Transcript Document

Consultation and Referral
in Primary Care
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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Aim-Objectives
• Aim: At the end of this session, the participants will be
aware of the coordinating role of the primary care
physician and they will have knowledge on the principles
of referral and consultation.
• Objectives:
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Can describe referral
Can describe consultation
Advocate team work in patient management
Knows the importance of under and overreferral
Can tell the most common reasons for referral
Can explain the referral process
Is aware of the importance of communication in referral and
consultations
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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
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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: 4
do we understand what we're doing? – Editorial. Journal of Family Practice, July, 1992
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; 258:1920-3.
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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; 314:512-4
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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; 302:1250-2
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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; 11:12530.
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; 40:134-6.
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The spectrum between consultation
and referral
Informal consultation
(“Sidewalk consultation”)
Transfer of full responsibility
(End stage renal disease)
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Factors affecting referrals
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Availability of qualified consultants
Patient characteristics
Physician specialty
Length of training,
Reimbursement plan
Quality of referrals (NS)
Unexplained ??
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Why do we physicians refer?
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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.
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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:
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why general practitioners refer patients to specialists outpatient clinics. BMJ 1989; 299:304-8.
Dowie 1983:
• 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.
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• Both underreferral and overreferral may be
prevalent. Both have significant cost and
outcomes implications !!
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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
[26]McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communication between primary care
physicians and subspecialty consultants? Arch Intern Med 198; 144:1265-8.
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• Problems can arise at any step but
• many of the problems are attributed to
failures in communication and discordant
expectations !!
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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
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• 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
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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
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Commonly referred areas
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Surgery
Gastroenterology
Ophthalmology
Physical Therapy
OB/GYN
Orthopedics
Cardiology
Psychology/Behavioral Science
Ear/Nose/Throat
Dermatology
Psychiatry
Pediatrics
Other physician
Other nonphysician
Total
No. (%)
48 (15.7)
27 (8.8)
23 (7.5)
23 (7.5)
21 (6.9)
22 (7.2)
17 (5.6)
14 (4.6)
12 (3.9)
10 (3.3)
7 (2.3)
5 (1.6)
36 (11.8)
41 (13.4)
306
Claire Bourguet, Valerie Gilchrist, Gary McCord . The consultation and referral process: a
report from NEON - Northeastern Ohio Network. Journal of Family Practice, Jan, 1998
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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
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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; 15:651-6.
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• 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; 15:651-6.
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• 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; 13:287-93.
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Suggestions
• Carefully explore with your patients the
reasons for and the expectations from the
consultation in order to improve patient
attendance.
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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.
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Suggestions
• Don’t hesitate to mobilize the health
resources for your patient !
• But also don’t forget that as the chef of the
orchestra YOU have to take care of the
efficient use of the country resources !
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Suggestions
• The use of computer and communications
technology may provide opportunities to
facilitate the consultation process. Use them
if available.
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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.
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