title: Minor surgery in general practice and effects on referrals to hospital care: observational study.
abstract: BACKGROUND
  Strengthening primary care is the focus of many countries, as national healthcare systems with a strong primary care sector tend to have lower healthcare costs. However, it is unknown to what extent general practitioners (GPs) that perform more services generate fewer hospital referrals. The objective of this study was to examine the association between the number of surgical interventions and hospital referrals.
  
  
  METHODS
  Data were derived from electronic medical records of 48 practices that participated in the Netherlands Information Network of General Practice (LINH) in 2006-2007. For each care-episode of benign neoplasm skin/nevus, sebaceous cyst or laceration/cut it was determined whether the patient was referred to a medical specialist and/or minor surgery was performed. Multilevel multinomial regression analyses were used to determine the relation between minor surgery and hospital referrals on the level of the GP-practice.
  
  
  RESULTS
  Referral rates differed between diagnoses, with 1.0% of referrals for a laceration/cut, 8.2% for a sebaceous cyst and 10.2% for benign neoplasm skin/nevus. The GP practices performed minor surgery for a laceration/cut in 8.9% (SD:14.6) of the care-episodes, for a benign neoplasm skin/nevus in 27.4% (SD:14.4) of cases and for a sebaceous cyst in 26.4% (SD:13.8). GP practices that performed more minor surgery interventions had a lower referral rate for patients with a laceration/cut (-0.38; 95%CI:-0.60- -0.11) and those with a sebaceous cyst (-0.42; 95%CI:-0.63- -0.16), but not for people with benign neoplasm skin/nevus (-0.26; 95%CI:-0.51-0.03). However, the absolute difference in referral rate appeared to be relevant only for sebaceous cysts.
  
  
  CONCLUSIONS
  The effects of minor surgery vary between diagnoses. Minor surgery in general practice appears to be a substitute for specialist medical care only in relation to sebaceous cysts. Measures to stimulate minor surgery for sebaceous cysts may induce substitution.
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands. c.vandijk@nivel.nl
authors.forename: Christel E
authors.initials: CE
authors.lastname: van Dijk
authors.forename: Robert A
authors.initials: RA
authors.lastname: Verheij
authors.forename: Peter
authors.initials: P
authors.lastname: Spreeuwenberg
authors.forename: Peter P
authors.initials: PP
authors.lastname: Groenewegen
authors.forename: Dinny H
authors.initials: DH
authors.lastname: de Bakker
mesh_terms: D004814:Epidermal Cyst / Q000601:surgery; D005194:Family Practice / Q000706:statistics & numerical data*; D005251:Fees, Medical; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D013511:Minor Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data*; D009426:Netherlands; D009506:Nevus / Q000601:surgery; D019370:Observation; D010818:Practice Patterns, Physicians'; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012878:Skin Neoplasms / Q000601:surgery