Reasons for outpatient referrals from generalists to specialists.
OBJECTIVE
To determine the relative importance of medical and nonmedical factors influencing generalists' decisions to refer, and of the factors that might avert unnecessary referrals.


METHODS
Prospective survey of all referrals from generalists to subspecialists over a 5-month period.


METHODS
University hospital outpatient clinics.


METHODS
Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology.


RESULTS
For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals.


CONCLUSIONS
Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost.
Donohoe
M T
MT
Robert Wood Johnson Clinical Scholars Program, Stanford, Calif., USA.
Kravitz
R L
RL
Wheeler
D B
DB
Chandra
R
R
Chen
A
A
Humphries
N
N
D000553:Ambulatory Care / Q000379:methods; D003625:Data Collection; D003657:Decision Making; D005194:Family Practice / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008511:Medicine / Q000379:methods* / Q000706:statistics & numerical data; D010045:Outpatients / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000592:standards / Q000706:statistics & numerical data*; D013038:Specialization; D014481:United States