Dropping the Baton: Specialty Referrals in the United States
Dropping the Baton: Specialty Referrals in the United States
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DOI：
10.1111/j.1468-0009.2011.00619.x
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发表时间：
2011-03-01
影响因子：
6.6
通讯作者：
Lin, Caroline Y.
中科院分区：
文献类型：
--
作者：
Mehrotra, Ateev;Forrest, Christopher B.;Lin, Caroline Y.
背景：在美国，每年有超过三分之一的患者被转介到专科医生那里，专科就诊占门诊就诊的一半以上。尽管转诊的频率和专科转诊过程的重要性，但这一过程本身一直是初级保健医生(PCP)和专家感到沮丧的长期来源。这些挫折，加上降低成本的愿望，导致了许多改善专科转诊流程的策略，例如使用看门人和转诊指南。方法：本文回顾了有关专科转诊流程的文献，以便更好地了解目前转诊流程中存在的问题以及提出了哪些解决方案。本文首先提供了一个概念框架，然后回顾了以前关于转诊决策、护理协调(包括信息传输)和获得专科护理的文献。结果：专科医生转诊患者的门槛不同，这导致专科医生的使用不足和过度使用。许多转诊不包括向专家传递信息或从专家那里传递信息；当他们这样做时，往往包含用于医疗决策的不足的数据。跨初级-专科接口的护理整合程度很差；专科医生通常不知道患者是否真的去看了专科医生，或者专科医生推荐了什么。专科医生和专科医生也经常对专科医生在转诊过程中的角色存在分歧(例如，单一会诊或持续共同管理)。结论：专科转诊过程的所有组成部分都存在故障和效率低下。尽管有许多有希望的机制来改进转介程序，但需要对这些改进进行严格的评估。
Context:In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty‐referral process, the process itself has been a long‐standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty‐referral process, such as using gatekeepers and referral guidelines.Methods:This article reviews the literature on the specialty‐referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care.Findings:PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary‐specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co‐management).Conclusions:There are breakdowns and inefficiencies in all components of the specialty‐referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.