title: Referral patterns of Israeli pediatricians of common primary care office procedures.
abstract: BACKGROUND
  Pediatric primary care is the cornerstone of health care services for children. Performance of common office procedures is an integral part of primary care. Ideally, the community-based primary care pediatrician provides comprehensive health care services and only refers a small minority of patients for consultation. However, knowledge regarding Israeli pediatricians' practices of office procedures is scant.
  
  
  OBJECTIVE
  To describe primary care pediatricians' patterns in the provision of common office procedures and to analyze factors associated with performance or referral.
  
  
  METHODS
  
  
  
  METHODS
  Self-completed structured questionnaire consisting of 1) demographic variables; 2) practice characteristics description; 3) List of ten procedures (treatment of subungual hematoma, laceration suturing and adhesive closure, elbow subluxation/reduction , urinary bladder catheterization, supra-pubic aspiration, inguinal hernia reduction, umbilical granuloma and labial fusion treatment, and short lingual frenulum management) followed by questions regarding referral practice for each procedure; and 4) causes and indications for referral when relevant.
  
  
  METHODS
  Primary care pediatricians attending anational pediatric conferences.
  
  
  METHODS
  Descriptive statistics and association assessment.
  
  
  RESULTS
  The questionnaire was completed by 162 primary care pediatricians, 58.7 % male; mean age 53 ± 9 years, 88.4 % board certified. Of the respondents, 57 % worked in group practices and the remainder solo; salaried employees 68.2 %, independent contractors 31.8 %. Referral rate varied by procedure; least likely to be referred was labial fusion (7.7 %) and most likely was short lingual frenulum (81.3 %). For most procedures, the most frequent non-performance cause was lack of expertise followed by lack of appropriate conditions. The overall number of procedures in which the response selected was out-of-clinic referral was not associated with demographic or employment characteristics. However, association was found for certain specific procedures (e.g. experience with catheterization, gender with suturing and adhesive closure).
  
  
  CONCLUSIONS
  Many common office procedures are referred out of primary care pediatric community settings in Israel. Considerable variability was found among procedures. Lack of experience or lack of appropriate conditions were frequently reported causes for referral and need to be addressed in reducing unnecessary referral with its attendant costs and patient inconvenience. Possible approaches include updates in pediatric residency training, focused in-service training, time allocation and work environment reorganization.
authors.affiliation: Jerusalem District Health Office - Ministry of Health, 86 Jaffa Road, Jerusalem, 94341 Israel.
authors.forename: Deena R
authors.initials: DR
authors.lastname: Zimmerman
authors.affiliation: Meuchedet Health Services, 31 Yitzchak Mirsky St., Jerusalem, 97284 Israel.
authors.forename: Yona
authors.initials: Y
authors.lastname: Amitai
authors.affiliation: Department of Management, Bar Ilan University, Max and Anna Webb St., Ramat Gan, 52900 Israel.
authors.forename: Zahi
authors.initials: Z
authors.lastname: Grossman
authors.affiliation: Braun School of Public Health and Community Medicine Hebrew University in Jerusalem, Ein Karem, PO Box 12272, Jerusalem 91120 Israel.
authors.forename: Chen
authors.initials: C
authors.lastname: Stein-Zamir
keywords: Based medicine; Children; Community; Office procedures; Pediatrics; Primary care; Referrals