39: Changing referral patterns to urogynecology

Abstract

To identify sources of and changes in referral patterns for pelvic floor disorders. After IRB approval, we used the Enterprise Data Warehouse, our institution’s electronic repository of electronic medical records, to identify all new patient visits (NPV) to urogynecology between January 2010 and December 2015. We excluded patients referred for obstetric injury or without documented referral source from analysis. Demographics, referral source, insurance type, and visit diagnoses using ICD-9 codes were abstracted. ICD-9 codes were grouped into 18 common urogynecologic diagnoses. Data were analyzed using SPSS. A total of 5799 NPV were included in the analysis. Women had mean age ± SD of 54 ± 17. 59% were white, 11% Black, 2% Hispanic, 2% Asian, and 25% did not provide their race. NPV increased by 280% over 6 years from 507 in 2010 to 1418 in 2015. Overall, 44% of patients were referred by obstetrician/gynecologists (OG), 32% by primary care providers (PCP), 14% by self-referral, and 9% by other subspecialties (Figure 1). Insurance plans were as follows: 43% Participating Provider Organization (PPO); 32% Medicare; 19% Health Maintenance Organization (HMO); and 6% Medicaid. The proportion of self and PCP referrals increased substantially by 480% and 320%, respectively. OG referrals increased by 229% over 6 years. Primary referral source differed by patient age with OG referring the majority of women <65 (50% OG vs 27% PC, P < 0.001) and PC referring the majority >65 (46% PC vs 30% OG, P < 0.001). Likewise, insurance type was associated with referral source. Patients with PPO and HMO were more likely to be referred by an OG than a PCP (32% vs 16%, p < 0.001) while patients with Medicare were more likely to be referred by a PCP than OG (14% vs 10%, p < 0.001). New patients diagnosed with pelvic organ prolapse and stress urinary incontinence were more likely to be referred by an OG (p < 0.001) while those with mixed incontinence, neurogenic bladder and hematuria, were equally likely to be referred by an OG (3%) as by a PCP (3%). PCPs were more likely to refer patients for urinary tract infections (p < 0.005) and for urgency urinary incontinence (p < 0.001) than OGs. This association remained significant (p = 0.03) when controlling for age and insurance status as women over 65 are more likely to have urgency incontinence, have Medicare and be referred by a PCP. Demand for pelvic floor services at our center exceeds prior predictions, increasing by 280% in the last 6-years. OGs account for less than half of referrals with PCP and self-referrals accounting for the greatest growth. This study emphasizes the importance of ongoing outreach to PCPs and OGs as well as to women directly.