title: Extent of diagnostic agreement among medical referrals.
abstract: OBJECTIVE
  Diagnostic uncertainty is often encountered in a medical practice. Patients with ambiguous, uncertain, and undiagnosed problems are frequently referred for second opinions. Comparing referral diagnoses to final diagnoses provides an opportunity to determine how frequently final diagnoses vary and changes the direction of medical care.
  
  
  METHODS
  A retrospective study was done at a single academic medical center using a sample of 286 patients referred by physician assistants, nurse practitioners, and physicians from primary care practices from January 1, 2009 to December 31, 2010. Patients' referral and final diagnoses were compared and classified into 1 of 3 categories: referral diagnosis and final diagnosis the same, referral diagnosis better defined/refined, and referral diagnosis distinctly different from final diagnosis. Episode costs for the respective categories were calculated for the referral visit and services that occurred at our facility within the first 30 days.
  
  
  RESULTS
  In 12% (36/286) of cases, referral diagnoses were the same as final diagnoses. Final diagnoses were better defined/refined in 66% (188/286) of cases; but in 21% of cases (62/286), final diagnoses were distinctly different than referral diagnoses. Total costs for cases in category 3 (different final diagnoses) were significantly higher than costs for cases in category 1 (P = .0001) and category 2 (P = <.0001).
  
  
  CONCLUSIONS
  Referrals to advanced specialty care for undifferentiated problems are an essential component of patient care. Without adequate resources to handle undifferentiated diagnoses, a potential unintended consequence is misdiagnoses resulting in treatment delays and complications leading to more costly treatments.
authors.affiliation: Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Monica
authors.identifier: http://orcid.org/0000-0002-6079-6405
authors.initials: M
authors.lastname: Van Such
authors.affiliation: Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Lohr
authors.affiliation: Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Beckman
authors.affiliation: Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: James M
authors.initials: JM
authors.lastname: Naessens
mesh_terms: D000046:Academic Medical Centers; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D003933:Diagnosis; D005260:Female; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000191:economics* / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013038:Specialization / Q000706:statistics & numerical data*
keywords: diagnostic uncertainty; face-to-face visit; provider referrals