Referrals from general practice to consultants in Germany: If the GP is the initiator, patients' experiences are more positive

Referrals of patients from primary care to medical specialist care and back to primary care, comprise an important activity in any healthcare system [1]. Optimal referring processes are crucial for the effectiveness, safety and efficiency of medical care [2]. Across Europe delivering and financing care in the primary care sector is quite differently organized. There is evidence, that the gate keeping role of general practitioners (GPs) increases efficacy of the system and reduces costs [3]. Due to decreasing financing resources and the potential effectiveness and efficiency of a primary care centred system, an intense political discussion has started on the gate keeper role of the GP for access to hospital care in Germany [4]. Since 2004, patients can access medical specialists directly, but as a first step towards a GP gate keeper role they have to pay an additional fee if they do not consult their GP first. Moreover, the GP can determine if the specialist is allowed to refer the patient to other medical specialists or if he has to be referred back after the consultation. National data showed that due to the introduction of this fee, the number of referrals from primary care to hospital care has increased tremendously. Consequently, the quality of communication between GP an specialists has come into the focus of health care professionals and politicians. Critics argue for example, that it may cause dissatisfaction among patients that the GP has to – at least formally – initiate the referral. However, data on the actual experiences of German patients, GPs and consultants regarding referrals were hardly available.

An optimal referral has a clear purpose, related to diagnosis or treatment, which is specified by the GP in the communication with the consultant. Also, patients have specific expectations of the referral, related to diagnosis or treatment, which may or may not have been discussed with the GP. We wondered, whether the GPs' and the patients' experiences were associated with the purpose or expectation regarding the referral. We hypothesised, tentatively, that diagnostic goals would be clearer and more feasible to accomplish, resulting in more positive experiences in GPs and patients. Furthermore, we expected that patients' experiences would be most positive if the referral was initiated by the patient.

Tables 1, 2, 3 show that patients' provided data on 446 referrals, while consultants reported on 430 referrals and GPs on 411 referrals. About 60% concerned male patients, while patient age varied largely. GPs referred to various consultants, orthopedics, cardiologists, surgeons and radiologists accounted for the largest numbers. The information of who initiated the referral was collected from GPs and patients: the GP could state whom he regarded as the initiator, the patient could state if the referral was recommended by the GP or if he asked for the referral. Comparison of these data did not reveal noteworthy differences (<1%). The GPs' purposes of these referrals comprised both diagnosis and treatment. The majority of the patients was referred back to the GP.

Table 4 shows that consultants were very positive about the clarity of the referral purpose indicated by the GP (95%), the appropriateness of the referral (91%) and the information provided to the patient by the GP (87%). They were somewhat more critical regarding the information provided on the patients' medical history (61%) and prescriptions (48%). In 93 referrals (22%) consultants wanted more information on the patient. In 46 referrals (11%) they thought that the patient should have been referred earlier. Ten consultants (2%) stated that they would have preferred to refer the patient to a different medical specialist, although the GP had mentioned on the referral letter that he did not want referral to further consultants.

The experiences of consultants varied across medical disciplines. Cardiologists had less positive experiences than other consultants (beta = -0.289, p < 0.001).

This study described the experiences of consultants, GPs and patients with referrals from primary care to medical specialist care. Overall, the majority of the three groups had positive experiences with the referrals. There was some variation regarding the consultants' experiences across their medical disciplines, with cardiologists having the least positive experiences. GPs (but not patients) had more positive experiences with the referral, if the referral had a diagnostic purpose. As assumed, GPs experiences were more positive if they initiated the referral. In contrast to our expectations, patients had more positive experiences if the referral had been initiated by the GP.

Previous studies revealed high and mostly unexplained variation across GPs regarding referrals [5–11]. But despite a very large variation, GPs referral rates do not correlate with the appropriateness of the referral [11]. Consequently the referral rate represents an unsatisfactory indicator of quality [12]. Our study focussed on the perceived value of the referral, including patient, GP and consultant views.

The evaluation by all involved goups, GPs, patients and specialists revealed quite good results. Some studies in other countries have shown less positive results regarding the value of referrals, but some of these studies tend to be small [8]. Studies involving larger numbers of GPs revealed different estimations of appropriateness: with 90.4% of appropriate referrals Fertig et al. found a higher rate than in the present study [7].

It could be assumed, that GPs experiences were more positive with the referral, as our study revealed. Moreover, an interesting finding of our study, which was also contrary to our expectations, was not yet assesssed nor reflected in previous studies: Patient satisfaction is associated with the initiator of the referral. We can only speculate about factors leading to the unexpected results. We assume that patients expect optimal information about disease and treatment, but they respect GPs superiority in judging if a referral is necessary or not. Our findings contradict statements of critics of the gate-keeper role, saying that patient satisfaction increases if they initiate the referral. Previous findings indicating this, were shown in completely different settings, where the patients did not have a trustfull relationship to their GP [13]. Regarding referrals, it seems that many patients may appreciate some guidance and co-ordination by the GP. GPs satisfaction was higher if the referral purpose was diagnostic than therapeutic. An explanation for this result could be that the aim of diagnostic referrals is to exclude serious diseases or to confirm suspected diseases. In most cases, the purpose is well defined and the results may help the GP to proceed in his course in case of confirmation as well as in case of exclusion. In contrast to referrals with a diagnostic aim, specialists treatments are nearly completely outside the GP's influence and may not always be perfomed according to his ideas.

The study has some limitations. Although the sample of referrals was reasonably large, it may suffer from selection bias as it was derived from a group of 25 GPs in a specific region. The study was based on self-report measures, which were not previously validated, but we believe that most questions were rather straightforward. In case of somatoform symptoms, the dissatisfaction of patients could be increased due to the fact that no organic cause has been found. It could be assumed that many of these referrals had been initiated by the patient. This could have been a source of bias, but we could only collect and link the data from consultants, GPs and patients regarding a certain referral process, but not with individual patient data. Additional information on diseases, comorbidities, social statuts, and former health care utilization would have increased the power of our data since it is known that these factors influence referrals [14]. Due to the design of the study, we have no data about the outcome of consultations that were made directly by patients without visiting a GP first. Comparing these outcomes would increase the significance of our results but is associated with multiple problems of data collection.

This observational study suggests that referrals from primary to secondary care in Germany are reasonably appropriate and that satisfaction with referrals is high among GPs, consultants and patients. Nevertheless, GPs should try to meet the different consultants' needs for different information [11]. For instance, detailed diagnostic and therapeutic information is essential for cardiologists but less important for orthopedic surgeons. Possible approaches for improvement could be frequent joint consultations or the possibility to discuss a referral with the consultant [15–18]. Sharing information on the patient, his history and medication is necessary to increase efficacy and to improve continuity of care [19]. However, the fact that GPs as well as patients' satisfaction was higher if the referral was suggested or initiated by the GP supports the role of a qualified gate-keeper.