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Primary Care

Comparison of specialty referral rates in the United Kingdom and the United States: retrospective cohort analysis

BMJ 2002; 325 doi: (Published 17 August 2002) Cite this as: BMJ 2002;325:370
  1. Christopher B Forrest, associate professor of health policy and management and paediatrics (,
  2. Azeem Majeed, senior lecturer in primary careb,
  3. Jonathan P Weiner, professor of health policy and managementa,
  4. Kevin Carroll, specialist registrar in public health medicinec,
  5. Andrew B Bindman, professor of medicine, epidemiology and biostatistiticsd
  1. a Health Services Research and Development Center, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
  2. b School of Public Policy, University College London, London WC1H 9QU
  3. cOffice for National Statistics, London SW1V 2QU
  4. d Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
  1. Correspondence to: C B Forrest, Johns Hopkins Medical Institutions, 624 N Broadway, Room 689, Baltimore, MD 21205, USA
  • Accepted 25 February 2002

Although several studies have shown that US physicians make greater use of medical technologiesthan UK physicians, no study has examined variation in specialty referral rates, the step before specialised procedures. We compared rates of referral to specialists in the United Kingdom and the United States. To hold the effects of gatekeeping systems constant, we studied US managed care settings that used a structured referral process similar to that in the United Kingdom.

Participants, methods, and results

We included non-pregnant patients aged 0 to 64 years, with at least six months of enrolment on a health plan or general practice registration and at least one consultation with their primary care physician during 1996 (US) or 1997 (UK). The US sample comprised 384 693 patients from five health maintenance organisations. All US patients had been assigned physician gatekeepers, who authorised specialty referrals. We used the general practice research database for the UK sample (n=757,680).1

We measured referral rates as the annual percentage of patients with a new referral to a specialist physician. In the United …

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