Comparison of specialty referral rates in the United Kingdom and the United States: retrospective cohort analysis
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7360.370 (Published 17 August 2002) Cite this as: BMJ 2002;325:370
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Dr. Kersnik provides interesting information about referral rate
estimates in Slovenia. Whereas 5% of office visits result in a referral
in BOTH the US and UK, approximately 8% of visits in Slovenia result in
referral. Many OECD countries have referral rates equal to approximately
5%, but there is some variation around this estimate (see Douglas Fleming
and colleague's work on the European Study of Referrals). Why such a
large difference? In our study, we did not find that differences in
health status between the US and UK were substantive. I would speculate
that if we compared the health status of Slovenians visiting their GP with
those in the US or UK, we would find a similar need for referral across
the 3 countries. The key difference in the office visit referral rates
may be in how a referral is defined. In our study, we measured referrals
to physician specialists. I agree with Dr. Kersnik that how we define a
referral is of utmost importance when interpreting cross-national
comparisons. I suspect that if we examined referrals to physician
specialists only in Slovenia, we may obtain a similar estimate of about 5%
of office visits referred.
Competing interests: No competing interests
Ranjit Shail noted that US patients were referred at all levels of
morbidity burden. Although the rates were substantively lower, even UK
patients in the lowest morbidity burden group (the healthiest) were
referred (a rate of about 2-4% per year). In unpublished analyses, we
founnd that The US/UK gap in referral rates actually increases with higher
levels of morbidity burden compared with lower levels. That is, the
slopes of the trend lines estimated for the Figure in the published
article are statistically unequal, with greater slope in the US. It
should be noted that all patients in our study had at least one contact
with a GP/PCP. Thus, even when the healthiest patients make contact with
the healthcare system, there is a small risk of referral to a specialist.
The high referral rate in the US among the healthiest patients (about 15%
per year were referred) is most likely a result of an excess supply of
specialists in the US and high patient demand for direct access to
specialists.
Competing interests: No competing interests
Dear Sir,
This study included patients aged 0 to 64 years. What was the average
age at referral in the two groups?
Referral rates were measured as the annual percentage of patients.
What are the doctor patient ratios for GPs and specialists?
If higher scores indicate sicker patients, greater morbidity burden,
and greater need for referral, why are US patients referred "regardless
of the morbidity burden"?
Competing interests: No competing interests
In the last BMJ we can read a paper on referrals (1). Variation of
health services is an interesting research as well policy topic. It is an
useful instrument in policy decisions within defined health care system
but it can be misleading in direct comparisons and in its use within
another health care system. It strikes me a perfect match between the
inclination of the slopes in all health plans from the USA and NHS (1). As
health care plans, NHS and health care system in Slovenia share a lot of
similarities the paper elicited some interesting parallels with referral
rates in our country. Slovenia has a long tradition in routine reporting
system on referrals issued by the GPs. The referral rate is 8 % of all
primary care contacts with wide variation among individual GPs (2). If we
take into account high numbers of primary contacts for our country, which
lie at an average 6 visits per person per year (2), then we can see that
referral rate per person per year can rise as high as calculated 48 % of
patients at first visit to a GP referred to the specialist or to the
hospital. This is somehow in line with self-reported rates from a sample
of patients who visited a GP at least once in the past year, which lies at
42 % of interviewed patients in the age group from 18 – 64 saw a clinical
specialist in one year or at 43 % in all age groups. 68 % of frequent
attenders saw a clinical specialist per year that almost duplicate 35 % of
patients who do not visit their GPs frequently (3). How can that happen?
What happened to the gate keeping role of GPs? Part of the answer lies in
the data collection methods and in the interpretation of such data, which
are country specific. Is referring to x-ray examination to another
department a referral or not? In spite of enormous referral rates we still
lack universally accepted definition of a referral. There should be also a
sound theory behind such routine or research activities which should
address the managerial part of referring process as this is the main issue
behind every plot of referral data.
Referring process is an important feature of primary care work.
Speaking in the terms of health policy decision making controlling
referrals could contain health care costs. Unfortunately, referring
patients is far more complex task as any other one in health care. Besides
knowledge and skills of a referring GP one should take into account also
organisation of health services in respected country. Referral is a
mixture of the decision of a GP that the services needed by the patient
can be effectively provided only by clinical specialist and of the
administrative regulations which foresee a referral as a billing
prerequisite to be eligible to be seen by a clinical specialist. By-
passing a GP for emergencies or by out-of-pocket payments or by self-
referring by the clinical specialists blurs the picture furthermore. Who
should take the blame?
This blame culture of blaming and curing outlires is highly
contraproductive. A GP in a managed health care system has referrals in
his/her hands but are many times beyond his/her power to cut them down
rationally. High referral rates should serve us in identifying underlying
problem, that is the flow of patients within the health care system which
should provide optimal care for our patients in complex and fragmented
health care services. This is one of the key issues of the future public
health debates, if we want to preserve basic attributes of managed care:
affordability, accessibility, equity and quality.
References
1. Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB. Comparison of
specialty referral rates in the United Kingdom and the United States:
retrospective cohort analysis. BMJ 2002;325:370-371.
2. Anon. Statistical yearbook. Ljubljana: Republic of Slovenia -
Department for Statistics, 1998.
3. Kersnik J, Svab I, Vegnuti M. Frequent attenders in general practice:
quality of life, patient satisfaction, use of medical services and GP
characteristics. Scand J Prim Health Care. 2001 Sep;19(3):174-7.
Competing interests: No competing interests
Referral Guidelines are Part of the Answer
Editor
Forrest et al provide a useful insight into the variation in
specialty referral rates between the UK and the US(ref 1). However, their
assertion that "given the low referral rates in the UK relative to the US,
it seems unlikely that referral guidelines ..... will dramatically enhance
specialty capacity by decreasing demand" is both a non sequeter and
probably not true.
We studied the referral rates for dermatology across the 16 practices
in a Primary Care Group with a relatively uniform population mix. We found
variations ranging from 2 per 1000 practice population to 47 per 1000 (see
graph) whilst the dermatologists believed that around 60% of referrals
were for conditions which should be easily manageable by GPs with access
to the right information. Indeed, the practice with the lowest referral
rate included a clinical assistant in dermatology and had modified their
referral process so that all patients were referred through her. We found
similar variability in orthopaedics and cardiology.
There are many ways to reduce referral rates. The aim should be for
the right patients have access to the right level of expertise at the
right time and not necessarily to go to the hospital. These include better
education, more community based expertise, mature clinical networks and
better use of technology such as clinical decision support (incl. referral
guidelines) and telemedicine. One thing seems certain though, there is
plenty of room for improvement.
Reference
1 Comparison of specialty referral rates in the United Kingdom and
the United States: retrospective cohort analysis.
Christopher B Forrest, Azeem Majeed, Jonathan P Weiner, Kevin Carroll, and
Andrew B Bindman.
BMJ 2002; 325: 370-371
Competing interests: No competing interests