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Specialty Referral Patterns and Curricula Across I3 Collaborative

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Specialty Referral Patterns and Curricula Across I3 Collaborative ORIGINAL ARTICLES What’s the Right Referral Rate? Specialty Referral Patterns and Curricula Across I3 Collaborative Primary Care Residencies Mark Gwynne, DO; Cristen Page, MD, MPH; Alfred Reid, MA; Katrina Donahue, MD, MPH; Warren Newton, MD, MPH BACKGROUND AND OBJECTIVES: Specialty physician visits ac- million specialty referrals annually.3 count for a significant portion of ambulatory visits nationally, con- In many settings, specialty consulta- tribute significantly to cost of care, and are increasing over the tions and referrals lack coordination past decade. Marked variability in referral rates exists among pri- and may generate testing redundan- mary care practices without obvious causality. We present data cy, disagreement on the role of the describing the referral process and specialty referral curriculum specialty physician, and lateral or within the I3 collaborative. cross-referrals among subspecialty 4 METHODS: Residency directors were surveyed about residency care. The result can be poor qual- characteristics related to referrals. Specialty physician referral rates ity, overutilization, and subsequent were obtained from each program and then correlated to pro- increased cost of care, and a patient gram characteristics referral rates in four domains: presence and experience that has been described type of referral curriculum, process of referral review, faculty pre- as “a perilous journey through the ceptor characteristics, and use of referral data for administrative Health Care System.”5 However, cost processes. and quality in primary care can be dramatically improved by carefully RESULTS: The survey response rate was 87%; 10 programs sub- defined relationships with specialty mitted complete referral data. Three programs (23%) reported a consultants.6 formal curriculum addressing the process of making a referral, There is increasing evidence that and four programs (31%) reported a curriculum on appropriate- ness of subspecialty referrals. Specialty referral rates varied from residency training has a long-term 7%–31% of active residency patients, with no relationship to age, impact on how graduates practice 7 payor status, or race. throughout their career; however, little information exists to describe DISCUSSION: Marked variability in referral rates and patterns how family medicine residencies exist within primary care residency training programs. Specialty train the process of referrals. Re- referral practices are a key driver of total cost of care yet few cur- ferring to specialty care is a funda- ricula exist that address appropriateness, quantity, or process of mental skill within primary care, specialty referrals. Practice patterns often develop during residen- and management of the process is cy training, therefore an opportunity exists to improve training and a central role of the patient-centered practice around referrals. medical home. Yet there is little re- (Fam Med 2017;49(2) 91-96.) ported about residency referral rates, appropriateness of referrals and cur- riculum to address these skills with- he consultation and referral frequency of referrals, defined as an in primary care training programs process from primary care outpatient referral made by a pri- Tto specialty care is complex, mary care provider to a subspecial- varies widely among primary care ty physician service, is increasing as providers, and is a key driver of well and has almost doubled in the From the Department of Family Medicine, 1,2 the total cost of health care. The last decade, resulting in almost 100 University of North Carolina at Chapel Hill. FAMILY MEDICINE VOL. 49, NO. 2 • FEBRUARY 2017 91 ORIGINAL ARTICLES and few standards exist to guide the program reported initial practice Results process of specialty referrals within characteristics, which included size Characteristics of primary care. This lack of training and setting of the residency, num- Participating Programs clarity may contribute to special- ber of providers and staff, electron- Table 1 summarizes the characteris- ty referral rate variability reported ic health record (EHR) used, faculty tics and distribution of participating among practicing primary care phy- physician involvement in quality I3 residency programs. The majority sicians.8,9 It is unlikely that we can and program priorities for improve- of residencies were family medicine, reduce cost as a health care system ment. For this project, a referral was mostly urban community and uni- unless we address the process and defined as an outpatient ambulato- versity-based programs, although a training around subspecialty refer- ry referral made by a primary care wide distribution of training environ- rals. provider to a subspecialty physician ments were represented. We set out to evaluate referral service. Referral rate was defined as Surveys were distributed to 24 curriculum and referral processes the percentage of annual outpatient residency program directors with an among 24 primary care residencies visits for empaneled patients result- 87% response rate (21/24). Of the 21 in North Carolina, South Carolina, ing in an ambulatory subspecialty residency programs who responded and Virginia. referral. This definition focused our to the survey, 13 had also submit- evaluation to subspecialty physician ted baseline specialty referral rate Methods care and therefore procedures and data. Table 2 summarizes the rela- Setting and Participants ancillary services such as physical tionship between question respons- The I3 collaborative consists of 24 therapy, nutritionist, diabetes edu- es within the four domains and the family medicine, internal medicine, cation, and were not included. Pro- relationship to referral rates. Three and pediatric residencies in North grams reported referral rates as the programs (23%) had a formal curric- Carolina, South Carolina, and Vir- sum total of referrals to their 10 ulum addressing the process of mak- ginia designed to improve quality most common specialties. With re- ing a referral, and four programs of care in residency practices. Prior spect to the survey, focus group dis- (31%) had a formal curriculum for phases of I3 have focused on chronic cussions of residency directors, the the appropriateness of subspecialty care and PCMH recognition.10,11 I3 academic collaborative, and others referrals. Figure 1 shows the com- POP, the current phase, focused on helped to frame the questions and bined specialty referral rates to the improving population health through calibrate the answers. I3 residency 10 most common subspecialties as implementing the triple aim of im- directors were surveyed using Qual- reported by participating practices. proving quality, the patient experi- trics software11 about four domains Although the referral frequency to ence, and health care utilization for of referral curricula: presence and each subspecialty varied, the most active patients in participating resi- type of referral curriculum, referral common specialties represented in- dencies. Methods are similar to those review process, faculty preceptor cluded GI, ophthalmology, orthope- described in prior phases10,11 and in characteristics, and use of referral dics, surgery, behavioral health, ENT, the description of baseline data.12 The data for administrative processes. dermatology, neurology, cardiology, I3 POP Collaborative used the Insti- Complete objective data on subspe- and OB-Gyn. The combined referral tute for Health Care Improvement cialty referrals were submitted from rates varied from 7% to 31% with a Breakthrough Series Collaborative 13 residencies participating in the median of 25%. There was no corre- design to assess practice transfor- I3 collaborative. Programs submit- lation between university relation- mation and rapidly spread change ted objective referral data abstracted ship, payor status or percentage of specifically in primary care residen- from their electronic medical records minority patients and rate of refer- cies. Collaborative participants met or other practice management soft- rals. There were no statistically sig- through monthly webinars as well ware. In total, 10 programs submit- nificant differences in referral rates as face to face collaborative meetings ted both baseline referral data and within the four domains assessing every six months. Baseline data from survey response data for compara- the relationship between curriculum the practices, including specialty re- tive analysis. Using chi-square test- and referral rates in the question- feral data, were reported annually ing, we assessed the likelihood and naire, but there were trends toward and for some metrics monthly and significance that programs with decreased referral rates in programs quarterly. This project was approved referral rates less than the medi- that had formal review processes for by the I3 POP Academic Collabora- an of the collaborative rate (25%) referrals from advanced practice pro- tive. would answer “yes” or “no” to each viders, used report cards for provid- question. This study was reviewed ers that included individual referral Data Collection and Analysis and exempted by the University of data, had curriculum that addressed As a requirement of participation North Carolina’s Institutional Re- the appropriateness of subspecial- in the I3 POP collaborative, each view Board. ty referrals, and had a greater 92 FEBRUARY 2017 • VOL. 49, NO. 2 FAMILY MEDICINE ORIGINAL ARTICLES Table 1: Characteristics of I3 Collaborative Residency the first available data comparing Programs Participating in Referral
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