Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

Fertig, Alexis M.; Roland, Martin; H, King; Moore, Tim

doi:10.1136/bmj.307.6917.1467

Cited by 82 publications

(55 citation statements)

References 10 publications

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“…These included more training in specific procedures, consultation with a trusted colleague, telephone consults with a specialist, the presence of a health educator, availability of clinical practice guidelines, longer visit lengths, computerized medical expert systems, MEDLINE search capabilities, and subspecialty texts (Donohoe et al, 1999) Although these studies suggest that physicians who make inappropriate referrals may require additional training or support to reduce this behavior, not all researchers agree. Fertig et al (1993) found that a high variation in referral rates among PCMs was not explained by inappropriate referrals. They concluded that the application of referral guidelines could help improve the quality of referrals but probably would not be useful in reducing the number of referrals to hospitals.…”

Section: Referral Process Improvement 18mentioning

confidence: 96%

Referral Process Improvement: A Study of the Efficiency and Tracking Processes for In-house Referrals at Blanchfield Army Community Hospital

Hoiden¹

2002

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Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. REPORT DATE AUG 20022. REPORT TYPE The purpose of this study was to evaluate the referral process from primary care managers (PCMs) to specialists at Blanchfield Army Community Hospital (BACH). Specifically, the study revealed key elements of an ideal referral process from the literature review and compared those elements with the referral process at BACH. Indicators were then developed to determine the efficiency of BACHs referral process. Statistical significance was found to exist in both the developed benchmarks (n = 1885) of each indicator at the 95% confidence interval. Finally, recommendations for improving the referral process were made based on the detailed systems and data analyses conducted. These recommendations focused on PCMs management of their impaneled patients and the referral process itself. Referral Process Improvement 3 SUBJECT TERMS Referral process improvement, Primary Care Physician AbstractThe purpose of this study was to evaluate the referral process from primary care managers (PCMs) to specialists at Blanchfield Army Community Hospital (BACH). Specifically, the study revealed key elements of an ideal referral process from the literature review and compared those elements with the referral process at BACH. Indicators were then developed to determine the efficiency of BACH's referral process. Statistical significance was found to exist in both the developed benchmarks (n = 1885) of each indicator at the 95% confidence interval. Finally, recommendations for improving the referral process were made based on the detailed systems and data analyses conducted. These recommendations focused on PCMs' management of their impaneled patients and the referral process itself.

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Section: Referral Process Improvement 18mentioning

confidence: 96%

Referral Process Improvement: A Study of the Efficiency and Tracking Processes for In-house Referrals at Blanchfield Army Community Hospital

Hoiden¹

2002

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“…13 A larger question than whether UR decreases referral rates, however, is whether it leads to more cost-effective care. There is little agreement on when patients should be referred from primary to specialty care, 8 and there is evidence for both underutilization 3,14 and overutilization 3,6,7 of specialty services. The enormous variation in physician referral rates is problematic, and UR may be one mechanism to reduce the variation.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 Referral rates vary even when there are no associated financial consequences, [1][2][3] and the variation cannot be explained by patient factors or practice characteristics. 1 Thus, physicians may have individual referral thresholds, 4 and some patients may be referred unnecessarily.…”

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confidence: 99%

Effect of ambulatory utilization review on referrals from generalists to specialists

Grimm

Gomez

1998

J Gen Intern Med

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We studied whether ambulatory utilization review (UR) alters how many patients internal medicine residents refer to subspecialists, and whether the effect persists without reinforcement. We compared referral rates of residents from a firm that held UR meetings (intervention firm residents, n ‫؍‬ 20) with those of residents from a firm that did not (control firm residents, n ‫؍‬ 21). We then compared referral rates of 17 intervention firm residents while they were participating in UR with their rates after not participating for at least 4 weeks. Intervention firm residents submitted 30% fewer referrals than control firm residents (9% vs 13%, p ‫؍‬ .05). However, the effect was short-lived; after 4 weeks without UR, intervention firm resident referral rates were similar to control firm referral rates.KEY WORDS: ambulatory utilization review; internal medicine residents; referral to subspecialists. J GEN INTERN MED 1998;13:778-780.

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“…That part of variation that is not legitimate should be reduced. Although, up to now, there is no evidence that less variation is related to a higher quality of care (Weide et al 1999;Fertig et al 1993). Patients should receive the treatment that works best, against acceptable costs.…”

Section: Conclusion and Discussionmentioning

confidence: 99%

Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work?

Jong

Westert²,

Lagoe³

et al. 2005

Health Services Research

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Objective. To test the hypothesis that physicians who work in different hospitals adapt their length of stay decisions to what is usual in the hospital under consideration. Data Sources. Secondary data were used, originating from the Statewide Planning and Research Cooperative System (SPARCS). SPARCS is a major management tool for assisting hospitals, agencies, and health care organizations with decision making in relation to financial planning and monitoring of inpatient and ambulatory surgery services and costs in New York state. Study Design. Data on length of stay for surgical interventions and medical conditions (a total of seven diagnosis-related groups [DRGs]) were studied, to find out whether there is more variation between than within hospitals. Data (1999Data ( , 2000Data ( , and 2001) from all hospitals in New York state were used. The study examined physicians practicing in one hospital and physicians practicing in more than one hospital, to determine whether average length of stay differs according to the hospital of practice. Multilevel models were used to determine variation between and within hospitals. A t-test was used to test whether length of stay for patients of each multihospital physician differed from the average length of stay in each of the two hospitals. Principal Findings. There is significantly ( po.05) more variation between than within hospitals in most of the study populations. Physicians working in two hospitals had patient lengths of stay comparable with the usual practice in the hospital where the procedure was performed. The proportion of physicians working in one hospital did not have a consistent effect for all DRGs on the variation within hospitals. Conclusion. Physicians adapt to their colleagues or to the managerial demands of the particular hospital in which they work. The hospital and broader work environment should be taken into account when developing effective interventions to reduce variation in medical practice.

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Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

Abstract: Objectives-To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines.

Cited by 82 publications

References 10 publications

Referral Process Improvement: A Study of the Efficiency and Tracking Processes for In-house Referrals at Blanchfield Army Community Hospital

Referral Process Improvement: A Study of the Efficiency and Tracking Processes for In-house Referrals at Blanchfield Army Community Hospital

Effect of ambulatory utilization review on referrals from generalists to specialists

Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work?

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