A study published in the American Journal of Managed Care examines the guidelines for referring orthopedic patients.
The referral rates in ambulatory settings doubled from 1999 to 2009; specialty visits currently constitute more than half of all ambulatory care visits and two-thirds of ambulatory care expenditures in the country, according to the report. The American College of Physicians Council of Subspecialty Society’s developed the patient-centered medical home neighbor framework to address the relationship between primary care physicians and specialty practices, highlighting the referral process and care coordination.
The researchers at the University of California San Francisco Health System, which includes 24 orthopedists and 65,000 primary care patients, reported 5,000 referrals to orthopedics per year. The researchers performed a 2-phase Delphi study with web-based surveys of primary care physicians and orthopedic surgeons to identify consensus on musculoskeletal problems.
There were 214 questions for 36 clinical scenarios that 21 primary care physicians and 17 orthopedists participated in during round one; in round two, 20 primary care and 16 orthopedists participated. The researchers found:
1. Around half—51 percent—of questions reached a consensus after round one. Another 16 percent of the questions reached consensus after round two.
2. The clinicians agreed confirming patient interest in orthopedic procedures should be completed before the referral in 81 percent of the clinical scenarios.
3. The primary care physicians and orthopedists agreed upon specific conservative management before referrals in 80 percent of the scenarios. The breakdown includes:
• Physical therapy in 60 percent of scenarios
• X-ray in 42 percent of the scenarios
• MRI in 14 percent of scenarios, including acute knee ligament or meniscal tear, acute and chronic full thickness rotator cuff and spinal stenosis
4. The clinicians agreed an X-ray shouldn’t be performed before the referral in 27 percent of the clinical scenarios and MRI shouldn’t be performed in 58 percent of the scenarios.
5. eConsults, or non-face-to-face consults could be appropriate for 39 percent of the clinical scenarios, according to the consensus. It would be inappropriate in 3 percent of the clinical scenarios.
The physicians didn’t reach a consensus in 36 percent of the cases. “In the absence of national guidelines, a process for local guideline generation is needed in order to provide nuanced and detailed decision support at the point of referral,” concluded the study authors. “The Delphi method proved an effective process to achieve this end.”