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Primary care physician and health care system characteristics influence the likelihood of referral to specialists

Only 5 percent of primary care visits include referral of a patient to a specialist. Referral decisions of primary care physicians (PCPs) are influenced by a complex mix of patient, physician, and health care system structural characteristics, according to a study supported by the Agency for Healthcare Research and Quality (HS09377). Patient characteristics had the largest effect on any referral. Increased likelihood of referral was also associated with less tolerance of uncertainty by PCPs, larger practice size, health plans with gatekeeping arrangements (the PCP was the gatekeeper who had to approve specialty referrals), and practices with high levels of managed care.

The likelihood that PCPs would refer patients to specialists for discretionary reasons (for conditions normally handled in primary care) was increased by capitated primary care payment (PCPs are paid a set amount per patient regardless of diagnosis or resources used), internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice.

Discretionary referrals were not strongly associated with patient factors, which suggests that the need for specialty care was not a major determinant. These findings were based on background questionnaires completed by 142 PCPs in 83 practices, located in 30 States, and survey data for 34,069 patient visits. The researchers modeled the occurrence of any specialty referral, which occurred during 5.2 percent of visits, as a function of patient, physician, and health care system structural characteristics. They did a subanalysis to examine determinants of referrals made for discretionary indications (17 percent of referrals), that is, referrals for problems commonly managed by PCPs, which have a high level of diagnostic and therapeutic certainty and low urgency for specialist involvement.

See "Primary care physician specialty referral decision making: Patient, physicians, and health care system determinants," by Christopher B. Forrest, M.D., Ph.D., Paul A. Nutting, M.D., M.S.P.H., Sarah von Schrader, M.A., and others, in the February 2006 Medical Decision Making 26, pp. 76-85.

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