Primary Care

Primary care doctors are more likely to refer patients with uncommon problems to specialists

Primary care physicians (PCPs) see patients with a variety of common problems every day. They seem to recognize the boundaries of their practices and expertise, however. They are more likely to refer patients with uncommon problems to a specialist, according to a recent study supported by the Agency for Healthcare Research and Quality (HS09377). This finding highlights the responsible judgment that PCPs use in recognizing their scope of practice, note Christopher B. Forrest, M.D., Ph.D., of the Johns Hopkins School of Hygiene and Public Health, and Robert J. Reid, M.D., Ph.D., of the University of British Columbia.

Drs. Forrest and Reid correlated the frequency of a health problem seen by PCPs (practice prevalence) with the chances of specialty referral during a primary care visit based on data on 78,000 primary care visits detailed in the 1989-1994 National Ambulatory Medical Care Surveys. The odds of specialty referral for visits with common problems with intermediate and high practice prevalence were 51 percent and 78 percent less, respectively, than specialty referrals for uncommon problems. Surgical conditions were 39 percent more likely to be referred than medical ones (probably since PCPs usually perform only minor, office-based surgical procedures). Also, the more coexisting medical conditions a patient had, the higher their odds of referral.

Although complexity of coexisting conditions influenced referral to specialists, patients with uncommon conditions often were referred regardless of the complexity of other conditions. Thus "rare" presentations for which specialist assistance is sought may be a result of either the practice prevalence of the presenting problem or the overall complexity of the patient. The researchers conclude that managed care plans that penalize providers for high referral behavior, without adjusting for practice prevalence and coexisting conditions, work contrary to the goal of providing quality patient care in the most appropriate settings.

More details are in "Prevalence of health problems and primary care physicians' specialty referral decisions," by Drs. Forrest and Reid, in the May 2001 Journal of Family Practice 50(5), pp. 427-432.

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