Medicine
Most clinical review articles about health conditions that may require co-management of specialist physicians contain a short section or Table titled "Indications for Referral." For example, a recent article on prevention and care of outpatient burns includes a list of criteria from the American Burn Association for considering the transfer of a patient to a burn center. This and other lists generally represent expert consensus on appropriate reasons to refer a patient in a typical primary care setting; obviously, availability and accessibility of specialists has a large influence on a family physician's practice with regard to management of "referable" conditions. Clinicians' training and expertise also affect their comfort levels in caring for patients with complex problems and, as previous studies have shown, these factors lead to variations in referral rates.
Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago.
What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?
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The above post was first published on the AFP Community Blog.
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- Moneyball And Health Care Quality Statistics - Part 1 Of 2
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Medicine
How many physician referrals is too many?
Most clinical review articles about health conditions that may require co-management of specialist physicians contain a short section or Table titled "Indications for Referral." For example, a recent article on prevention and care of outpatient burns includes a list of criteria from the American Burn Association for considering the transfer of a patient to a burn center. This and other lists generally represent expert consensus on appropriate reasons to refer a patient in a typical primary care setting; obviously, availability and accessibility of specialists has a large influence on a family physician's practice with regard to management of "referable" conditions. Clinicians' training and expertise also affect their comfort levels in caring for patients with complex problems and, as previous studies have shown, these factors lead to variations in referral rates.
Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago.
What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?
**
The above post was first published on the AFP Community Blog.
- Changing The Structure Of Health Care Delivery Systems: To Benefit The Patient, The Providers, Or The Insurers?
In an important series of 3 articles beginning on the Sunday before the New Year, “Doctors Inc.”, Alan Bavley of the Kansas City Star looked at the increasing acquisition of physician practices by hospitals, and the impact this has on access to, quality...
- Limitations Of Clinical Protocols: The Example Of Sepsis
Unwarranted variations in medical care contribute to poor health outcomes in the United States. In many cases, following a standard management protocol is likely to produce as good or better results than clinical judgment alone. For example, American...
- Conservative Medicine: Why Is Now The Right Time For It?
Forty years ago, Dr. Jack Wennberg and colleagues at Dartmouth Medical School published the first of a series of groundbreaking studies of medical resource utilization and practice variations that would eventually become the Dartmouth Atlas of Health...
- Your Primary Care Team Will See You Now
In a previous post about how health reform will change your doctor's visits, I mentioned that you're likely to see your future primary care delivered by a "team" of health professionals rather than your doctor. You might be surprised to hear that...
- Moneyball And Health Care Quality Statistics - Part 1 Of 2
At a recent conference, Harvard surgeon and best-selling author Atul Gawande told the audience of health professionals and policy makers that he always assigns his medical students a book about baseball called Moneyball: The Art of Winning an Unfair Game....