High referral rates to secondary care by general practitioners in Norway are associated with GPs’ gender and specialist qualifications in family medicine, a study of 4350 consultations

Unni Ringberg,Nils Fleten,Toralf Hasvold,Trygve S Deraas,Olavhelge Førde

doi:10.1186/1472-6963-13-147

Abstract

BackgroundReferral rates of general practitioners (GPs) are an important determinant of secondary care utilization. The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The main objective of this study was to assess the GPs’ referral rate to secondary care in Norway, any associations between the referral decision and patient, GP, health care characteristics and who initiated the referring issue in the consultation.MethodsThe probabilities of referral to secondary care and/or radiological examination were examined in 100 consecutive consultations of 44 randomly chosen Norwegian GPs. The GPs recorded whether the issue of referral was introduced, who introduced it and if the patient was referred. Multilevel and naive multivariable logistic regression analyses were performed to explore associations between the probability of referral and patient, GP and health care characteristics.ResultsOf the 4350 consultations included, 13.7% (GP range 4.0%-28.0%) of patients were referred to secondary somatic and psychiatric care. Female GPs referred significantly more frequently than male GPs (16.0% versus 12.6%, adjusted odds ratio, AOR, 1.25), specialists in family medicine less frequently than their counterparts (12.5% versus 14.9%, AOR 0.76) and salaried GPs more frequently than private practitioners (16.2% versus 12.1%, AOR 1.36).In 4.2% (GP range 0%-12.9%) of the consultations, patients were referred to radiological examination. Specialists in family medicine, salaried GPs and GPs with a Norwegian medical degree referred significantly more frequently to radiological examination than their counterparts (AOR 1.93, 2.00 and 1.73, respectively).The issue of referral was introduced in 23% of the consultations, and in 70.6% of these cases by the GP. The high referrers introduced the referral issue significantly more frequently and also referred a significantly larger proportion when the issue was introduced.ConclusionsThe main finding of the present study was a high overall referral rate, and a striking range among the GPs. Male GPs and specialists in family medicine referred significantly less frequently to secondary care, but the latter referred more frequently to radiological examination. Our findings indicate that intervention on high referrers is a potential area for quality improvement, and there is a need to explore the referral decision process itself.

Highlights

Referral rates of general practitioners (GPs) are an important determinant of secondary care utilization
Primary health care is well developed in Norway; still, only 55% of Norwegian GPs are specialists in family medicine [4], and no speciality is required to practice as a GP
Recruitment and data collection Of all 476 GPs in Northern Norway 88 GPs were excluded, due to electronic patient records (EPR) incompatibility with our electronic questionnaire (n= 44), vacancy (n=35), the two practices housing 3 GPs participating in piloting (n=8), and one GP practicing without EPR

Summary

Introduction

Referral rates of general practitioners (GPs) are an important determinant of secondary care utilization The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The Norwegian Patients’ Rights Act states that the patients have a right to participate in the decision of which available and medically sound methods of examination and treatment they will receive [8]. This creates a dilemma, and many GPs find it difficult to identify with and fill the gatekeeper role [9]

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