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Health Care Decisionmaking

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Family physicians value personal knowledge of specialists over all other factors when making referrals

Despite the formal constraints put on referrals to medical specialists over the past decade, 5 percent of visits to family physicians still lead to referral to a specialist. About one-third of these referrals are made during encounters other than office visits to physicians, such as by telephone or office staff. The type of medical problem involved is a powerful determinant of whether a patient is referred, and obtaining advice is by far the most common reason for referral, according to a study supported by the Agency for Healthcare Research and Quality (HS09377).

Researchers from Johns Hopkins University, the University of Colorado, and the Center for Research Strategies in Denver examined 35,519 visits to family physicians and 2,534 new referrals made in the offices of 141 family physicians in 87 practices located in 31 States. Although 68 percent of referrals were made by physicians during office visits, 18 percent were made by doctors during telephone conversations with patients, 11 percent were made by office staff with input from the physician, and 3 percent were made by staff without physician input. Doctors sought specialists' advice on either diagnosis or treatment for 52 percent of referrals and asked the specialist to direct medical management for 26 percent and surgical management for 38 percent of referred patients. Patient request to see a specialist prompted 14 percent of referrals.

Fifty medical conditions accounted for 76 percent of referrals. Surgical specialists were sent the largest share of referrals (45 percent), followed by medical specialists (31 percent), nonphysician clinicians (12 percent), obstetrician-gynecologists (5 percent), mental health professionals (4 percent), other practitioners (2 percent), and generalists (0.8 percent). Family physicians recommended a specific specialist to the patients for 86 percent of referrals, primarily because of their personal knowledge of the specialist.

See "Family physicians' referral decisions: Results from the ASPN referral study," by Christopher B. Forrest, M.D., Ph.D., Paul A. Nutting, M.D., M.S.P.H., Barbara Starfield, M.D., M.P.H., and Sarah von Schrader, M.A., in the March 2002 Journal of Family Practice 51(3), pp. 215-222.

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