What's the Right Referral Rate? Specialty Referral Patterns and Curricula Across I3 Collaborative Primary Care Residencies.

BACKGROUND AND OBJECTIVES: Specialty physician visits account for a significant portion of ambulatory visits nationally, contribute significantly to cost of care, and are increasing over the past decade. Marked variability in referral rates exists among primary care practices without obvious causality. We present data describing the referral process and specialty referral curriculum within the I3 collaborative.

METHODS: Residency directors were surveyed about residency characteristics related to referrals. Specialty physician referral rates were obtained from each program and then correlated to program characteristics referral rates in four domains: presence and type of referral curriculum, process of referral review, faculty preceptor characteristics, and use of referral data for administrative processes.

RESULTS: The survey response rate was 87%; 10 programs submitted complete referral data. Three programs (23%) reported a formal curriculum addressing the process of making a referral, and four programs (31%) reported a curriculum on appropriateness of subspecialty referrals. Specialty referral rates varied from 7%-31% of active residency patients, with no relationship to age, payor status, or race.

DISCUSSION: Marked variability in referral rates and patterns exist within primary care residency training programs. Specialty referral practices are a key driver of total cost of care yet few curricula exist that address appropriateness, quantity, or process of specialty referrals. Practice patterns often develop during residency training, therefore an opportunity exists to improve training and practice around referrals.