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Primary Care

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Coordination between primary care physicians and specialists improves the quality of the referral process

When a primary care physician (PCP) decides to refer a patient to specialty care, he or she must coordinate service delivery across settings, multiple providers, and time to maintain continuity of care. Breakdowns in coordination of primary and specialty care have the potential for missed or delayed diagnoses and treatments, repeated or unnecessary testing, adverse drug reactions, and a host of other problems, including an increased risk of litigation. Yet, integrating referral care with primary care is a complex and time consuming process that often is not adequately reimbursed.

A recent study supported by the Agency for Healthcare Research and Quality (HS08430) examined how physicians coordinate patient care for specialty referrals and the effects of these activities on the completion of referral care (written communication of referral results from the specialist) and referring physicians' satisfaction with the specialty care their patients receive. The study involved a consecutive sample of 963 referrals made from the offices of 122 pediatricians in 85 practices in the Pediatric Research in Office Settings (PROS) network, a practice-based research network. Participating physicians completed a survey when the referral was made and 3 months later.

The researchers found that referring physicians often do not communicate relevant patient information to specialists when making referrals, and even when they do, the reasons for the referral are often absent. Yet when PCPs schedule a patient's appointment with the specialist and/or send information to the specialist, it substantially improves the chances that the specialist will give the referring physician feedback on the specialty care provided. This in turn improves the referring physician's satisfaction with the specialty care provided to the patient, according to the study's co-leaders, Christopher B. Forrest, M.D., Ph.D., and Barbara Starfield, M.D., M.P.H., of Johns Hopkins University.

In this study, pediatricians scheduled appointments with specialists for 39 percent of the patients they referred and sent patient information to specialists for 51 percent of referrals. The odds of referral completion increased three-fold for those referrals for which the pediatrician scheduled the appointment and communicated with the specialist compared with those for which neither activity occurred. The satisfaction ratings of referring pediatricians increased significantly by any type of specialist feedback, especially feedback by both telephone and letter.

Elements of specialists' letters that significantly increased physician ratings of quality included presence of patient history, suggestions for future care, followup arrangements, and plans for the specialist and referring physician to comanage the patient's care. These results support the need for physicians who receive either primary care or subspecialty training to be educated on ways that patients can be successfully comanaged, suggest Drs. Forrest and Starfield.

Details are in "Coordination of specialty referrals and physician satisfaction with referral care," by Dr. Forrest, Gordon B. Glade, M.D., Alison E. Baker, M.S., and others in the May 2000 Archives of Pediatric and Adolescent Medicine 154, pp. 499-506.

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