The following article is a summary of a BMJ editorial which accompanied new research suggesting that the age, sex and wealth of a patient all affect GP referrals…
We do not know the extent to which people who are denied access to specialist services by the gatekeeper are disadvantaged. The appropriate referral of cases to secondary care has economic, quality, and safety ramifications that resonate across the health sector and the globe.
In light of this, the linked study by McBride and colleagues, presenting referral data for 130,000 British patients, is useful.
A conceptual framework that could be used to analyse this study was published by Glasziou and Haynes. It proposes that, for patients to receive evidence-based care, their doctor must be aware of the latest research findings, accept the need to act on that evidence, and target the patients who might benefit from that research. Interventions should be practical and recalled by the practitioner at the time of the consultation. Finally the patient and the practitioner should agree on the necessary action, and the task must be completed. In practice, if each step were completed 80% of the time, then the appropriate management would occur in only one in five encounters with relevant patients.
According to McBride and colleagues a respectable but still unsatisfactory 61.4% of women with postmenopausal bleeding were referred despite ample evidence of benefit from referral. Furthermore, the three conditions examined in the study - hip pain, postmenopausal bleeding, and gastric cancer - are more common in older people and in deprived communities. However, older patients (85 years or older) with postmenopausal bleeding or hip pain were significantly less likely to be referred than younger patients (55-64 year olds). Patients who were more deprived and had hip pain and dyspepsia (if under 55 years old) were also less likely to be referred.
The authors suggest several explanations. Setting aside the possibility that younger people and more affluent people may be over-referred, the reasons for under-referral include the possibility that specialist services are not as readily available in socially disadvantaged areas.
In primary care, the decision to refer or offer further treatment is made during a brief medical consultation, in which the patient will usually present undifferentiated symptoms, sometimes among a host of unrelated problems.
The extent to which the patient’s problem is appropriately dealt with is a function of how effectively the doctor and patient communicate. Sometimes treatment decisions follow a series of consultations after several objective tests. All of these factors - including consultation skills, continuity of care, and the correct interpretation of test results - introduce risk and may reduce the chances that the patient is referred.
The reasons for seeking an expert opinion have remained unchanged for decades and are not limited to diagnosis or treatment. In many cases patients are referred for reassurance as a response to perceived medico-legal risk, to avert a complaint, or to share the burden of caring for a patient whose problems are resistant to appropriate treatment.
It is unsafe to assume that the reasons for referral can be readily gleaned in any document or database. Neither do doctors always record the multiple reasons for referral in their records.
Research using databases is attractive because it can use data from thousands of cases to explore several interesting associations. However, databases cannot provide information to help understand patterns that arise from human interactions.
Older people may be less willing to be referred for investigation, may be reticent because of social isolation, or may adopt a stoic attitude to symptoms. Whatever the reasons they are almost certainly best understood within the context in which they were observed.
Research is needed on the interaction between doctors and patients in the primary care consultation, which ultimately determines who is referred and who is not. Caution is needed in generalising the results to other primary care systems because the results will be context specific, even within national boundaries.
Read the full article.
