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Referrals are, of course, only effective when patients complete them, and physicians have long wondered why some patients fail to follow through. A recent study finds good news: Many patients—most, in fact—fulfill referrals within 3 months.1
But what about the ones who don't? The study reveals that patients don't make or follow up on appointments largely because of two reasons: time constraints and overconfidence in their health. Armed with this knowledge, primary care physicians may be better able to improve their referral processes.
The study, which appeared in the July/August issue of Annals of Family Medicine, included 776 patients with a wide variety of health conditions who received referrals from 133 physicians. Overall, about 80 percent of the patients completed their specialist referrals—a number that might seem unusually high to some physicians, according to lead author Christopher B. Forrest, MD, PhD, professor of pediatrics at University of Pennsylvania School of Medicine in Philadelphia. One reason for the high number of follow-ups could be that this was self-reported behavior, Forrest speculates.
Forrest was curious why the remaining 20 percent of patients did not successfully pursue referrals—an important problem given these patients' need for more specialized care—so he teased out the reasons for lack of follow-through.
REFERRAL GAPS
The most common reason patients gave for failing to follow up on referrals was the belief that the problem had resolved (47.5%), though it was not clear from the results whether or not it actually had. The second reason was lack of time (37.3%), and the third was disagreement with their doctor over why the referral was made (26.5%).
A small subset of patients (2.3%) said an insurance company's refusal to pay prevented them from following up on referral appointments. This was particularly an issue with Medicaid, either because the specialist limits or denies visits with Medicaid patients, or because Medicaid denies the referral.
"We have specialists who won't see Medicaid patients," explains Judith Chamberlain, MD, FAAFP, a family physician in Maine and member of the AAFP Board of Directors. "Sometimes I have to ask the patient to drive a huge distance because the closest specialist who will see them is 100 miles away. I've had some cases where I had to treat patients myself because I couldn't get them seen."
FOSTERING FOLLOW-UP
One factor that seemed to bolster referrals was the longevity of the physician/patient relationship. Only 75 percent of patients in the study who had been with their doctor <3 months completed referrals, compared with 86 percent of those who had been seeing their doctor >5 years.
"There's a negotiation process doctors and patients have, and that negotiation process is facilitated by the bedrock of trust between the doctor and patient," says Forrest.
Just taking time to sit down and explain the rationale for the referral can significantly increase a patient's likelihood of pursuing it, says Thomas Weida, MD, a professor of family and community medicine at Penn State College of Medicine in Hershey, Pa. Weida finds when he utters the word "surgeon," his patients blanch. Then he gives them his reason for making the referral, which is often that he's merely sending them for an opinion to aid his own decision-making.
"I explain why I want them to go to the specialist and what the outcomes might be," he says. "I think it helps decrease their reluctance to go."
Checking back in with the patient after the scheduled referral visit is also key, says Forrest. According to his study, physicians were no more accurate than a flip of a coin at knowing whether their patients had actually seen a specialist.
What's needed is thorough documentation by the primary care physician's staff, says Chamberlain. She notes that the electronic medical system in her office keeps each referral active until the specialist confirms the appointment was honored. That way, her office can follow up and help resolve any problem impeding a visit.
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Some insurance companies will facilitate the referral process by contacting doctors to let them know when it's time for a patient to get an eye exam or see another type of specialist. However, relying on these companies is difficult because their records are often outdated, says Chamberlain. Ultimately, the responsibility for making sure patients complete referrals remains with primary care physicians themselves, who can ensure more effective referrals through considered decisions to refer and communication with the patient and the specialist about that decision (see sidebar).
"I would have patients leaving with the appointment scheduled, have a
mechanism for transferring information from the primary care doctor to the
specialists, and develop a shared understanding between doctor and patients
about the need for a referral," says Forrest. 
Clear Those Referral Hurdles
Physicians see it happen all the time: Patients stuff the referral in their pocket and promptly forget about it. A few weeks later they return with another symptom flare-up, the physician writes another referral, and so it goes.
To prevent such time-wasting and ultimately improve patient care, referrrals researcher Christopher B. Forrest, MD, PhD, professor of pediatrics at University of Pennsylvania School of Medicine in Philadelphia, suggests some ways to bolster patients' follow-up:
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