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The American Journal of Managed Care August 2019
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Tools to Improve Referrals From Primary Care to Specialty Care
Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
Cost of Dementia in Medicare Managed Care: A Systematic Literature Review
Paul Fishman, PhD; Norma B. Coe, PhD; Lindsay White, PhD; Paul K. Crane, MD, MPH; Sungchul Park, PhD; Bailey Ingraham, MS; and Eric B. Larson, MD, MPH

Tools to Improve Referrals From Primary Care to Specialty Care

Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
Data from a national survey of Veterans Health Administration specialists indicate that referral templates may improve the appropriateness, clarity, and completeness of primary care–specialty care referrals.
In a separate section of the survey, respondents reported the appropriateness, clarity, and completeness of referrals by answering 3 questions: “How often did consult requests reflect an understanding on the part of the PCP about what constitutes an appropriate referral to your specialty clinic?”, “How often was the reason for the consult request sufficiently clear, such that you understood what the referring PCP was asking of you?”, and “How often did the consult request itself include sufficient clinical history and other information to meet your immediate needs?”. Response options were provided on a 7-point scale (never, rarely [less than 10% of the time], occasionally [about 30% of the time], sometimes [about 50% of the time], frequently [about 70% of the time], usually [about 90% of the time], and always). Based on the distribution of responses, and to retain meaningful categories, we dichotomized responses as “half the time or less” versus “more than half the time.”

Statistical Analysis

The goal of our analysis was to characterize the associations between 3 care coordination tools (service agreements, templates, and e-consults) and the appropriateness, clarity, and completeness of referrals. We hypothesized that, for each tool, specialists who used the tool to coordinate care with PCPs would be more likely to report that referrals received from PCPs were appropriate, clear, and complete more than half the time. We used logistic regression models to estimate associations between use of each of the 3 tools and the outcomes (separate models for each of specialists’ perceptions of the appropriateness, clarity, and completeness of referrals). Based on their potential impact on specialists’ perceptions of the quality of PCP referrals, we adjusted for specialist age, sex, years in VHA, number of VHA clinical sessions per week, and percentage of consult requests related to procedures (≤25% vs >25%).

We also hypothesized that those who rated a tool as very helpful would be more likely to report that referrals were appropriate, clear, and complete than would specialists who rated the tool as at most somewhat helpful. The analysis for this hypothesis was limited to specialists who reported using all 3 tools, so that all respondents would be able to provide meaningful ratings of the perceived relative helpfulness of all 3 tools. Because crude odds ratios (ORs) and 95% CIs for all analyses were very similar to adjusted results (data not shown), we display only the adjusted results in the Tables.

RESULTS

Sample Characteristics

The analytic sample was composed of 497 specialists who provided complete information on all relevant variables. Thirty-nine percent were female, 48% were younger than 50 years, and 54% had been a VHA specialist for less than 10 years (Table 1). Twenty-one percent had more than 5 clinic sessions weekly, and 58% reported that 25% or fewer of referrals were related to procedures.

E-consults were the most commonly used coordination tool (87%), followed by referral templates (69%) and service agreements (41%). One-third (33%) of respondents used all 3 referral tools.

About half (55%) of specialists reported that referrals were appropriate more than half the time, 67% reported that referrals were clear more than half the time, and 25% reported that referrals were complete more than half the time.

Use of Coordination Tools and Perceptions of Referral Characteristics

Specialists who provided templates to structure PCP referrals were statistically more likely to report that referrals were appropriate, clear, and complete more than half the time (Table 2). Specialists who used e-consults were statistically more likely to report that referrals were clear more than half the time. Use of service agreements was not associated with any referral characteristic (Table 2).

Helpfulness of Tools and Perceptions of Referral Characteristics

Among specialists who reported using all 3 coordination tools (33%; n = 163), 54% rated e-consults as very helpful, 26% rated templates as very helpful, and 17% rated service agreements as very helpful (Table 3). Those describing templates as very helpful were statistically more likely to report that referrals were clear and complete more than half the time compared with those describing templates as at most somewhat helpful. Perceived helpfulness of e-consults and service agreements were not associated with any referral characteristics.


 
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