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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.

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:

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