Specialty Is Seen to Guide Referrals

Primary care physicians and specialists use different criteria for choosing the doctors to whom they refer patients, researchers from Harvard Medical School, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center said in the first study to explore how referral decisions differ by specialty.

The study is part of a larger effort to understand how and why physicians make referrals.

“Patient referrals have strong implications for both the cost and the quality of care,” said Bruce Landon, professor of health care policy at HMS. A referral can trigger a cascade of diagnostic tests, follow-up visits and procedures.

The findings suggest that any interventions to influence referral practices ought to be tailored by speciality, the researchers said.

The study, led by Michael Barnett, now a first-year resident in internal medicine and primary care at Brigham and Women’s, reports that primary care physicians are more likely to cite reasons related to patient access (such as availability of appointments) or physician-to-physician communications (such as a shared electronic records system), whereas medical or surgical specialists cite reasons related to patient experience with the chosen physician. For example, specialists are more likely to refer to doctors with whom previous patients report positive experiences.

“It’s clear that primary care physicians have different priorities than other physicians when choosing a specialist,” Barnett said. “This is particularly important since we found that many referrals are initiated by specialists, not just primary care physicians.” The paper was released online by the Journal of General Internal Medicine on Sept. 16.

Barnett and team examined reasons why primary care and specialist physicians choose certain specific colleagues to refer to, and how those reasons differ by specialty. Using a web-based survey, they asked 616 physicians, who treated 46,937 Medicare patients in 2006, about their referral and information-sharing relationships with other physicians of any specialty.

The researchers first identified referral relationships for each physician. They then asked respondents to identify the two most important reasons for choosing a specific physician the last time they referred a patient to him or her. The researchers grouped reasons for referral into three categories: patient experience with physician, patient access and physician-to-physician communication. Clinical expertise was excluded from the list of criteria because in pre-testing, physicians uniformly chose it as the most important reason for referral. Excluding expertise as a criterion enabled researchers to examine how physicians choose among physicians of similar quality.

To date, much of the work looking at the referral process has focused on primary care physicians as the sole source for referrals, consistent with their role as coordinators of care.

For more information, students may contact Bruce Landon at landon@hcp.med.harvard.edu.