[Factors related to inappropriate referral between primary and specialized care: qualitative study among primary care physicians].
OBJECTIVE
To characterise the factors that, from a primary care physician's point of view, are related to inappropriate referral from primary to specialised health care.


METHODS
We conducted two focus groups and two semi-structured interviews with primary care physicians. Each of the participant's profiles was defined according to variables related to inappropriate referral found in previous studies. Discussions were recorded on audio tape and later transcribed verbatim onto paper. We analysed the factors related to inappropriate referral according to frequency and capacity for generating discussion.


RESULTS
Primary care physicians have different concepts regarding inappropriate referral, besides health problems that can be solved in primary care. Inappropriate referral is usually justified. Factors related to inappropriate referral can be divided into four groups: 1) related to the patient and patient/doctor relationship: pressure exerted on the primary care physician, caused by a belief in specialists' greater competence, the right of the patient to specialist referral and mass media pressure; 2) related to the health system: lack of coordination between care levels, consultancy time pressure, lack of equipment and distance to the specialist; 3) related to primary care physicians: lack of training and defensive medical practise; 4) related to specialists: professional competence and behaviour with patients.


CONCLUSIONS
A notable gap can clearly be seen between primary and specialised care, and this generates problems in the health system. It is difficult to implement prevention and control measures with the factors related to inappropriate referral. Primary care physicians form opinions that are not based on available evidence. Further research is needed in both qualitative and quantitative fields.
Alonso Pérez de Agreda
Servicio de Planificación e Información Sanitaria, Diputación General de Aragón, Zaragoza, 50004, España. jpalonso@aragob.es
Febrel Bordejé
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M
Domeco de Jarauta
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J
D000368:Aged; D001291:Attitude of Health Personnel; D005260:Female; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D011320:Primary Health Care; D012017:Referral and Consultation; D013030:Spain