Coordination of primary care referrals and the development of ongoing interactions between primary care physicians and specialists.

摘要

Goal and objectives. The goal of this study is to examine the ways in which coordination between primary care physicians and specialists evolves during a referral episode, including the performance of specific integrative tasks, the development of ongoing, collaborative care, and the effect of these interactions on referral results.; Methods. Data are from the Ambulatory Sentinel Practice Network Referral Study---a prospective cohort study of primary care physicians' specialty referrals and their outcomes. The study includes information on 1,882 new referrals made by 150 physicians from 90 practices. The outcome variables were: (1) referral coordination; (2) ongoing specialist involvement; and, (3) referral results . Multivariable regression models were used to model the effects of continuity of care and characteristics of patients, referrals, and referring physicians on referral coordination and ongoing specialist involvement. Multivariable regression models were also developed to examine the effects of referral coordination on referral results. The generalized estimating equation was used to account for correlation of observations within physicians.; Results. Breakdowns in coordination were common. The chances that the referral was extensively coordinated (i.e., five coordinating activities were performed) increased when there was continuity of primary care, the referral was for a chronic condition, the patient was a women, and when the referring physician was from a rural practice. Continuity of primary care decreased the chances that the specialist continued to be involved in the care for the referred health problem 3-4 months after the initial referral visit. Performing referral coordination was positively associated with physicians' perceptions of the quality and the educational benefit of the referral, with patients' evaluations of coordination, and with better agreement between referring physicians and patients.; Conclusions. Our findings show that continuity with a primary care physician can contribute to greater participation of primary care physicians in the ongoing care of their referred patients and to overall coordination of care at the primary care - specialty interface. The coordination measures developed in this dissertation can guide the development of guidelines for referral coordination aimed at preventing breakdowns in patient care (e.g., duplications, delays, or conflicts in treatment) for various health problems in different care settings.