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Primary Care

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Family physicians vary in the types of referrals they make for patients with several common conditions

Why some family doctors refer patients with a particular condition to surgeons while others refer patients with the same condition to medical specialists is unclear. However, the referral predispositions of family physicians greatly affect the nature of subsequent care received by patients, that is, whether they receive medication or surgery, the extent of tests and procedures they undergo, and related costs. A recent study supported in part by the Agency for Healthcare Research and Quality (HS09377) examined primary care physician decisionmaking about referrals for several common adult and pediatric conditions.

Lead author, Barbara Starfield, M.D., M.P.H., of Johns Hopkins University, and her colleagues asked 136 family physicians in 80 office-based practices their reasons for referrals made during office visits to the most common types of specialists and what they expected from the specialists. Office staff recorded all referrals in a log, and physicians completed a questionnaire for each referral made during the 15 practice-day study period.

Family doctors most commonly referred patients to 15 types of specialists, ranging from psychiatrists and gastroenterologists to neurologists, cardiologists, and orthopedic surgeons. Of the 147 conditions with referrals, 53 were referred to only one type of specialist. Twenty-eight conditions had referrals to both physicians and nonphysicians.

More than 50 percent of referrals to specialists were for consultation only rather than direct intervention. Most referrals to allergists, psychiatrists, and nonphysicians were for shared management. In contrast, most referrals to general surgeons, gastroenterologists, obstetricians-gynecologists, and otolaryngologists were for tests or special procedures. Four of the 10 conditions with more than seven referrals to each type of specialist had referrals to both medical and surgical specialists. However, in most cases, there were no apparent differences in the reason for the referral (including severity of the condition) or expectations about the referral that would explain the choice of specialist.

See "Variability in physician referral decisions," by Dr. Starfield, Christopher B. Forrest, M.D., Ph.D., Paul A. Nutting, M.D., M.S.P.H., and Sarah von Schrader, M.A., in the November 2002 Journal of the American Board of Family Practice 15, pp. 473-480.

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