Study explores differences in referral decisions between primary care and specialist physicians

Study suggests that interventions to influence referral practices need to be tailored by speciality

How do physicians decide which colleague to refer their patient to? It differs depending on whether you ask primary care or specialist physicians, according to research from Harvard Medical School, Brigham and Women's Hospital, and Beth Israel Deaconess Medical Center in Boston, USA, led by Michael Barnett. Primary care physicians are more likely to cite reasons relating to patient access or physician-to-physician communication whereas medical or surgical specialists cite reasons related to patient experience with the chosen physician. Barnett and colleagues' work appears online in the Journal of General Internal Medicine, published by Springer.

Barnett and team examined reasons why primary care and specialist physicians choose certain specific colleagues to refer to, and how those reasons differ by speciality. 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 speciality.

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. They grouped reasons for referral into three categories: patient experience with physician; patient access; and physician-to-physician communication. Clinical expertise as a criterion was excluded from the list of reasons because in pre-testing, physicians uniformly chose it as the most important criteria for referral and this enabled them to examine how physicians choose among physicians of similar quality.

Primary care physicians initiated two-thirds of their referrals within their professional network, whereas medical and surgical specialists initiated half of their referrals within their networks. Overall, physicians of all specialities most frequently cited "my patients have good experiences with this physician" among the choices given as the most important reason for selecting that physician, besides clinical expertise.

Specialists and primary care physicians, however, also gave different reasons for choosing referral partners. Specialists were more likely to rely on patient experience with physicians whereas primary care physicians relied more on patient access and physician communication.

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. The substantial proportion of referral relationships cited by specialists, however, shows that specialists also influence the mix of physicians a patient sees.

The authors conclude: "This study is the first to explore differences in the referral decisions between primary care and specialist physicians. Our findings suggest that interventions to influence referral practices will need to be tailored by speciality."