title: Is Self-Referral Associated with Higher Quality Care?
abstract: OBJECTIVE
  To assess the extent to which patients self-refer to cancer specialists and whether self-referral is associated with better experiences and quality of care.
  
  
  METHODS
  Data from surveys and medical record abstraction collected through the Cancer Care Outcomes Research and Surveillance Consortium.
  
  
  METHODS
  Observational study of patients with lung and colorectal cancer diagnosed from 2003 through 2005 in five geographically defined regions and five integrated health care delivery systems.
  
  
  METHODS
  Multivariable logistic regression models used to assess factors associated with self-referral and propensity score-weighted doubly robust models to test the association between self-referral and experiences/quality of care.
  
  
  RESULTS
  Among 5,882 patients, 9.7 percent of lung cancer patients and 14.9 percent of colorectal cancer patients self-referred to at least one cancer specialist. Black patients were less likely to self-refer than white patients (odds ratio: 0.48, 95 percent confidence interval: 0.35, 0.64); patients with high incomes (vs. low) and with a college degree (vs. non-high school graduates) were significantly more likely to self-refer. Self-referral was associated with lower ratings of overall physician communication for patients with lung cancer but, conversely, higher odds of curative surgery among patients with stage I/II lung cancer.
  
  
  CONCLUSIONS
  A small but significant proportion of patients self-referred to their cancer specialists; rates varied by patient race and socioeconomic status. To the extent that self-referral is associated with quality, it may reinforce disparities in care.
authors.affiliation: Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD.
authors.forename: Craig Evan
authors.initials: CE
authors.lastname: Pollack
authors.affiliation: RAND Corporation, Santa Monica, CA.
authors.forename: Afshin
authors.initials: A
authors.lastname: Rastegar
authors.affiliation: Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA.|Department of Health Care Policy, Harvard Medical School, Boston, MA.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Keating
authors.affiliation: Research & Evaluation, Kaiser Permanente, Pasadena, CA.
authors.forename: John L
authors.initials: JL
authors.lastname: Adams
authors.affiliation: Division of Preventive Medicine and Comprehensive Cancer Center, University of Alabama, Birmingham, AL.
authors.forename: Maria
authors.initials: M
authors.lastname: Pisu
authors.affiliation: Division of General Internal Medicine, University of California, Los Angeles, CA.|RAND Corporation, Los Angeles, CA.
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Kahn
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D000367:Age Factors; D000368:Aged; D015179:Colorectal Neoplasms / Q000628:therapy*; D003142:Communication; D006297:Health Services Accessibility; D006801:Humans; D007348:Insurance, Health; D008175:Lung Neoplasms / Q000628:therapy*; D008495:Medical Oncology / Q000706:statistics & numerical data; D008875:Middle Aged; D009367:Neoplasm Staging; D010817:Physician-Patient Relations; D057216:Propensity Score; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D018787:Radiation Oncology / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012737:Sex Factors; D012959:Socioeconomic Factors; D044465:White People / Q000706:statistics & numerical data
keywords: Self-referral; colorectal cancer; lung cancer; referral