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Primary Care

Largest U.S. study ever examines pediatric referrals to specialists

In the United States, primary care physicians (PCPs) refer patients to specialists at rates that vary from two-fold to five-fold. Many managed care organizations use PCPs, including pediatricians, as gatekeepers to reduce costs by curtailing referrals for presumably inappropriate specialty care. A concern among many doctors and their patients is that gatekeeping pits the PCPs' traditional role as clinical advocates for patients against their managerial role as cost controllers.

But two recently published articles derived from the largest U.S. study ever conducted on pediatricians' referral patterns contain some surprises. The study examined office visits to 142 pediatricians in 94 practices across 36 States. It was supported by the Agency for Health Care Policy and Research (HS08430) and led by Christopher B. Forrest, M.D., Ph.D., and Barbara Starfield, M.D., M.P.H., of Johns Hopkins School of Public Health. Study findings in the first paper reveal that referrals to specialists are uncommon among all pediatricians. The second paper's findings suggest that doctors who have many patients enrolled in gatekeeping plans are more, not less, apt to refer their patients to specialists than others.

Forrest, C.B., Glade, G.B., Baker, A.E., and others (1999, July). "The pediatric primary-specialty care interface." Archives of Pediatric and Adolescent Medicine 153, pp. 705-714.

Referrals to specialists are uncommon among pediatricians, concludes this study. It found that pediatricians refer children and adolescents to specialists during only 2.3 percent (or 1 out of 40) of office visits. Referrals made during telephone conversations with parents accounted for 27.5 percent of all referrals. After adjustment for patient characteristics, there was a 4.4-fold variation in referral rates.

Getting advice on diagnosis or treatment from a specialist was the most common reason for referral (74.3 percent of referrals). Referral for medicolegal reasons or because the PCP had insufficient time to manage the patients' health problem was uncommon. Most (53 percent) referrals were made for new health problems and for 50 clinical conditions (especially chronic ear infections). Referrals were made to surgical subspecialists (52.3 percent), followed by medical subspecialists (27.9 percent), nonphysicians (11.4 percent), and mental health practitioners (8.4 percent). Also, in most cases (75 percent), physicians wanted to share medical management of the patient with the specialists.

These results suggest that the boundaries of the primary-specialty care interface are fluid, shifting in response to physicians' demands for advice or specialized skills and parents' or patients' expectations for specialty care. The researchers suggest that evidence-based guidelines on when to refer patients would be most useful for the 50 most commonly referred conditions reported in this study. Their findings are based on analysis of 58,771 visits made to 142 pediatricians during 20 consecutive practice days.

Forrest, C.B., Glade, G.B., Starfield, B., and others (1999, July). "Gatekeeping and referral of children and adolescents to specialty care." Pediatrics 104(1), pp. 28-34.

This study found unexpectedly that gatekeeping arrangements nearly doubled the odds of patient referrals from pediatricians' offices to specialty care, even though they compromised some aspects of care coordination. During the study period (October 1996 to September 1997), patients made 27,104 visits to 142 pediatricians during 1,228 practice days. Most visits (55.6 percent) were for patients in plans with gatekeeping arrangements. Patients in these plans were more apt to be referred than patients not enrolled in gatekeeping plans (3.16 vs. 1.85 percent of office visits for privately insured patients, and 5.39 percent vs. 3.73 percent of office visits for Medicaid-insured patients).

Physicians who saw 75 percent or more of their patients in gatekeeping plans saw 4 more patients per day (26 vs. 22) than those with 25 percent or fewer patients in gatekeeping plans. Increased practice intensity could be associated with less time to manage patients in the primary care setting, thereby leading to more referrals, suggest the researchers. Their study also found that coordination of referrals made during office visits was more problematic at the time of referral for patients in gatekeeping plans. Physicians were less likely to schedule an appointment or communicate with the specialist for referred patients in gatekeeping plans.

Primary care physicians unfamiliar with the panel of specialists in a patient's health plan may be less likely to contact that consultant to schedule a referral visit or to provide information about the patient. This breakdown in coordination limits a PCP's ability to clarify referral questions for the consultant and to provide background information on the history, previous evaluation, and management of the patient's health problem, explain the researchers. They suggest that as market penetration of gatekeeping insurance plans increases, doctors may need to hire additional administrative staff to help them coordinate an increasing volume of referrals.

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