title: Comparative performance information plays no role in the referral behaviour of GPs.
abstract: BACKGROUND
  Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient's needs. We investigated how GPs view their role in using CPI to choose providers and support patients.
  
  
  METHODS
  We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network.
  
  
  RESULTS
  Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of-care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI.
  
  
  CONCLUSIONS
  Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP's role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs' ability and willingness to use CPI to guide their patients in the referral process.
authors.affiliation: Radboud university medical center, Scientific Institute for Quality of Healthcare 114, P,O, Box 9101, 6500, HB, Nijmegen, The Netherlands. Nicole.Ketelaar@radboudumc.nl.
authors.forename: Nicole A B M
authors.initials: NA
authors.lastname: Ketelaar
authors.forename: Marjan J
authors.initials: MJ
authors.lastname: Faber
authors.forename: Glyn
authors.initials: G
authors.lastname: Elwyn
authors.forename: Gert P
authors.initials: GP
authors.lastname: Westert
authors.forename: Jozé C
authors.initials: JC
authors.lastname: Braspenning
mesh_terms: D001291:Attitude of Health Personnel; D005260:Female; D058006:General Practice / Q000379:methods*; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013038:Specialization / Q000592:standards*; D011795:Surveys and Questionnaires