Family Physicians’ Referral Decisions

Frequency of referral

The 141 family physicians had 34,519 office visits and made 2165 referrals during 1771 practice-days; 5.1% of office visits were referred. Physicians saw an average of 19.7 patients per day (range 7.0 to 48.4) and made 1.23 referrals per full practice-day (range 0 to 3.90). Referrals made during telephone conversations with patients accounted for 18.9% of all referrals made by physicians (range 0% to 100% per physician).

An additional 369 referrals (a rate of 0.21 referrals per practice-day) were made by staff. Overall, 68% of all referrals were made by physicians during visits with patients, 18% by physicians during telephone conversations with patients, 11% by staff with physician input, and 3% by staff without physician input. In 43.6% of referrals made during telephone conversations with patients, the telephone encounter was the first presentation to medical care for the health problem.

We compared percentages of office visits in which a referral was made in the study sample with percentages of such referrals by family physicians from the NAMCS surveys (1989–1994). The overall percentages did not significantly differ between the 2 groups (4.0% vs 3.7%, P > .05). Although physicians in the study sample were statistically less likely than NAMCS counterparts to refer children (1.6% vs 2.5%, P = .030), more likely to refer the elderly (4.8% vs 4.1%, P = .045), and more likely to refer females (4.1% vs 3.9%, P = .009), these differences were small. There were no differences between the groups in condition-specific referral rates. In sum, these results show that patients in the ASPN sample were equally likely to be referred as those in the NAMCS sample.

Reasons for referral

Table 2 shows the distribution of physicians’ reasons for making the referral. Physicians endorsed a mean of 1.8 different reasons for making the typical referral. Although patients requested to see a specialist for 13.6% of referrals, physicians recorded patient request as the only reason for referral just 1.1%.

We compared referrals made for uncommon conditions (lowest tertile of practice-prevalence) with common conditions (highest practice-prevalence tertile). The calculation of practice-prevalence was based on prior research: the numerator was visits made for the index condition, and the denominator was all visits in the sample.⁵ Uncommon conditions were more likely to be referred for medical management (38.5% vs 25.4%, P < .001), patient request (19.8% vs 12.3%, P = .005), and specialist request (4.9% vs 2.1%, P = .021). Common conditions were more likely to be sent to specialists because of failed current therapy (13.6% vs 3.8%, P < .001) and endoscopy (4.3% vs 0.5%, P = .013). There were no significant differences between the 2 groups in the chances of referral for advice on either diagnosis or treatment.

TABLE 2
REASONS FOR REFERRAL

Conditions referred

Table 3 presents condition-specific referral rates and the 2 most common types of specialists referred to for the top 25 referred health problems. (A complete listing of these data for all conditions reported by study physicians can be found in Table W1.) The 50 most commonly referred health problems accounted for 76% of all referrals made during office visits. Signs or symptoms accounted for 22.4% of all referrals. Condition-specific referral rates varied from a low of 1.9% for patients with otitis media to a high of 45.7% of visits referred for patients with cholelithiasis or cholecystitis. This range in referral rates translates into 24-fold variation in the chances of referral during an office visit based solely on the presenting problem.

TABLE 3
NUMBER OF OFFICE VISITS, REFERRAL RATES, AND SPECIALISTS REFERRED TO FOR TOP 15 REFERRED CONDITIONS*