Recognition of patient referral desires in an academic managed care plan -Frequency, determinants, and outcomes

OBJECTIVE: To determine the frequency and determinants of provider nonrecog nition of patients' desires for specialist referral, DESIGN: Prospective study. SETTING: Internal medicine clinic in an academic medical center providing p rimary care to patients enrolled in a managed care plan, PARTICIPANTS: Twelve faculty internists serving as primary care providers ( PCPs) for 856 patient visits. MEASUREMENTS AND MAIN RESULTS: Patients were given previsit and postvisit q uestionnaires asking about referral desire and visit satisfaction. Provider s, blinded to patients' referral desire. were asked after the visit whether a referral was discussed, who initiated the referral discussion, and wheth er the referral was indicated. Providers failed to discuss referral with 27 % of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significa nt variability in provider recognition of patient referral desire. Recognit ion is defined as the provider indicating that a referral was discussed whe n the patient marked a definite or possible desire for referral. Provider r ecognition improved significantly (P < .05), when the patient had more than one referral desire, if the patient or a family member was a health care w orker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P < .05) to initiate a referral d iscussion when they had seen the PCP previously and had more than one refer ral desire. Of patient-initiated referral requests, 14% were considered "no t indicated" by PCPs. Satisfaction with care did not differ in patients wit h a referral desire that were referred and those that were nor referred. CONCLUSIONS: These PCPs frequently failed to explicitly recognize patients' referral desires. Patients were more likely to initiate discussions of a r eferral desire when they saw their usual PCP and had more than a single ref erral desire.