Roughly one-fourth of all cases seen in a family or internal medicine practice are referred out for diagnostics or for consultations by specialists, according to a new study from Halley Consulting Group and athenahealth.

And younger, poorer patients are generating most of the roughly 450 annual referrals made by primary care practitioners each year, researchers found.

The study, titled “ReferralView: A First Look at National Referral Patterns from Primary Care Providers,” polled more than 1,000 medical providers across the country, each a client of athenahealth. The practices use the company’s cloud-based software, which collects data from every patient encounter, including referrals. Researchers focused the study on referral volumes and patterns in primary care—including family practice, internal medicine, pediatrics, and obstetrics and gynecology. The providers had more than 2.5 million patient visits over the 1-year study period, with a total of 200,000 consult referrals and almost 350,000 diagnostic referrals.

Altogether, the PCPs referred at a rate of 8% for specialty consults, with family medicine and internal medicine practices each referring 11% of their cases for consults. Family doctors referred another 14% for diagnostics, whereas internists referred 18% of their cases for diagnostic consultations. Ob/gyns referred 2% for consult referrals and 29% for diagnostic referrals; pediatricians referred 3.5% and 2.2%, respectively.

Those in family practice, internal medicine, and pediatrics most frequently made diagnostic referrals for x-rays, followed by ultrasounds, mammograms, electrocardiography, and audio testing. Ob/gyns made diagnostic referrals for ultrasounds and mammograms.

Consult referrals were most often made by family practices and internal medicine practices for gastroenterology, followed by physical therapy, dermatology, and orthopedic surgery. Pediatric practices most often referred consultations to otolaryngologists, dermatologists, orthopedic surgeons, and ophthalmologists.

Overall, the most consult referrals in primary care practices occurred in the West, with 10.3% of cases referred out for consultations. In the Northeast, 9.8% of cases were referred, followed by 8.1% in the Midwest and 6.2% in the South. The study notes that lower referral rates in the Midwest and South are probably due to those regions having more rural areas and less access to specialists to whom to refer cases, meaning primary care practices must provider a wider scope of medicine.

The presence of more health maintenance organizations (HMOs) in the West and Northeast could contribute to higher referral rates in those areas, too, because most HMOs require direct referrals from PCPs to specialists.

The study also tested correlations between practitioner referral rates and key practice factors, such as productivity and workload. For family practitioners, no significant correlation was found between productivity levels and referral rates, but a slight negative correlation was found between referral rates and collections per work relative value unit.

“Collections are generally lower in practices serving a lower socioeconomic patient base, so it would seem that lower income patients are referred out at a higher rate than more affluent patients,” the study noted.

For internists, a statistically significant negative correlation existed between the median age of the patient base and the referral rate. This negative correlation led researchers to conclude that referral rates are associated with a younger patient population—“an apparent contradiction to the previous supposition about older patients driving higher referral rates.”

“Further analysis ... reveals that there is a ‘sweet spot’ in the 45-65 age range for internal medicine patients where the referral rates are highest. Beyond that age range the referral rates decline,” the report noted. “We speculate that this may be because older patients already have relationships established with certain specialists due to prior or chronically occurring conditions. Younger patients may be encountering these medical issues for the first time and consequently would be in need of that initial referral.”

Researchers said the data found in the report could be used by hospitals and specialists to track referrals and possibly forecast the yield of primary care referrals. For example, the study outlines that the typical family doctor refers 11 out of 100 visits. With 4,100 annual visits, that pattern generates about 450 referrals annually. An orthopedic surgeon, who sees about 0.9% of family physician cases through referral, would therefore be likely to see about 37 of the family doctor’s 451 referrals in a given year. That amount could translate to 74 patient visits, 59 in-office diagnostics, 21 office procedures, about 10 outpatient procedures, three inpatient procedures, 12 referrals out for diagnostics, and seven referrals out to other specialists, study researchers estimate. The study concludes that such data could help validate the need for primary care practitioners in the healthcare “demand chain.”

The company athenahealth offers cloud-based practice management services, electronic health records, and care coordination services. Halley Consulting Group is a physician practice management and consulting firm specializing in strategic development and performance turnaround of both hospital-owned medical practice networks and large independent medical offices.

From Modern Medicine, by Rachael Zimlich, Oct. 31, 2012