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Primary Care Physician Specialty Referral Decision Making: Patient, Physician, and Health Care System Determinants

Author

Listed:
  • Christopher B. Forrest

    (Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health, Baltimore, MDcforrest@jhsph.edu)

  • Paul A. Nutting

    (Center for Research Strategies and the Department of Family Medicine, University of Colorado, Denver)

  • Sarah von Schrader

    (Department of Psychological and Quantitative Foundations, University of Iowa, Iowa City)

  • Charles Rohde

    (Department of Biostatistics Johns Hopkins Bloomberg School of Public Health, Baltimore, MD)

  • Barbara Starfield

    (Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health, Baltimore, MD)

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.

Suggested Citation

  • Christopher B. Forrest & Paul A. Nutting & Sarah von Schrader & Charles Rohde & Barbara Starfield, 2006. "Primary Care Physician Specialty Referral Decision Making: Patient, Physician, and Health Care System Determinants," Medical Decision Making, , vol. 26(1), pages 76-85, January.
  • Handle: RePEc:sae:medema:v:26:y:2006:i:1:p:76-85
    DOI: 10.1177/0272989X05284110
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    Citations

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    Cited by:

    1. Sisira Sarma & Nirav Mehta & Rose Anne Devlin & Koffi Ahoto Kpelitse & Lihua Li, 2018. "Family physician remuneration schemes and specialist referrals: Quasi‐experimental evidence from Ontario, Canada," Health Economics, John Wiley & Sons, Ltd., vol. 27(10), pages 1533-1549, October.
    2. Saeede Eftekhari & Niam Yaraghi & Ram D. Gopal & Ram Ramesh, 2023. "Impact of Health Information Exchange Adoption on Referral Patterns," Management Science, INFORMS, vol. 69(3), pages 1615-1638, March.
    3. Barkowski, Scott, 2021. "Physician Response to Prices of Other Physicians: Evidence from a Field Experiment," MPRA Paper 108966, University Library of Munich, Germany.
    4. McDonnell, Thérèse & Nicholson, Emma & Bury, Gerard & Collins, Claire & Conlon, Ciara & De Brún, Aoife & Doherty, Edel & McAuliffe, Eilish, 2023. "The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department in Ireland: A Discrete Choice Experiment," Health Policy, Elsevier, vol. 132(C).
    5. Kushida, Shuya & Kawashima, Michie & Abe, Tetsuya, 2021. "Recommending no further treatment: Gatekeeping work of generalists at a Japanese university hospital," Social Science & Medicine, Elsevier, vol. 290(C).
    6. van Dijk, Christel E. & Korevaar, Joke C. & Koopmans, Berber & de Jong, Judith D. & de Bakker, Dinny H., 2014. "The primary–secondary care interface: Does provision of more services in primary care reduce referrals to medical specialists?," Health Policy, Elsevier, vol. 118(1), pages 48-55.
    7. Ryan Tandjung & Seraina Morell & Andreas Hanhart & Andreas Haefeli & Fabio Valeri & Thomas Rosemann & Oliver Senn, 2017. "Referral determinants in Swiss primary care with a special focus on managed care," PLOS ONE, Public Library of Science, vol. 12(11), pages 1-10, November.
    8. Yu-Hua Yan & Chih-Ming Kung & Horng-Ming Yeh, 2019. "The Impacts of the Hierarchical Medical System on National Health Insurance on the Resident’s Health Seeking Behavior in Taiwan: A Case Study on the Policy to Reduce Hospital Visits," IJERPH, MDPI, vol. 16(17), pages 1-10, August.
    9. Sebastian Linde, 2019. "The formation of physician patient sharing networks in medicare: Exploring the effect of hospital affiliation," Health Economics, John Wiley & Sons, Ltd., vol. 28(12), pages 1435-1448, December.

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