When is a general practitioner's referral of a patient to a specialist an appropriate one that will likely lead to better outcomes, and when is it a categorical waste of money? Even worse, when is it something that provokes an unnecessarily harmful intervention involving more radiation, more specialists, false positives, or even useless surgery?
And on the flip side, when is a referral that would be appropriate denied because it conflicts with a primary care physician's pecuniary interests?
These questions surround the latest quality issue emerging from the dramatic increase in referrals to specialists, highlighted this week by Harvard Medical School researchers. In a study, they pose even more questions about whether and when a generalist should recommend a patient see another doctor.
The report, by Michael Barnett, MD, Zirui Song, and Bruce Landon, MD, and published in the Archives of Internal Medicine, looks at a sample of data from nearly one million ambulatory visits to primary care providers collected by two respected surveys. They found the number of referrals to a specialist doubled from 1999 to 2009, while during the decade before, rates were stable.
"That fact alone has significant implications for the cost of care and care patterns, because the referral isn't a single visit to a specialist," Landon explains in an interview this week. "It potentially opens up a whole cascade of testing and treatments and hospitalizations and procedures, and additional referrals.
"Understanding more about the nature of these referrals, and their appropriateness and the drivers of these changing patterns, is going to be important as we tackle the cost problem going forward," he said.