Primary care physician specialty referral decision making: Patient, physician, and health care system determinants

Christopher B. Forrest, Paul A. Nutting, Sarah Von Schrader, Charles A Rohde, Barbara Starfield

Research output: Contribution to journalArticle

Abstract

Purpose. To examine the effects of patient, physician, and health care system characteristics on primary care physicians' (PCPs') specialty referral decision making. Methods. Physicians (n = 142) and their practices (n = 83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n = 34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist. Results. Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gatekeeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice. Conclusions. PCPs' referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs' thresholds for referring problems that could have been managed in their entirety within primary care settings.

Original languageEnglish (US)
Pages (from-to)76-85
Number of pages10
JournalMedical Decision Making
Volume26
Issue number1
DOIs
StatePublished - Jan 2006

Fingerprint

Primary Care Physicians
Decision Making
Patient Care
Referral and Consultation
Delivery of Health Care
Physicians
Managed Care Programs
Primary Health Care
Gatekeeping
Internal Medicine
Uncertainty
Health

Keywords

  • Managed care
  • Medical decision making
  • Primary care
  • Referral-consultation
  • Uninsured

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Health Informatics
  • Health Information Management
  • Nursing(all)

Cite this

Primary care physician specialty referral decision making : Patient, physician, and health care system determinants. / Forrest, Christopher B.; Nutting, Paul A.; Von Schrader, Sarah; Rohde, Charles A; Starfield, Barbara.

In: Medical Decision Making, Vol. 26, No. 1, 01.2006, p. 76-85.

Research output: Contribution to journalArticle

Forrest, Christopher B. ; Nutting, Paul A. ; Von Schrader, Sarah ; Rohde, Charles A ; Starfield, Barbara. / Primary care physician specialty referral decision making : Patient, physician, and health care system determinants. In: Medical Decision Making. 2006 ; Vol. 26, No. 1. pp. 76-85.
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