Currently Viewing:
The American Journal of Managed Care May 2016
Greater Potential Cost Savings With Biosimilar Use
Benjamin Yu, PharmD
Implementing a Hybrid Approach to Select Patients for Care Management: Variations Across Practices
Christine Vogeli, PhD; Jenna Spirt, MPH; Richard Brand, PhD; John Hsu, MD, MPH; Namita Mohta, MD; Clemens Hong, MD, MPH; Eric Weil, MD; and Timothy G. Ferris, MD, MPH
Medicaid Managed Care Penetration and Drug Utilization for Patients With Serious Mental Illness
Aaron L. Schwartz, PhD; Jacqueline Pesa, PhD, MPH; Dilesh Doshi, PharmD; John Fastenau, PhD, MPH; Seth A. Seabury, PhD; Eric T. Roberts, PhD; and David C. Grabowski, PhD
Clinical Interventions Addressing Nonmedical Health Determinants in Medicaid Managed Care
Laura M. Gottlieb, MD, MPH; Kim Garcia, MPH; Holly Wing, MA; and Rishi Manchanda, MD, MPH
Physician Perceptions of Choosing Wisely and Drivers of Overuse
Carrie H. Colla, PhD; Elizabeth A. Kinsella, BA; Nancy E. Morden, MD, MPH; David J. Meyers, MPH; Meredith B. Rosenthal, PhD; and Thomas D. Sequist, MD, MPH
Potential of Risk-Based Population Guidelines to Reduce Cardiovascular Risk in a Large Integrated Health System
Galina Inzhakova, MPH; Hui Zhou, PhD, MS; Macdonald Morris, PhD; Megan I. Early, MD, MPH; Anny H. Xiang, PhD; Steven J. Jacobsen, MD, PhD; and Stephen F. Derose, MD, MSHS
Enhanced Primary Care and Impact on Quality of Care in Massachusetts
Asaf Bitton, MD, MPH; Amy W. Baughman, MD, MPH; Sara Carlini, BA; Joel S. Weissman, PhD; and David W. Bates, MD, MSc
Breast Cancer Multigene Testing Trends and Impact on Chemotherapy Use
G. Thomas Ray, MBA; Jeanne Mandelblatt, MD; Laurel A. Habel, PhD; Scott Ramsey, MD, PhD; Lawrence H. Kushi, ScD; Yan Li, MD; and Tracy A. Lieu, MD, MPH
A Cost-Effectiveness Analysis of Over-the-Counter Statins
Christopher Stomberg, PhD; Margaret Albaugh, MA; Saul Shiffman, PhD; and Neeraj Sood, PhD
Currently Reading
Referring Wisely: Orthopedic Referral Guidelines at an Academic Institution
Maria E. Otto, MD; Carlin Senter, MD; Ralph Gonzales, MD, MSPH; and Nathaniel Gleason, MD

Referring Wisely: Orthopedic Referral Guidelines at an Academic Institution

Maria E. Otto, MD; Carlin Senter, MD; Ralph Gonzales, MD, MSPH; and Nathaniel Gleason, MD
The authors used the modified Delphi method to develop local orthopedic referral guidelines, enabling detailed decision support and non—face-to-face consultation at the point of referral.
The Delphi method is not without limitations. In addition to being time-consuming, study designers may impose preconceptions through the Delphi questions that prevent other perspectives from surfacing. Consensus may represent a middle-of-the-road compromise, eliminating extreme positions and potentially obscuring the best judgment26—where consensus is not reached, no guideline results. Furthermore, panel members may have a conflict of interest or not be generally representative. In our study, we sought to ensure the representativeness of the panel by inviting all PCPs and orthopedists at UCSF to participate; among the PCP panel, a broad range of experience is represented, although internists were disproportionately represented over family practice providers. The small number of orthopedists available to participate in the survey for some of the joint-specific questions, due to the sub-specialized nature of orthopedic care, is also a limitation. 

The specific findings in our health system are local and not necessarily generalizable. Reproduction of the process by individual institutions may have a greater impact than implementation of referral guidelines based on these specific clinical findings. Local implementation of the process has the advantage of engagement of local clinicians in the care delivery improvement effort, as well.

 
CONCLUSIONS
The referral process is fundamental to the thoughtful and appropriate use of specialty care in an integrated high-value healthcare system. With the advent of the EHR, we have the opportunity to provide decision support at the moment of referral. Existing guidelines do not typically address this point in the care of a patient and are difficult to create at a national level due to variation in practice patterns. The Delphi method proved to be a feasible and robust way to identify local guidelines for referral appropriateness. 

Author Affiliations: University of California, San Francisco (MEO, CS, RG, NG), San Francisco, CA.

Source of Funding: Delivery System Reform Incentive Payments for the state of California.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MEO, RG, NG, CS); acquisition of data (MEO); analysis and interpretation of data (MEO, RG, NG, CS); drafting of the manuscript (MEO, NG, CS); critical revision of the manuscript for important intellectual content (MEO, NG, CS); administrative, technical, or logistic support (RG).

Address correspondence to: Maria E. Otto, MD, University of California, San Francisco, 1701 Divisadero St, Ste 500, San Francisco, CA 94143. E-mail: maria.otto@ucsf.edu.
REFERENCES

1. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163-170. doi:10.1001/archinternmed.2011.722.

2. Machlin SR, Carper K. Expenses for office-based physician visits by specialty, 2004. Agency for Healthcare Research and Quality website. http://meps.ahrq.gov/mepsweb/data_files/publications/st166/stat166.pdf. Published March 2007. Accessed October 16, 2014.

3. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39-68. doi:10.1111/j.1468-0009.2011.00619.x.

4. Song Z, Sequist TD, Barnett ML. Patient referrals: a linchpin for increasing the value of care. JAMA. 2014;312(6):597-598. doi: 10.1001/jama.2014.7878.

5. Kirschner N, Greenlee M. The patient-centered medical home neighbor: the interface of the patient-centered medical home with specialty/subspecialty practices. American College of Physicians website. https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/pcmh_neighbors.pdf. Published 2010. Accessed October 16, 2014.

6. Gleason N, Ho C, Wang M, et al. Implementation of a structured electronic referral system to support the principals of the PCMH-Neighborhood. J Gen Intern Med. 2013;28(supp 1):445.

7. Ackerman SL, Gleason N, Monacelli J, et al. When to repatriate? clinicians’ perspectives on the transfer of patient management from specialty to primary care. J Gen Intern Med. 2014;29(10):1355-1361. doi:10.1007/s11606-014-2920-z.

8. St Peter RF, Reed MC, Kemper P, Blumenthal D. Changes in the scope of care provided by primary care physicians. N Engl J Med. 1999;341(26):1980-1985. doi: 10.1056/NEJM199912233412606.

9. Bodenheimer T. Coordinating care—a perilous journey through the health care system. N Engl J Med. 2008;358(10):1064-1071. doi:10.1056/NEJMhpr0706165.

10. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80(10):1421-1427.

11. Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT. Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. Ann Intern Med. 2011;155(11):725-732. doi: 10.7326/0003-4819-155-11-201112060-00004.

12. Jevsevar DS, Brown GA, Jones DL, et al; American Academy of Orthopaedic Surgeons. The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition. J Bone Joint Surg Am. 2013;95(20):1885-1886.

13. Izquierdo R, Voloshin I, Edwards S, et al. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: the treatment of glenohumeral joint osteoarthritis. J Bone Joint Surg Am. 2011;93(2):203-205.

14. Pedowitz RA, Yamaguchi K, Ahmad CS, et al. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: optimizing the management of rotator cuff problems. J Bone Joint Surg Am. 2012;94(2):163-167.

15. Keith MW, Masear V, Chung KC, et al; American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of carpal tunnel syndrome. J Bone Joint Surg Am. 2010;92(1):218-219. doi: 10.2106/JBJS.I.00642.

16. Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011;11(1):64-72. doi:10.1016/j.spinee.2010.10.023.

17. Kreiner DS, Shaffer WO, Baisden JL, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013;13(7):734-743. doi:10.1016/j.spinee.2012.11.059.

18. Watters WC 3rd, Bono CM, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J. 2009;9(7):609-614. doi:10.1016/j.spinee.2009.03.016.

19. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.

20. Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189. doi: 10.7326/0003-4819-154-3-201102010-00008.

21. Tuot DS, Sewell JL, Day L, Leeds K, Chen AH. Increasing access to specialty care: patient discharges from a gastroenterology clinic. Am J Manag Care. 2014;20(10):812-819.

22. Giangregorio LM, McGill S, Wark JD, et al. Too fit to fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int. 2015;26(3):891-910. doi: 10.1007/s00198-014-2881-4.

23. Mansell G, Shapley M, van der Windt D, Sanders T, Little P. Critical items for assessing risk of lung and colorectal cancer in primary care: a Delphi study. Br J Gen Pract. 2014;64(625):e509-e515. doi:10.3399/bjgp14X681001.

24. Feigenbaum DF, Boscardin CK, Frieden IJ, Mathes EF. What should primary care providers know about pediatric skin conditions? a modified Delphi technique for curriculum development. J Am Acad Dermatol. 2014;71(4):656-662. doi:10.1016/j.jaad.2014.06.032.

25. McKenna HP. The Delphi technique: a worthwhile research approach for nursing? J Adv Nurs. 1994;19(6):1221-1225.

26. Yousuf MI. Using experts’ opinions through Delphi technique [available online]. Practical Assessment, Research & Evaluation. 2007;12(4). http://pareonline.net/getvn.asp?v=12&n=4. Accessed April 2016. 
PDF
 
Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up