visiting the specialist are lack of time, a belief that the health problem has resolved, or disagreement with the doctor about the need for a specialist. Patients in Medicaid plans are less likely than others to visit the specialist and more likely to have the referral denied by their health plan. Patients who have a longer relationship with the primary care doctor and those whose appointment is scheduled by the primary care doctor�s office are more likely to visit the specialist.

    Implications

    • Primary care offices can encourage referred patients to visit specialists by helping to schedule the appointment and promoting an ongoing relationship between the patient and the primary care doctor.
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The Annals of Family Medicine: 5 (4)
The Annals of Family Medicine: 5 (4)
Vol. 5, Issue 4
1 Jul 2007
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Specialty Referral Completion Among Primary Care Patients: Results From the ASPN Referral Study
Christopher B. Forrest, Efrat Shadmi, Paul A. Nutting, Barbara Starfield
The Annals of Family Medicine Jul 2007, 5 (4) 361-367; DOI: 10.1370/afm.703

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Specialty Referral Completion Among Primary Care Patients: Results From the ASPN Referral Study
Christopher B. Forrest, Efrat Shadmi, Paul A. Nutting, Barbara Starfield
The Annals of Family Medicine Jul 2007, 5 (4) 361-367; DOI: 10.1370/afm.703
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