title: Compliance with referrals to medical specialist care: patient and general practice determinants: a cross-sectional study.
abstract: BACKGROUND
  In a gatekeeper system, primary care physicians and patients jointly decide whether or not medical specialist care is needed. However, it is the patient who decides to actually use the referral. Referral non-compliance could delay diagnosis and treatment. The objective of this study was to assess patient compliance with a referral to medical specialist care and identify patient and practice characteristics that are associated with it.
  
  
  METHODS
  Observational study using data on 48,784 referrals to medical specialist care derived from electronic medical records of 58 general practices for the period 2008-2010. Referral compliance was based on claims data of medical specialist care. Logistic multilevel regression analyses were conducted to determine associations between patient and general practice characteristics and referral compliance.
  
  
  RESULTS
  In 86.6% of the referrals, patients complied. Patient and not practice characteristics were significantly associated with compliance. Patients from deprived urban areas and patients aged 18-44 years were less likely to comply, whereas patients aged 65 years and older were more likely to comply.
  
  
  CONCLUSIONS
  About 1 in 8 patients do not use their referral. These patients may not receive adequate care. Demographic and socio-economic factors appear to affect compliance. The results of this study may be used to make general practitioners more aware that some patients are more likely to be noncompliant with referrals.
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands. christelvdijk@hotmail.com.
authors.forename: Christel E
authors.initials: CE
authors.lastname: van Dijk
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands. j.dejong@nivel.nl.
authors.forename: Judith D
authors.initials: JD
authors.lastname: de Jong
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands. r.verheij@nivel.nl.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Verheij
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands. t.jansen@nivel.nl.
authors.forename: Tessa
authors.initials: T
authors.lastname: Jansen
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands. j.korevaar@nivel.nl.
authors.forename: Joke C
authors.initials: JC
authors.lastname: Korevaar
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands. d.debakker@nivel.nl.
authors.forename: Dinny H
authors.initials: DH
authors.lastname: de Bakker
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D058006:General Practice / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D009426:Netherlands; D010349:Patient Compliance / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012923:Social Class; D012959:Socioeconomic Factors; D013038:Specialization; D014505:Urban Population / Q000706:statistics & numerical data*; D055815:Young Adult
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