title: Referral from primary to secondary care in Germany: developing a taxonomy based on cluster analysis.
abstract: OBJECTIVE
  Referrals from primary to secondary care may differ regarding motivation and initiative. Previous research on the frequency and variation of referrals has mostly treated referrals as homogeneous. We intended to develop a taxonomy regarding referrals from primary to secondary care in Germany that could support decision making on a macro level.
  
  
  METHODS
  We analyzed 3,988 referrals by 29 German general practitioners (GPs). GPs were asked to document all referrals during one week; in subsequent audits they stated the reasons and initiative for any referral. We postulated the following five referral types: clinical problem, shared care, administrative, patient initiated and shared cost. The data were analyzed with k-means cluster analysis.
  
  
  RESULTS
  We identified three of our five postulated referral types with cluster analytic techniques: shared care, clinical problem, and patient initiated. This solution accounted for 11.7% of total variance. The majority of referrals in German primary care practices were initiated by the GP, or they were part of a shared decision with patients.
  
  
  CONCLUSIONS
  We suggest a taxonomy of referrals that might offer insights regarding the allocation of resources within the German health system. Referrals might be reduced by improved training of primary care physicians and by giving them more competencies in routine care of chronic patients.
authors.affiliation: Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany. oliver.hirsch@staff.uni-marburg.de
authors.forename: Oliver
authors.initials: O
authors.lastname: Hirsch
authors.forename: Susanne
authors.initials: S
authors.lastname: Träger
authors.forename: Stefan
authors.initials: S
authors.lastname: Bösner
authors.forename: Muazzez
authors.initials: M
authors.lastname: Ilhan
authors.forename: Annette
authors.initials: A
authors.lastname: Becker
authors.forename: Erika
authors.initials: E
authors.lastname: Baum
authors.forename: Norbert
authors.initials: N
authors.lastname: Donner-Banzhoff
mesh_terms: D000328:Adult; D002965:Classification / Q000379:methods; D016000:Cluster Analysis; D005194:Family Practice / Q000458:organization & administration*; D005260:Female; D058005:General Practitioners; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration*; D012017:Referral and Consultation / Q000145:classification* / Q000706:statistics & numerical data