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For two reasons I liked the conclusion of this paper that “it remains unclear whether GP- or practice-related variations in admission rates represent low- or high-quality practice”.
First, it took me back to early parts of my career - 30+ years ago - when there was a whole bunch of research in the UK on the relationship between practice characteristics and rates of referral to hospital which broadly produced very little. Indeed one of our studies studies suggested that GPs with particular expertise in a clinical area actually referred more patients to specialists in that area – not fewer (1).
Despite the evidence that much of the variation in rates of referral was simply random variation due to chance (2), the UK government at the time went ahead with publishing rates of referral of individual practices – with little effect on anything.
A second paper from that era that I’ve always liked is the one which showed a linear relationship between the rate of outpatient referral in orthopaedics and subsequent inpatient admission – almost as if you had a fixed probability of being listed for surgery if you crossed the threshold of the orthopaedic clinic (3).
The paper also makes me think of one regret of my career - maybe one that someone else could now take up. Although not directly addressed by these authors, the concept of ‘ambulatory care sensitive admissions’ (ACSCs) is widely – and in my view uncritically – used. Much of the original research showing that good primary care could avoid ACSCs was based in the US where patients who went from having no primary care to having a regular source of primary care showed reduced ACSCs. My impression is that in countries where the population has universal access to primary care, the link between ‘good’ and ‘poor’ primary care and ACSCs is very much weaker if it exists at all. Anyone want to take this up? The review could make a nice Masters project.
1. Reynolds GA, Chitnis JG, Roland MO General practitioner outpatient referrals. Do good doctors refer more patients to hospital? British Medical Journal 1991; 302: 1250-2. doi:10.1136/bmj.302.6787.1250
2. Moore AT and Roland MO How much of the variation in general practitioner referral rates is due to chance? British Medical Journal 1989; 298: 500-502. doi:10.1136/bmj.298.6672.500.
3. Coulter A, Seagroatt V, McPherson K. Relation between general practices' outpatient referral rates and rates of elective admission to hospital. BMJ 1990; 301: 273-6. doi:10.1136/bmj.301.6746.273.