Introduction to Primary Care:

1
Consultation and Referral in Primary Care
Introduction to Primary Care a course of the
Center of Post Graduate Studies In FM
Rabwa Postgraduate Center PO Box 27121 Riyadh
11417 Tel [phone] Fax [phone]
2
Definition of primary care

• The professional role is applied either directly
  or through the services of others according to
  health needs and the resources available within
  the community they serve, assisting patients
  where necessary in accessing these services.

Wonca Europe 2002
3
Definitions

• A consultation
• involves another physician performing a specific
  diagnostic or therapeutic task, without transfer
  of responsibility for the patient's care or even
  for ongoing management of the problem.
• Referral,
• on the other hand, involves sending a patient to
  another physician for ongoing management of a
  specific problem with the expectation that the
  patient will continue to see the original
  physician for coordination of total care.

Paul A. Nutting, Peter Franks, Carolyn M. Clancy.
Referral and consultation in primary care do we
understand what we're doing? Editorial. Journal
of Family Practice, July, 1992
4
Is it important?

• For each dollar generated by a family physician,
  2 are generated by the consultant physician, and
  4 by the associated hospital
• Consultations may increase the cost of care while
  they increase the quality of care.

Glenn JK, Lawler FH, Hoerl MS. Physician
referrals in a competitive environment. , An
estimate of the economic impact of a referral.
JAMA 1987 2581920-3.
5
From patient side

• Appropriate consultation and referral may lead to
  prompt diagnosis and treatment of conditions that
  were beyond the immediate expertise of the
  primary care physician.
• Inappropriate referral, however, may lead to
  unnecessary testing and a cascade of increasingly
  expensive, invasive, and risky procedures in an
  often futile search for diagnostic certainty.

Mold JW, Stein HF. The cascade effect in the
clinical care of patients. N Engl J Med 1986
314512-4
6
Experienced physicians refer more!

• Physicians with greater expertise had higher
  referral rates
• Why?
• Curious to learn?
• No toleration for uncertainty?

Reynolds GA, Chitnis JG, Roland MO. General
practitioner outpatient referrals do good
doctors refer more patients to hospital? Br Med J
1991 3021250-2
7
The place of uncertainty

• Physicians who are willing to tolerate more
  uncertainty generate less intense services,
  including laboratory testing and referral.

Holtgrave DR, Lawler F, Spann SJ. Physicians'
risk attitudes, laboratory usage, and referral
decisions the case of an academic family
practice center. Med Decis Making 1991
11125-30. Grol R, Whitfield M, De Maeseneer J,
Mokkink H. Attitudes to risk taking in medical
decision making among British, Dutch and Belgian
general practitioners see comments. Br J Gen
Pract 1990 40134-6.
8
The spectrum between consultation and referral
Informal consultation Transfer of full
responsibility (Sidewalk consultation) (End
stage renal disease)
9
Factors affecting referrals

• Availability of qualified consultants
• Patient characteristics
• Physician specialty
• Length of training,
• Reimbursement plan
• Quality of referrals (NS)
• Unexplained ??

10
Why do we physicians refer?

• Diagnosis or
• Confirmation of diagnosis
• Diagnosis and treatment recommendations
• Advice on treatment
• Treatment of a previous conditions
• Reassurance of patient, relative, or referring
  physician
• Specific investigations or specialty procedure
• Routine specialty examination
• Referring physician's education
• Specific request by patient
• Medical-legal reasons.

11
Reasons for Referrals

• To establish the diagnosis.
• For a specified investigation for example,
  colonoscopy, cardiac catheterization.
• For treatment or surgery for example,
  cholecystectomy.
• For advice on management for example, is gold or
  plaquenil better for this patient's rheumatoid
  arthritis.
• For a specialist to take over management for
  example, dialysis for renal failure.
• For a second opinion, to reassure you that you
  have done all that is necessary.
• For a second opinion to reassure the patient or
  the family that you have done all that is
  necessary (patient request).
• Medical-legal concerns by the physician, the
  patient, or both.
• An opportunity for physician education.
• Organizational requirement for a second opinion
  by an insurance company, residency program, or
  hospital policy for example, VBAC.
• Other.

Coulter A, Noone A, Goldacre M. General
practitioners referrals to specialist outpatient
clinics why general practitioners refer
patients to specialists outpatient clinics. BMJ
1989 299304-8.
12
Dowie's work

• Professional attributes,
• Knowledge of the health care system,
• Personal style.

Dowie R. General practitioners and consultants a
study of outpatient referrals. London King's
Fund, 1983.
13

• Both underreferral and overreferral may be
  prevalent. Both have significant cost and
  outcomes implications !!

14
Consultation and referral strategies

1. primary care physician and the patient recognize
   the need for consultation and referral
2. primary care physician communicates the reason
   for the consultation and referral along with
   relevant clinical information to the specialist
3. the specialist evaluates the patient's condition
   
4. the specialist communicates the findings and
   recommendations to the primary care physician
   and
5. the patient, primary care physician, and
   specialist understanding their responsibilities
   for continuing care

26McPhee SJ, Lo B, Saika GY, Meltzer R. How
good is communication between primary care
physicians and subspecialty consultants? Arch
Intern Med 198 1441265-8.
15

• Problems can arise at any step but
• many of the problems are attributed to failures
  in communication and discordant expectations !!

16
Referral/consultation rates

• Referring/consulting 3-12 percent of all office
  visits is considered to be OK
• Claire (USA) 5.97 per 100 office visits.

Claire Bourguet, Valerie Gilchrist, Gary McCord .
The consultation and referral process a report
from NEON - Northeastern Ohio Network. Journal of
Family Practice, Jan, 1998
17

• Female physicians (6) are more likely than male
  physicians (1) to indicate that the patient had
  requested the referral !!

Claire Bourguet, Valerie Gilchrist, Gary McCord .
The consultation and referral process a report
from NEON - Northeastern Ohio Network. Journal of
Family Practice, Jan, 1998
18
New vs. old problems

• New problems
• 9 times as likely to be referred at patient
  request (5.4 of new problems compared with 0.6
  of old problems).
• Old problems
• 3 times as likely to be referred for advice on
  management (18.7 of old problems compared with
  6.3 of new problems)

Claire Bourguet, Valerie Gilchrist, Gary McCord .
The consultation and referral process a report
from NEON - Northeastern Ohio Network. Journal of
Family Practice, Jan, 1998
19
Commonly referred areas

• No. () Rate x 100 Office Visits
• Surgery 48 (15.7)
  0.93
• Gastroenterology 27 (8.8)
  0.52
• Ophthalmology 23 (7.5)
  0.44
• Physical Therapy 23 (7.5)
  0.44
• OB/GYN 21 (6.9)
  0.41
• Orthopedics 22 (7.2)
  0.43
• Cardiology 17 (5.6)
  0.33
• Psychology/Behavioral Science 14 (4.6)
  0.27
• Ear/Nose/Throat 12 (3.9)
  0.23
• Dermatology 10 (3.3)
  0.19
• Psychiatry 7 (2.3)
  0.14
• Pediatrics 5 (1.6)
  0.10
• Other physician 36 (11.8)
  0.70
• Other nonphysician 41 (13.4)
  0.79
• Total 306
  5.97

Claire Bourguet, Valerie Gilchrist, Gary McCord .
The consultation and referral process a report
from NEON - Northeastern Ohio Network. Journal of
Family Practice, Jan, 1998
20
Does the consultation happen?

• Percentage of patients who fail to see the
  consultant range from 3 to 18
• Why?

Claire Bourguet, Valerie Gilchrist, Gary McCord .
The consultation and referral process a report
from NEON - Northeastern Ohio Network. Journal of
Family Practice, Jan, 1998
21
Feedback from the consultant

• Referring physicians receive verbal or written
  feedback from the consultant 26 to 80 of the
  time.
• There is a higher probability of receiving
  feedback from a physician in private practice
  than a physician in academic practice !!

Hansen JP, Brown SE, Sullivan RJ, Muhlbaier LH.
Factors related to an effective referral and
consultation process. J Fam Pract 1982 15651-6.
22

• There is evidence that a prior communication from
  the referring physician increases the probability
  of feedback from the consultant !!

Hansen JP, Brown SE, Sullivan RJ, Muhlbaier LH.
Factors related to an effective referral and
consultation process. J Fam Pract 1982 15651-6.
23

• A report from the consultant is more likely if a
  follow-up letter is specifically requested, or
• if the patient's diagnosis or medication has been
  changed by the consultant.

Haikio P-J, Linden K, Kvist M, Outcomes of
referrals from general practice. Scand J Prim
Health Care 1995 13287-93.
24
Suggestions

• Carefully explore with your patients the reasons
  for and the expectations from the consultation in
  order to improve patient attendance.

25
Suggestions

• There is good evidence that the behavior of the
  referring physician can influence the behavior of
  the consultant. Communication from the referring
  physician will increase the probability of
  feedback from the specialist and this will result
  in a short-term outcome of increased physician
  satisfaction with the referral.

26
Suggestions

• Dont hesitate to mobilize the health resources
  for your patient !
• But also dont forget that as the chef of the
  orchestra YOU have to take care of the efficient
  use of the country resources !

27
Suggestions

• The use of computer and communications technology
  may provide opportunities to facilitate the
  consultation process. Use them if available.

28
Suggestions

• Prepare a written request (a letter) for the
  consultant including patient data, the reason for
  referral, a summary of the findings so far, and
  your expectations.