title: Comparison of the quality of patient referrals from physicians, physician assistants, and nurse practitioners.
abstract: OBJECTIVE
  To compare the quality of referrals of patients with complex medical problems from nurse practitioners (NPs), physician assistants (PAs), and physicians to general internists.
  
  
  METHODS
  We conducted a retrospective comparison study involving regional referrals to an academic medical center from January 1, 2009, through December 31, 2010. All 160 patients referred by NPs and PAs combined and a random sample of 160 patients referred by physicians were studied. Five experienced physicians blinded to the source of referral used a 7-item instrument to assess the quality of referrals. Internal consistency, interrater reliability, and dimensionality of item scores were determined. Differences between item scores for patients referred by physicians and those for patients referred by NPs and PAs combined were analyzed by using multivariate ordinal logistical regression adjusted for patient age, sex, distance of the referral source from Mayo Clinic, and Charlson Index.
  
  
  RESULTS
  Factor analysis revealed a 1-dimensional measure of the quality of patient referrals. Interrater reliability (intraclass correlation coefficient for individual items: range, 0.77-0.93; overall, 0.92) and internal consistency for items combined (Cronbach α=0.75) were excellent. Referrals from physicians were scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each of the following items: referral question clearly articulated (86.3% vs 76.0%; P=.0007), clinical information provided (72.6% vs 54.1%; P=.003), documented understanding of the patient's pathophysiology (51.0% vs 30.3%; P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001), appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient to referring health care professional (67.8% vs 41.4%; P<.0001). Referrals from physicians were also less likely to be evaluated as having been unnecessary (30.1% vs 56.2%; P<.0001).
  
  
  CONCLUSIONS
  The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.
authors.affiliation: Division of General Internal Medicine, Mayo Clinic, Rochester, MN. Electronic address: rlohr@mayo.edu.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Lohr
authors.forename: Colin P
authors.initials: CP
authors.lastname: West
authors.forename: Margaret
authors.initials: M
authors.lastname: Beliveau
authors.forename: Paul R
authors.initials: PR
authors.lastname: Daniels
authors.forename: Mark A
authors.initials: MA
authors.lastname: Nyman
authors.forename: William C
authors.initials: WC
authors.lastname: Mundell
authors.forename: Nina M
authors.initials: NM
authors.lastname: Schwenk
authors.forename: Jayawant N
authors.initials: JN
authors.lastname: Mandrekar
authors.forename: James M
authors.initials: JM
authors.lastname: Naessens
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Beckman
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009722:Nurse Practitioners / Q000592:standards*; D010823:Physician Assistants / Q000592:standards*; D010820:Physicians / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*; D012017:Referral and Consultation / Q000592:standards*; D015203:Reproducibility of Results; D012189:Retrospective Studies
keywords: NP; PA; nurse practitioner; physician assistant