Referral Patterns Of General Practitioners Research Articles

Attributing practice variation by its sources: the case of varicose veins treatments in the Netherlands

BackgroundUnwarranted practice variation refers to regional differences in treatments that are not driven by patients’ medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment.MethodsA series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey.ResultsOur findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87–0.96) than at the point of treatment both conditional (0.14–0.25) and unconditional on an initial visit (0.65–0.74), suggesting that practice variation was present before the patient reached the specialist.ConclusionsWe present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists’ decisions meaningfully diminish rather than increase the amount of regional variation.

Danish general practitioners as gatekeepers for gynaecological patients in regions with different density of resident specialists in gynaecology: in which situations and to whom do they refer? A cross-sectional study

Background There are large differences in the density of Resident Specialists in Gynaecology (RSG) in the various regions of Denmark. It is unknown if this inequality affects the General Practitioner (GP) referral patterns of gynaecological patients. Objective To investigate the GP referral patterns of gynaecological patients to the RSG or to the Hospital/Outpatient Clinic (HOC) in specific situations according to the regional density of RSGs. Moreover, to examine whether GPs prefer to refer to the HOC or to the RSG, or whether they were treated by the GP depending on the density of RSGs, specifically, in six benign gynaecological diagnoses. Design A cross-sectional questionnaire survey. Setting In Denmark, GPs serve as gatekeepers to secondary care, being responsible for referrals to resident specialists and in- and outpatient hospital care. Subjects Five hundred Danish GPs were randomly selected and invited to take part in the questionnaire study. Main outcome measurements: Referral patterns: Own treatment, RSG, or HOC. Results GPs prefer to refer their gynaecologic patients to RSGs rather than to HOCs. In addition, the study shows the higher the density of RSGs, the more gynaecological patients are referred to the RSG. This also applies to the six diagnoses examined. Conclusion To allow patients’ equal access to specialist care, the density of RSGs must be equal all over the country.

Referrals to dietitians/nutritionists: A cross-sectional analysis of Australian GP registrars' clinical practice.

The present study aimed to describe referral patterns of general practitioner (GP) registrars to dietitians/nutritionists. There is a paucity of research regarding GP referral patterns to dietitians/nutritionists. Limited data show increasing referrals from established GPs to dietitians/nutritionists. There are no data on GP registrar (trainee) referrals. This was a cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multicentre, prospective cohort study of registrars, which documents 60 consecutive consultations of each registrar in each of the three six-month GP training terms. The outcome factor in this analysis was a problem/diagnosis resulting in dietitian/nutritionist referral (2010-2015). Independent variables were related to registrar, patient, practice and consultation. A total of 1124 registrars contributed data from 145 708 consultations. Of 227 190 problems/diagnoses, 587 (0.26% (confidence interval: 0.23-0.29)) resulted in dietitian/nutritionist referral. The most common problems/diagnoses referred related to overweight/obesity (27.1%) and type 2 diabetes (21.1%). Of referrals to a dietitian/nutritionist, 60.8% were for a chronic disease, and 38.8% were related to a Chronic Disease Management plan. Dietitian/nutritionist referral was significantly associated with a number of independent variables reflecting continuity of care, patient complexity, chronic disease, health equity and registrar engagement. Established patients with chronic disease and complex care needs are more likely than other patients to be referred by registrars to dietitians/nutritionists. Nutrition behaviours are a major risk factor in chronic disease, and we have found evidence for dietitian/nutritionist referrals representing one facet of engagement by registrars with patients' complex care needs.

The use of quality information by general practitioners: does it alter choices? A randomized clustered study

BackgroundFollowing the introduction of elements of managed competition in the Netherlands in 2006, General Practitioners (GPs) and patients were given the role to select treatment hospital using public quality information. In this study we investigate to what extent hospital preferences of GP’s are affected by performance indicators on medical effectiveness and patient experiences. We selected three conditions: breast cancer, cataract surgery, and hip and knee replacement.MethodsAfter an inquiry 26 out of 226 GPs in the region signed up to participate in our study. After a 2:1 randomization, we analyzed the referral patterns in the region using three groups of GPs: GPs (n=17) who used the report cards and received personal clarification, GPs that signed up for the study but were assigned to the control group (n=9), and the GPs outside the study (n=200).We conducted a difference in differences analysis where the choice for a particular hospital was the dependent variable and time (2009 or 2010), the sum score of the CQI, the sum score of the PI’s and dummy variables for the individual hospitals were used as independent variables.ResultsThe analysis of the conditions together and cataract surgery and hip and knee replacement separately, showed no significant relationships between the scores on the report cards and the referral patterns of the GPs. For breast cancer our analysis revealed that GPs in the intervention group refer 1.0% (p=0.01) more to hospitals that score one percent point better on the indicators for medical effectiveness.ConclusionOur study provides empirical evidence that GP referral patterns were unaffected by the available quality information, except for the outcome indicators for breast cancer care that were presented. This finding was surprising since our study was designed to identify changes in hospital preference (1) amongst the most motivated GP’s, (2) that received personal clarification of the performance indicators, and (3) selected indicators/conditions from a large set of indicators that they believed were most important. This finding may differ when quality information is based on outcome indicators with a clinically relevant difference, as shown by our indicators for breast cancer treatment. We believe that the current set of (largely process) hospital quality indicators do not serve the GP’s information needs and consequently quality plays little role in the selection of hospitals for treatment.

Survey based investigation into general practitioner referral patterns for spinal manipulative therapy

BackgroundIn the UK Physiotherapy, Chiropractic and Osteopathy are all statutory regulated professions. Though guidelines have supported the use of Spinal Manipulative Therapy (SMT) for low back pain (LBP), General Practitioners (GP) referral patterns to the 3 registered professions that perform SMT are generally unknown.MethodA short questionnaire was designed and piloted. Demographic information, patient referral to SMT and the GPs own personal utilisation of SMT were obtained. 385 GP’s were contacted representing approximately 20% of the GP’s in Wales Autumn 2007.Results and discussion182 (50.8%) completed questionnaires were returned.Profile characteristics: 2/3 of respondents were male, 79% were 40 years old or older (statistically reflective of the total population of GPs in Wales at that time) and 62% had 20 years or less in practise. Personal use of SMT by GP’s: 48 respondents had sought SMT treatment and a further 56% of those that had not previously sought SMT indicated that they would consider doing so. Patient referral to SMT by GP’s: 131 respondents (72%) had referred patients to SMT and of those who had not a further 13% would consider referring. The general referral pattern and utilisation pattern was Physiotherapy: Osteopathy: Chiropractic. 21% who had never referred patients neither had, nor would consider it for themselves. A small subgroup appeared to manage personal choice differently from patient referral: 5 individuals who had not referred patients either had or would consider it for themselves and 23 of the group that would refer patients neither had nor would seek it for themselves.ConclusionsThis limited investigation indicates that GP’s do practise consistently with guidelines on back pain and utilise SMT as a care option. Although the main option for referral was physiotherapy, slightly over 40% of respondents who expressed a preference would refer to either osteopathy or chiropractic, or both in preference to physiotherapy. There was a small proportion that did not and would not refer patients for SMT regardless of personal use of SMT; these suggested use of acupuncture. Further investigation is needed to determine the alternatives to SMT offered to patients and the decision-making criteria for patient referral to subtypes of SMT practitioner.

General practitioner referral patterns for women with gynaecological symptoms: a randomised incomplete block study design

To describe why, when and to whom general practitioners refer women with symptoms possibly attributable to cervical, endometrial or ovarian cancers, and to identify patient and GP factors that predict referral to either a gynaecologist or a gynaecological oncologist. A national survey of GPs between 1 April and 31 August 2009 using a randomised incomplete block design based on case vignettes, and using a self-completed postal or online questionnaire. A sample of GPs, stratified by location and randomly selected from a database of GPs maintained by the Australasian Medical Publishing Company. Proportion of vignettes that were deemed to reflect a high probability of cancer being referred; and the patient and clinician factors that were the strongest predictors of referral. Of the 3082 GPs who were selected for participation, 1402 responded, giving a response rate of 45.5%. Overall, for vignettes identified as describing women with a high probability of cancer, 75% were referred by metropolitan GPs and 73% by rural practitioners. Metropolitan GPs were significantly more likely to refer women in scenarios indicative of endometrial cancer than rural GPs. For all three cancers, GPs were significantly more likely to refer a patient to a gynaecologist (between 70.8% and 95.4%) than a gynaecological oncologist. Metropolitan GPs had significantly greater access to both private and public gynaecological oncologists than their rural counterparts. Referral rates were higher for ovarian and cervical cancer (83% and 80%, respectively) and lower for endometrial cancer (68%). For all three cancers, patient factors were stronger predictors of referral than the demographic factors of participating GPs. There appears to be significant variation in referral practices among GPs and this variation is greater for endometrial cancer, for which there are currently no evidence-based clinical practice guidelines in Australia. There is a need for further research into understanding the basis of these differences, including a review of the existing guidelines for ovarian and cervical cancer and the development of guidelines for endometrial cancer.

Who goes where? A prospective study of referral patterns within a newly established primary care team

Since the introduction of primary care teams, referral patterns of General Practitioners (GPs) in Ireland have not been studied. To study the referral patterns of GPs within a primary care team (PCT) to allied health care professionals in a PCT and to secondary care. To identify indirect referral pathways. To study variation in individual GP referral patterns. Questionnaire based survey. Statistical analysis was carried out using Epi Info version 3.5.1. Of 3,166 consultations, 2,841 (89.7%) were dealt with by the GP and required no referral, 107 (3.4%) were referred within the PCT, and 218 (6.9%) were referred elsewhere. Therefore, 93.1% of consultations were managed in primary care alone. Ninety percent of GPs refer patients to the PCT. Indirect referrals constituted 17% of all outpatient referrals. Females have significantly higher referral rates than males. Referral rates of GPs in single-handed practices are higher than GPs in group practices. GPs alone can manage the vast majority of presentations in general practice. Greater GP access to diagnostic and therapeutic interventions may reduce outpatient referrals. GPs in group practices may collectively have greater experience and expertise and therefore can manage more patients in primary care. There is a significant variation in referral rates between both genders.

The effects of population-based faecal occult blood test screening upon emergency colorectal cancer admissions in Coventry and north Warwickshire

Objective:The English arm of the UK Bowel Cancer Screening Pilot has recently concluded its third round. The primary aim of this study was to assess the effects of this programme...

Colorectal cancer – a prospective evaluation of symptom duration and GP referral patterns in an inner city teaching hospital

A high percentage of colorectal cancer patients (CRC) present as an emergency. Our aim was to evaluate delays in referral based on patient and general practitioner (GP) factors to see if there was any difference between elective and emergency patients. Symptom questionnaires were prospectively collected from 101 consecutive patients presenting to a single colorectal unit (58 male, 43 female; median age 72 years) and entered into a database. Questionnaires assessed time from symptom onset until first GP visit, time for GP to refer, and type of admission. Symptoms and Dukes stage were noted. Fifty-eight (57%) patients presented electively and 43 (43%) as an emergency. Eighty-eight patients (87%) saw their GP of which 34 (39%) later presented as emergency; 13 (13%) did not see their GP. The median time before patients first sought medical advice was 30 days (0-1095 days). Median delay until treatment was 90 days (range 0-1460 days). Emergency patients waited a median of 11.5 days before visiting the GP, and elective a median of 49.5 days (P = 0.04) (Mann-Whitney U). Nine of 13 patients who did not see their GP presented as an emergency (median wait 44 days). The median time taken for a GP to refer to a hospital specialist was 28 days in elective patients and 14 days in the emergency group. (P = ns) Thirty (38%) patients took longer than six weeks to be referred (33% as an emergency). Thirty-six patients had Dukes A or B and took a median of 30 days to first presentation. Sixty-five had Dukes C or D and took a median of 32 days to first presentation. (P = ns) Emergency patients have symptoms for less time before seeking medical advice compared to elective patients. The duration of these symptoms is unrelated to the histological stage at diagnosis. Although the majority of GPs referred CRC patients within six weeks, there was no association between time taken to refer and mode of presentation. The factors that relate to disease stage occur before symptoms are acted on.

Orthopaedic GP Fellowship: does it work?

General practitioners (GPs) see a significant number of musculoskeletal problems in their daily caseload. However, orthopaedic training often forms a relatively small part of their undergraduate and postgraduate training. A training fellowship for GPs was set up in Warrington to improve management of patients with common orthopaedic complaints in the primary care setting, and to facilitate more appropriate referrals to orthopaedic surgeons. Following the fellowship, GP referral patterns were examined. It was found that the GP fellows were managing many conditions more appropriately, either conservatively, or with skills learnt during the fellowship. There was an increase in the number of referred cases being listed for surgery indicating a more appropriate referral pattern to hospital. The Orthopaedic GP Fellowship has improved patient management in primary care and helped GPS better identify those patients who need to be referred for a specialist orthopaedic opinion.

Who do we see? A study of GP referral patterns.

The aim of this study was to assess which patients are referred from general practice, in order to target areas in which our service could be improved. An anonymous postal questionnaire was sent to 433 local general practitioners (GPs), 72.3% (313) of whom replied. The majority of GPs indicated that they would always send patients with a diagnosis of either gonorrhoea or syphilis to the department, while most would send less than 50% of patients with Chlamydia trachomatis infection. Viral infections (i.e. warts and herpes) were referred more frequently than chlamydia. Referral of trichomoniasis was uncommon, as was advice about contacts in all conditions except gonorrhoea and syphilis.

Changing referral patterns to ensure earlier identification of dysfluent pre-schoolers.

There has been a paucity of empirical research reported in the stuttering literature into dysfluency referral patterns and activities which promote early referral. Preliminary results of a three year UK-wide study are presented which illustrate how specific activities can positively influence the referral patterns of general practitioners, health visitors and other professionals. Analysis of pre-project data has identified current UK trends in paediatric dysfluency referrals (n = 2356), from which speech and language therapists (SLTs) can recognise specific aspects for individual service development. The current study describes the pre- and post-project referral trends of 12 community trusts. Data reveal that time lags can be reduced in order that more dysfluent pre-schoolers see a SLT at a clinically optimal time.

General practitioners use of hospital and community based paediatric out-patient services in Nottingham

The paper compares and contrasts the referral patterns of general practitioners in Nottingham for paediatric specialist opinion in a hospital and community setting. Data were collected from case notes review and medical activity data returns on 100 consecutive referrals made by GPs to a hospital paediatric consultant out-patient clinical and 100 consecutive referrals to a community based consultant clinic. Multiple diagnoses are more commonly made and recorded by community based paediatricians with a bias towards behavioural, nutrition, growth and neurodevelopmental problems. Hospital clinic staff made more system and disease based diagnoses with more investigations arranged than the community staff[53 cf. 15 (OR 6.39, 95% CI; 3.25–12.55, P = <0.0001)]. More children under five were seen in the community clinic sample compared to the hospital sample [75 cf. 57 under fives (OR 2.26, 95% CI; 1.24–4.13, P = 0.01)]. Patients are more likely to be discharged from the hospital clinic than the community clinic after the initial visit. [59 cf. 33 (OR 2.92, 95% CI; 1.64–5.20, P = 0.0004)]. Costs per new case consultation were substantially less in the community clinic than the hospital setting. A broadly similar range of clinic problems are referred to both hospital and community based paediatricians in Nottingham. The educational and liaison value of local community paediatric clinics together with relatively easier access by parents and lower per case costs is an advantage. Commissioners of paediatric and child health services need to take into consideration these factors when purchasing out-patient specialist paediatric opinion. Further research is required into the quality and desirability of these developments.

Referral of Asian patients to a GI clinic

This study compared gastrointestinal (GI) symptoms and psychiatric morbidity in consecutive new out-patients presenting to a district general hospital. In a 6-month period 36 patients of South Asian origin were referred to the clinic. They were compared in terms of GI symptoms and psychiatric morbidity with white European controls, both with a large sample of clinic attenders, and with a subsample of 36 matched for age, gender, and diagnosis. A total of 72% (26 of 36) of Asian patients had functional GI disorders compared to 48% (42 of 88) of white patients ( p < 0.05). However, comparisons of matched patients showed that Asian patients with functional GI disorders had less severe GI symptoms than the matched white patients, and fewer had psychiatric disorder (23% of Asians and 42% of white Europeans). These results suggest that the threshold for referral for Asian patients with functional GI disorders to hospital clinics is lower than for white patients. Detection and management of somatization in Asian patients in primary care need to be improved, and referral patterns of general practitioners need to be explored in future research.

Diabetic retinopathy: examination practices and referral patterns of general practitioners.

To investigate general practitioners' (GPs') examination and referral practices for diabetic retinopathy. A questionnaire survey of a random stratified sample of 500 Victorian GPs. The response rate was 88%. 53% of GPs examined none or less than half of their patients with diabetes for diabetic retinopathy. Those who did examine for retinopathy rarely performed funduscopy through a dilated pupil and 65% reported that they never did. Only 37% had dilating drops in their surgery. Only 45% often or always tested visual acuity. 88% often or always referred patients at the recommended frequency to an ophthalmologist. Although most GPs do not perform dilated fundus examinations, they report referring their patients with diabetes for assessment by an ophthalmologist at an early stage to prevent vision loss. Referral chain breakdown may explain the discrepancy between GPs' reported referral rates and the lower rates of ophthalmic examination reported in the Melbourne Visual Impairment Project.

General practitioner referral patterns

A survey of general practitioners (GPs) in the Western Health and Social Services Board was carried out in November 1990. The main objectives were to determine the factors which influence GPs' decisions to refer to particular hospitals and to ascertain current out-patient referral patterns. A self-administered questionnaire was sent to 157 GPs. The response rate was 94 per cent. It was found that waiting lists and personal knowledge of consultants' expertise were considered to be of particular importance in making referral decisions for elective/non-urgent procedures. Referrals were usually made to the nearest hospital with a relevant out-patient clinic. The majority (96 per cent) of respondents indicated that they would be willing to change their referral patterns for elective/non-urgent procedures in response to shorter waiting times. It is concluded that GPs may be more willing to change their referral patterns than might have been expected.

The influence of referral patterns on the characteristics of diagnostic tests

The discrimination of a diagnostic test—characterized by sensitivity, specificity, likelihood ratio and ROC curve—may be influenced by referral patterns of general practitioners. Symptoms and test results in particular. will affect the probability of referral, while the degree of development of the pathological process directly influences the probability of positive test results. Using numerical examples, we analyse and discuss a few specific situations: (1) referral depends only on symptoms; (2) referral depends both on symptoms and on test results; (3) referral depends only on test results. In the first situation, test characteristics and predictive values are invariant over the strata of symptomatology, while in the third situation the predictive values are unchanged. If there is a positive relationship between positive test results and referral probability, overall sensitivity will increase while specificity and likelihood ratio will decrease. A general representation is given for the evaluation of the direction of change of the likelihood ratio as a function of referral probabilities. The shape of receiver-operating characteristic curves is less sensitive to bias, but at the level of specific cut-off points considerable changes may occur.

Metastatic cervical lymph nodes: general practitioner referral patterns.

Premature excision biopsy of a cervical lymph node infiltrated by metastatic carcinoma may compromise patient survival since it is associated with an increased incidence of local wound recurrence and distant metastases. Seventy per cent of such patients have an identifiable head and neck primary, obviating the need for an excision biopsy. It is important therefore that they are examined by surgeons who are experienced in inspecting the upper aerodigestive tract and who are competent in performing definitive head and neck surgery. A questionnaire sent to all general practitioners of an Inner London and a District Health Authority revealed that only 18% and 33% respectively referred patients who they suspected of having a metastatic neck node to a department with an experienced head and neck surgeon. We conclude that greater emphasis on the correct management of these patients at both an undergraduate and postgraduate level may encourage subsequent generations of general practitioners to review their referral patterns.