- Email: [email protected]
Referrals to Psychiatrists
Referrals to Psychiatrists Assessing the Communication Interface Between Psychiatry and Primary Care TERRI L. TANIELIAN, M.A., HAROLD ALAN PINCUS, M.D. ALLEN J. DIETRICH, M.D., JOHN W. WILLIAMS, JR., M.D., M.H.S. THOMAS E. OXMAN, M.D., PAUL NUTTING, M.D., M.P.H. STEVEN C. MARCUS, PH.D.
The Study of Outpatient Referral Patterns was conducted in 1998 to examine the nature of the communication relationship between psychiatrists and primary care physicians regarding outpatient referrals. Nationally representative psychiatrists were surveyed (N⳱542) regarding their aggregate experience with outpatient referrals from non-psychiatric physicians in the previous 60 days. Data regarding frequency and type of information and mode of communication were gathered. Results indicate that primary care physicians represent a significant source of referrals to psychiatrists and that psychiatrists are generally satisfied with the communication interface with the referring physicians. Psychiatrists’ level of satisfaction was related to the quantity and quality of information provided by referring physicians. (Psychosomatics 2000; 41:245–252)
P
rimary care physicians have long been a significant source of referrals for psychiatrists.1 However, the dramatic changes in the U.S. health care system, particularly the growth of managed care programs that employ selective contracting, may have modified the nature of the consultative process.2 Data from the Center for Health System Change Community Tracking Study3demonstrate that primary care physicians perceive high-quality mental health care to be more difficult to obtain than non-mental health medical care. There are also recent indications that primary care physicians report dissatisfaction with their referrals to psychiatrists. Williams et al.4 reported that in a survey of primary care physicians regarding the treatment of depression, physicians were less satisfied with mental health referrals made to psychiatrists, psychologists, or social workers compared with other medical specialties. These data also indicate that primary care physicians’ ratings of satisfaction with referrals to psychiatrists were somewhat
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lower than the ratings regarding referrals to psychologists or social workers. Given this context, the present study aims to understand the nature of the referral process between psychiatry and primary care. In particular, we focused on examining the current communication interface (from the psychiatrists’ point of view) between psychiatrists and non-psychiatric physicians with regard to outpatient referrals and measured psychiatrists’ satisfaction with the referral and the communication process with non-psychiatric physicians. We Received April 15, 1999; revised June 29, 1999; accepted September 14, 1999. From the American Psychiatric Association; Department of Psychiatry, University of Pittsburgh Medical School, and RAND; the Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH; the Division of General Internal Medicine, South Texas Veterans HealthCare System: The University of Texas Health Science Center, San Antonio, TX; and Center for Research Strategies, Denver, Colorado. Address reprint requests to Ms. Tanielian, RAND, 1200 South Hayes Street, Arlington, VA 22202-5050; email: [email protected] Copyright 䉷 2000 The Academy of Psychosomatic Medicine.
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Referral to Psychiatrists began by conceptualizing the referral process to identify opportunities for interchange between physicians. According to the Goldberg and Huxley model,5 a patient must pass through a number of filters in order to arrive at the specialized mental health care level. First, the patient must decide to seek help. Then, the “second filter” occurs in the office of the primary care provider (PCP), and the outcome depends on the PCP’s ability to recognize psychiatric disorders, to integrate them with the patient’s total profile of health care needs, and to assess the need for specialized mental health services. If the PCP decides that the patient requires specialized care (“third filter”), the PCP must recommend the type of specialized care the patient should seek. Several factors influence the outcome of the third filter, including the characteristics of the patient, community, provider, and system.6,7 This paper focuses on the third filter and its issues such as the relationship and influence at the provider and system levels, particularly with regard to how providers interact at the referral interface (labeled as the “communication interface”) for specialized mental health care from a psychiatrist. In designing this study, we identified several factors from the psychiatrists’ point of view that impinge on the communication interface between primary care physicians and psychiatrists. These factors include patient factors (e.g., the diagnosis, the patient’s relationship with the primary care physician, the patient’s beliefs/attitudes, and the perceived goals of mental health care); health care environment factors (e.g., health plan, setting, community resources, availability/accessibility of care); and physician factors (knowledge/skills, pressures, perceived goals, time/ economic pressures, collegial relationship with one or more patients). The success of the communication interface will depend on how these factors interact and the compatibility between primary care physician factors and psychiatrist factors. Our research asked the following questions. How do the providers who make and receive referrals interact and what are the outcomes (e.g., satisfaction, treatments provided, etc.) for the physician and patient? How can systems and providers be influenced to interact more successfully and improve patient care? This report describes the first phase in our efforts to understand this communication interface. Data are presented on psychiatrists’ aggregate communication experiences with referrals from non-psychiatric physicians. The data we present describe current experiences from the psychiatrists’ point of view and generate additional hypotheses regarding factors that may affect the communication interface. 246
METHODS Study Population This study uses data collected from the American Psychiatric Association’s (APA) Practice Research Network (PRN). At the time of the study, the PRN consisted of 542 APA members who report spending at least 15 hours per week in direct patient care. Forty-two percent of PRN members had been randomly selected and invited to join the network; the remaining members are self-identified volunteers. The randomly selected cohort was recruited from among respondents to the 1996 National Survey of Psychiatric Practice. The survey was conducted among a random sample (n⳱1,481) of the 40,866 psychiatrist members of the APA at that time (representing approximately 70% of the psychiatrists in the United States). Of those deemed eligible (i.e., still in psychiatric practice; n⳱1,375), 970 psychiatrists (70.55%) responded, and 693 (50.40%)of them met the PRN eligibility criteria.8 The selfidentified volunteer component of the network was recruited through advertisements in APA publications and at national psychiatric conferences.7 Analytic comparison of 78 sociodemographic and practice variables (e.g., sex, age, board certification in general and/or child psychiatry, and practice variables, such as setting and patients’ type of health plan) have shown that PRN members are representative of the full APA. Only 4 variables showed statistically significant differences: the percentage of psychiatrists who were board certified in geriatric psychiatry, the percentage affiliated with a medical school, the percentage residing in the Midwest, and the percentage of those who indicated “other” or “mixed race.” Furthermore, we compared univariate distributions for 33 demographic, clinical, and treatment variables to identify any differences between patients of volunteers vs. randomly selected PRN members. Only 2 variables were significantly different (P⳱ 0.05): use of psychotherapy without medications (17.1% random vs. 11.0% volunteer) and the mean number of medications prescribed per patient (1.9 random vs. 2.2 volunteer). Given the few statistical differences, the 2 groups were combined for our analyses. The PRN will continue to expand over the next several years and the proportion of randomly selected members will increase over time, thereby enhancing the network’s representativeness.7 All PRN members were asked to participate in the Study of Outpatient Referral Patterns, a cross-sectional, observational study. Of the 542 sampled, 534 were eligible Psychosomatics 41:3, May-June 2000
Tanielian et al. for participation. Eight psychiatrists were ineligible because of retirement, closing of practices, or insufficient clinical hours. Of those who were eligible, 435 (81.5%) completed the study. Other publications have described the rationale and infrastructure of the PRN, the professional characteristics of psychiatrists, and the characteristics of their patients.7–9 PRN members spend an average of 32 hours providing direct patient care and treat an average of 43 patients during a typical work week. PRN members report spending a little over half their patient care time in an office practice (54%, see Table 1). The results presented in this article are based on psychiatrists who spend at least some patient care time in an outpatient setting (95%; n⳱413) and who received at least one new outpatient referral in the past 60 days (82%; n⳱340) Data Sources and Measures Psychiatrists were asked to complete a 10-item selfreport survey. The survey was designed by a multidisciplinary panel that included PCPs and mental health specialists. The survey contained several questions regarding the frequency and nature of new outpatient referrals during the previous 60 days. For this study, referral is defined as “any new outpatient directed to a psychiatrist for any psychiatric purpose” (e.g., for consultation, psychotherapy, psychopharmacology, or other treatment) and whether the recommendation TABLE 1.
Characteristics of the practice research network respondents (Nⴔ435)
Demographic
% Psychiatrists
% Male Mean age White, non-Hispanic International medical graduates Board certified in psychiatry Patient Care Setting Office practice Hospital Clinic/outpatient facility Staff/group model HMO Other
66.4 49.5 years 73 15 72 % of Time 54 25 14 1 7 % Psychiatrists
Spend any direct patient care time in an outpatient setting Received new outpatient referral from non-psychiatric physician in past 60 days
95 82
* Percentages may add to more than 100% because of rounding
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to the patient was general (“You should seek psychiatric care for this mental health issue.”) or specific (“You should see Dr. Jones for medication.”). The survey focused specifically on new outpatient referrals that involved a nonpsychiatric physician anywhere in the referral process. The survey also gathered information on the psychiatrists’ experiences and satisfaction with the referral and communication process with non-psychiatric physicians. In particular, data were collected on the frequency and source of outpatient referrals, the types of information received from the referring physician before the first visit, the frequency of communication or information provided by the referring physician, and the type and frequency of feedback given to the referring physician. Response choices for satisfaction with communication were “poor,” “fair,” “very good,” “excellent,” and “can’t rate.” For nature and frequency of communication choices were “never,” “almost never,” “sometimes,” “often,” and “always.” Data were also collected on whether confidentiality concerns influenced the exchange of treatment information between the psychiatrist and non-psychiatric physician. In addition, the study gathered information on psychiatrists’ overall satisfaction with the communication process for referrals with non-psychiatric physicians. Implementation Survey materials were mailed to all PRN members. Before the first mailing, a study alert was faxed or mailed to all PRN members. Post card and fax reminders were sent to encourage the submission of survey responses. Non-respondents to the first mailing were sent a second mailing 3 weeks later. Thank-you letters and a token gift were sent to all PRN members who completed the study. All methods for data collection were approved by the American Psychiatric Association Institutional Review Board. Analytic Methods Summary statistics to describe referral patterns between psychiatry and non-psychiatric physicians were generated. Because psychiatrists who receive a higher number of referrals from non-psychiatric physicians may be more satisfied with the referral process, we partitioned psychiatrists according to the number of new outpatient referrals for analyses. Psychiatrists were divided into three groups (low, moderate, and high), according to the number of new outpatient referrals received during the previous 60 days. 247
Referral to Psychiatrists The “low referrals” received fewer than 5, “moderate referrals” received between 5 and 19, and “high referrals“ received 20 or more. In addition, to examine whether the psychiatrists more satisfied with non-psychiatric referrals might use verbal forms of communication, we categorized psychiatrists according to their satisfaction level with the overall communication process. Psychiatrists who rated the overall quality of interactions with nonpsychiatric physicians “very good” or “excellent” were included in the “very satisfied” group. Psychiatrists who rated the overall quality “poor” or “fair” were included in the “not satisfied” group. Potential relationships among the frequency of referrals, the psychiatrists’ satisfaction, and the types of communication received, and among the psychiatrists’ satisfaction and types of communication used were assessed with Chi-square tests. RESULTS Responding psychiatrists who spent time in an outpatient setting (n⳱413) indicated that they saw an average of 24 new outpatients during the previous 60 days (range⳱0– 160, median⳱16). Based on the psychiatrists’ report, an average of 42% of their new outpatients had a nonpsychiatric physician involved at some point in the referral process and 35.8% were directly referred to the psychiatrist by a non-psychiatric physician. The remaining results are presented for psychiatrists who received at least 1 new outpatient referral directly from a non-psychiatric physician during the previous 60 days (n⳱340). Figure 1 displays the percentage of patients referred directly to psychiatrists, sorted by physician specialty. As shown, 82% of the patients referred to psychiatrists by nonpsychiatric physicians were from primary care physicians. Forty-three percent of psychiatrists reported that they actively seek referrals or consultations from primary care physicians. Fifty-one percent of psychiatrists reported that they often or always receive the reason for the referral, 32.6% often or always receive the patient’s demographic information, and 26.2% often or always receive the patient’s medical history before their visit with the referred patient (See Table 2). Only 17.2% of psychiatrists reported that they often or always receive the patient’s treatment history, and 33.0% indicated that they often or always receive no information from the referring physician before the first visit. As shown in Table 2, a telephone call was the most 248
common mode of transmission of information from nonpsychiatric physicians regarding the patient, with 35.3% of psychiatrists reporting that they often or always receive information in this manner. Use of a standard referral/authorization form was the second most common mode of communication, with 18.8% of psychiatrists reporting that they often or always receive a copy of this form before the first visit. Psychiatrists Who Report Back to the Referring Physician Table 2 also details the proportion of psychiatrists who report sending information back to the referring physician after their evaluation by type and mode of communication. As noted, a majority of psychiatrists report often or always sending diagnostic (79.6%) and treatment (79.3%) information back to the referring physician. A letter was the most common form of transmission; 49.1% of psychiatrists reported often or always sending this form of communication after their evaluation of the patient. Almost two-thirds (63.8%) of psychiatrists reported never or almost never having been prevented by confidentiality concerns or patients’ request from sharing information that might help the other physician treat the patient. Thirty percent responded sometimes, and 4.5% of the psychiatrists responded as often having been prevented by confidentiality concerns or patient requests. FIGURE 1.
Percentage of patients referred directly to psychiatrists by physician speciality
Other/Speciality Unknown OB/GYN 5% 5% Medical/Surgical 8% General Pediatrics 9%
General/Internal 40%
Family Practice 33%
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Tanielian et al. Psychiatrists’ Satisfaction With Their Interactions With Primary Care Physicians Although 63.5% of psychiatrists reported that the accessibility/ availability of primary care physicians was very good or excellent, 68.5% reported that the communication with primary care physicians regarding follow-up for care was poor or fair (Table 3 shows the proportion of psychiTABLE 2.
atrists by level of satisfaction). The level of satisfaction with interactions was lowest for adequacy and sufficiency of patient information provided (69.7% of psychiatrists reported poor or fair). However, half (50.0%) of psychiatrists indicated that their level of satisfaction with the overall quality of interactions with primary care physicians was very good or excellent. No significant differences were observed among psy-
Characteristics of communication transfer (Nⴔ340 psychiatrists)
Type of information received from non-psychiatric physician Demographic Reason for referral Medical history Treatment history No information Mode of communication received from non-psychiatric physician Letter Telephone Standard form Copy of medical records In-person discussion Other (e.g., e-mail) Types of information sent to referring physician by psychiatrists Diagnostic information Treatment information Educational information Results of psychological or neuropsych tests Recommendations for specific actions/treatments Mode of communication used by psychiatrists to referring physician Letter Telephone Standard form Copy of medical records In-person discussion Other (e.g., email)
Never 16.1 3.0 8.1 9.5 10.7 Never 24.6 6.2 28.3 17.1 14.8 10.0 Never 0.3 0.3 6.0 15.4 0.9 Never 6.3 0.6 56.5 29.6 11.6 8.2
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 23.9 13.7 25.5 30.6 33.0
27.5 32.3 40.4 42.7 21.4
23.0 33.8 21.7 14.2 33.0
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 37.0 18.1 25.5 34.2 39.5 3.2
30.0 40.4 27.4 36.3 37.7 4.4
8.2 30.3 16.4 10.5 6.9 4.7
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 2.4 3.3 26.2 29.9 12.8
17.8 17.2 44.1 29.5 33.3
34.9 35.8 17.6 15.7 31.0
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 22.9 9.5 16.7 25.1 30.5 2.1
21.7 43.9 11.6 24.8 42.4 2.4
23.5 35.9 10.3 12.7 13.7 2.1
Always 9.6 17.2 4.5 3.0 1.8 Always 0.3 5.0 2.4 1.8 1.2 1.5 Always 44.7 43.5 6.3 9.5 22.0 Always 25.6 10.1 4.9 7.9 1.8 0.9
* Percentages do not add up to 100% because of rounding
TABLE 3.
Psychiatrists’ satisfaction with experience communicating with non-psychiatric physician
Overall quality of interactions Accessibility/availability of non-psychiatric physicians Sufficiency of background patient-information provided Nonpsychiatric physicians’ communication of expectations Communication with nonpsychiatric physicians regarding follow-up care
Poor
Percentage of Psychiatrists Reporting Fair Very Good Excellent
5.3 3.8 19.7 19.4 30.0
42.4 30.0 50.0 47.6 38.5
35.9 37.9 21.5 26.2 19.4
14.1 25.6 6.5 3.5 4.4
Can’t Rate 0.9 1.2 1.2 2.4 6.5
* Percentages will not add to 100% because of missing data
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Referral to Psychiatrists chiatrists who received a low, moderate, or high number of referrals in the reporting of the frequency of receiving demographic, reason for referral, medical history, and treatment history from the referring physician (data not shown) (Table 4 shows the distribution of psychiatrists according to level of referrals). However, significant variation by level of referrals was observed in the reporting of the frequency of receiving different modes of communication. For example, psychiatrists who reported receiving a letter or receiving a telephone call from the referring physician varied by level of referrals (v2⳱15.8, df⳱8, P⳱0.045; 3.6%, v2⳱23.9, df⳱8, P⳱0.002; respectively). A higher proportion of psychiatrists who received a high level of referrals reported that they often or always receive a letter and a higher proportion of psychiatrists who receive a low level of referrals reported that they often or always receive a telephone call. Significant differences were also observed in the reported frequency of receiving information from the nonpsychiatric physician according to the psychiatrists’ reported level of satisfaction with the communication process (see Table 5). Psychiatrists who reported being satisfied with the overall communication with non-psychiatric physicians were more likely to report receiving a telephone call from the non-psychiatric physician before the patient’s first visit (v2⳱41.941, df⳱4, P⬍0.0001). Psychiatrists who were satisfied with the communication process were also more likely to report receiving information regarding the reason for referral, the patient’s medical history, and the patient’s treatment history before the first visit (v2⳱20.12, df⳱4, P⬍0.0005; v2⳱32.25, df⳱4, P⬍0.0001; v2⳱31.52, df⳱4, P⬍0.0001; respectively). Psychiatrists who were unsatisfied were more likely to report receiving no information (v2⳱38.195, df⳱4, P⬍0.0001). DISCUSSION Primary care physicians represent a major source of referrals to psychiatrists. Given the increasing complexity of psychiatric patients and the treatments they receive, it is TABLE 4.
imperative to understand the interface between primary care and psychiatry, particularly with regard to the various types of relationships psychiatrists and primary care physicians can have with regard to referrals and patient care.6 Overall, psychiatrists’ perceptions of communications with primary care physicians are positive. There appears, however, to be some inconsistency depending on the domain of communications measured. Psychiatrists also identify the inadequacy of information and communication from primary care physicians to psychiatrists as a major problem. This is especially true regarding previously provided medical and treatment history and communication of expectations. These data also indicate that psychiatrists who are most satisfied with the referral interface with primary care physicians are receiving more information regarding the patients that are referred to them. Psychiatrists who receive a high number of referrals tend to use written forms of communication. Practitioners with a high volume of patients in their practice may find it difficult to arrange schedules, telephone calls, etc. to establish in-person discussions. Written communications may provide a mechanism that is more effective and efficient for psychiatrists with a high volume of referrals. Study Strengths and Limitations Previous reports have demonstrated the generalizability of PRN findings to APA psychiatrists with regard to demographic and practice characteristics.2 However, generalizations regarding these data can only be made to psychiatrists who spend at least 15 hours per week providing direct patient care and who spend at least some time practicing in an outpatient setting. This represents approximately 95% of patient care time.7 These findings are also limited to the extent that they are based on physician-reported aggregate experiences. In particular, the validity of psychiatrists reporting back to referring physicians may be questioned. Responding psychiatrists may have exaggerated how much they reported back because of a social pressure to report communicating
Referral characteristics of study psychiatrists (Nⴔ340)
Level of New Outpatient Referrals Received
% of Psychiatrists
Number of Referrals
Low (fewer than 5 in past 60 days) Moderate (between 5 and 19 in past 60 days) High (20 or more in past 60 days)
33.1 44.8 22.1
mean⳱2.3, median⳱2 mean⳱9.4, median⳱10 mean⳱34.7, median⳱30
* Overall number of referrals: mean⳱12.7, median⳱8.0, range: 0-98
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Tanielian et al. with the referring physician more often than psychiatrists actually do. This study did not assess the role of the nonpsychiatric physician in the care of patients who self-refer to psychiatrists. Also, electronic interaction may be a growing mode of communication between physicians; however, this survey did not inquire specifically about electronic communication. This study did not assess the possible relationships among clinician, patient, system, and setting factors, all of which may have an important contribution to the success of the communication and referral interface in mental health. Implications and Future Research In general, psychiatrists reported that they are satisfied with the communication and referral interface with primary TABLE 5.
care physicians despite primary care physicians’ reports of dissatisfaction. We can only speculate why psychiatrists’ satisfaction is positive despite reports of insufficient information from primary care physicians. Psychiatrists may not expect communication back from referring physicians and may see it as a bonus when it does occur. Concerns with patient confidentiality, lack of direct doctor-to-doctor referrals caused by carve-outs, and the difficulty of timely contact by letter, telephone, or in-person all present barriers to successful communication between physicians. Although communication gaps between psychiatrists and primary care physicians may interfere with patient care (only 17.2% of psychiatrists report often or always receiving the patient’s treatment history before the first visit), these data indicate that communication occurs at some level. Thus, it
Variation in communication by level of psychiatrist satisfaction
Type of Information Received From Non-psychiatric Physician Demographic Satisfied psychiatrists Non-satisfied psychiatrists Reason for referral Satisfied psychiatrists Non-satisfied psychiatrists Medical history Satisfied psychiatrists Non-satisfied psychiatrists Treatment history Satisfied psychiatrists Non-satisfied psychiatrists No information Satisfied psychiatrists Non-satisfied psychiatrists
Never
Percentage of Psychiatrists Reporting Almost Never Sometimes Often
Always
Statistic (Chi-square, df, P-value)
6.3 9.9
11.6 12.2
14.0 13.4
11.9 11.0
7.2 2.4
11.25, df⳱4, P⳱0.0252
1.8 1.2
4.8 8.9
12.8 19.6
19.9 14.0
11.6 5.6
20.12, df⳱4, P⳱0.0005
2.7 5.3
8.9 16.6
19.9 20.5
15.7 5.9
3.6 0.9
32.25, df⳱4, P⬍0.0001
3.3 6.2
10.4 20.2
24.6 18.1
9.8 4.5
2.7 0.3
31.519, df⳱4, P⬍0.0001
7.7 3.1
22.6 10.4
8.9 12.5
10.7 22.3
0.6 1.2
38.195, df⳱4, P⬍0.0001
10.6 13.9
17.0 20.0
18.5 11.5
4.9 3.3
0.0 0.3
9.920, df⳱4, P⳱0.0418
1.8 4.5
5.3 12.8
17.8 22.6
21.4 8.9
4.2 17.7
41.941, df⳱4, P⬍0.0001
13.4 14.9
13.7 11.9
13.4 14.0
9.1 7.3
0.9 1.5
1.88, df⳱4, P⳱0.7563
8.7 8.4
15.3 18.9
17.4 18.9
7.5 3.0
1.5 0.3
11.015, df⳱4, P⳱0.0264
6.3 8.4
17.2 22.3
22.0 15.7
4.2 2.7
1.2 0.0
13.293, df⳱2, P⳱0.0099
18.5 23.5
4.9 8.6
3.7 14.8
14.8 4.9
3.7 2.5
10.864, df⳱4, P⳱0.0281
Mode of Communication Received from Non-psychiatric Physician Letter Satisfied psychiatrists Non-satisfied psychiatrists Telephone Satisfied psychiatrists Non-satisfied psychiatrists Standard form Satisfied psychiatrists Non-satisfied psychiatrists Copy of medical records Satisfied psychiatrists Non-satisfied psychiatrists In-person discussion Satisfied psychiatrists Non-satisfied psychiatrists Other (e.g., email) Satisfied psychiatrists Non-satisfied psychiatrists
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Referral to Psychiatrists will be important to improve the quantity and quality of the flow of information between psychiatrists and primary care physicians. Some authorities advocate that the on-site presence of mental health providers in primary care settings will improve communication and patient care.10 Because this is not always feasible, communication by in-person contact, email, telephone, or letter should be a priority for physicians, including psychiatrists seeking more physician referrals and more information regarding patients. It is also possible that psychiatrists present an overly favorable picture with regard to their own actions particularly, with regard to communicating back to the referring physicians (nearly 80% of psychiatrists reported often or always sending back information regarding the diagnosis and treatment of the patients) because this is not necessarily what primary care physicians report.4 It is important to acknowledge that the referral process is a two-way street. Previous studies have addressed the PCPs’ perspectives regarding the communication interface with referrals. However, the current study focuses only on the psychiatrists’ point of view. The data reported here characterize psychiatrists’ aggregate experience of receiving referrals from primary care physicians and what communication occurs at the interface.11 To follow up on these findings with patient-level data, the PRN is conducting a second phase survey to gather detailed patient-level data on the actual practices of psychiatrists in the referral interface. This second survey will
characterize the nature, frequency, and type of communication regarding specific patients who were referred by a non-psychiatric physician and examine variation in the patients’ demographics, clinical/diagnostic, treatment, and reimbursement characteristics. The PRN patient-level study is designed to complement efforts by other physician practice based-research networks, such as the Ambulatory Sentinel Practice Network and the Pediatric Research in Office Settings who have conducted similar studies to characterize the referral interface between primary and specialty care. In addition, studies such as the Physician Referral Study12 will help us understand the dynamics of the referral process to specialty care and the impact of health care system factors on outcomes. Ultimately, these data will inform all of the design of an educational intervention or development of new systems aimed at improving the quality of interactions, the level of physician satisfaction with the interface, and patient outcomes. Findings from this study were presented in part during the National Institute on Mental Health Conference “Interventions in Primary Care,” July 1998, in Baltimore, Maryland. Work on this article was supported in part by the John D. and Catherine T. MacArthur Foundation and the federal Center for Mental Health Services. The authors acknowledge the PRN members who participated in this study and the APA staff who contributed to the project, including Deborah A. Zarin, M.D., Eve Kupersanin, and Heather Cohen.
References
1. Peterson BD, Pincus HA, Suarez A, et al: Referrals to psychiatrists. Psychiatric Serv 1998; 49:449 2. Pincus HA, Zarin DA, West JC: Peering into the “black box”: measuring outcomes of managed care. Arch Gen Psychiatry 1996; 53:870–877 3. The Center for Health System Change: PCPs reporting that they cannot always or almost always obtain selected services for their patients when medically necessary, June 1998, website: http:// www.hschange.com 4. Williams J, Rost K, Dietrich AJ, et al: Primary care physicians’ approach to depressive disorders. Arch Fam Med 1999; 8:58–67 5. Goldberg D, Huxley P: Mental Illness in the Community: The Pathway to Psychiatric Care. London, Tavistock Publications, 1980 6. Pincus HA: Patient-oriented models for linking primary care and mental health care. General Hospital Psychiatry 1987; 9:95–101
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7. Zarin DA, Pincus HA, West JC, et al: Practice-based research in psychiatry. Am J Psychiatry 1997; 154:1199–1208 8. Zarin DA, Pincus HA, Peterson BD, et al: Characterizing psychiatry with findings from 1996 national survey of psychiatric practice. Am J Psychiatry 1998; 155:397–404 9. Pincus HA, Zarin DA, Tanielian TL, et al: Psychiatric patients and treatments in 1997: findings from the American Psychiatric Practice Research Network. Arch Gen Psychiatry 1999; 56:441–449 10. Katon W, Van Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995; 273:1026–1031 11. Little DN, Hammond C, Kollisch D, et al: Referrals for depression by primary care physicians: a pilot study. J Fam Pract 1998; 47:375–377 12. Grembowski DE, Cook K, Patrick DL, et al: Managed care and physician referral. Med Care Res Rev 1998; 55:3–31
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The Study of Outpatient Referral Patterns was conducted in 1998 to examine the nature of the communication relationship between psychiatrists and primary care physicians regarding outpatient referrals. Nationally representative psychiatrists were surveyed (N⳱542) regarding their aggregate experience with outpatient referrals from non-psychiatric physicians in the previous 60 days. Data regarding frequency and type of information and mode of communication were gathered. Results indicate that primary care physicians represent a significant source of referrals to psychiatrists and that psychiatrists are generally satisfied with the communication interface with the referring physicians. Psychiatrists’ level of satisfaction was related to the quantity and quality of information provided by referring physicians. (Psychosomatics 2000; 41:245–252)
P
rimary care physicians have long been a significant source of referrals for psychiatrists.1 However, the dramatic changes in the U.S. health care system, particularly the growth of managed care programs that employ selective contracting, may have modified the nature of the consultative process.2 Data from the Center for Health System Change Community Tracking Study3demonstrate that primary care physicians perceive high-quality mental health care to be more difficult to obtain than non-mental health medical care. There are also recent indications that primary care physicians report dissatisfaction with their referrals to psychiatrists. Williams et al.4 reported that in a survey of primary care physicians regarding the treatment of depression, physicians were less satisfied with mental health referrals made to psychiatrists, psychologists, or social workers compared with other medical specialties. These data also indicate that primary care physicians’ ratings of satisfaction with referrals to psychiatrists were somewhat
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lower than the ratings regarding referrals to psychologists or social workers. Given this context, the present study aims to understand the nature of the referral process between psychiatry and primary care. In particular, we focused on examining the current communication interface (from the psychiatrists’ point of view) between psychiatrists and non-psychiatric physicians with regard to outpatient referrals and measured psychiatrists’ satisfaction with the referral and the communication process with non-psychiatric physicians. We Received April 15, 1999; revised June 29, 1999; accepted September 14, 1999. From the American Psychiatric Association; Department of Psychiatry, University of Pittsburgh Medical School, and RAND; the Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH; the Division of General Internal Medicine, South Texas Veterans HealthCare System: The University of Texas Health Science Center, San Antonio, TX; and Center for Research Strategies, Denver, Colorado. Address reprint requests to Ms. Tanielian, RAND, 1200 South Hayes Street, Arlington, VA 22202-5050; email: [email protected] Copyright 䉷 2000 The Academy of Psychosomatic Medicine.
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Referral to Psychiatrists began by conceptualizing the referral process to identify opportunities for interchange between physicians. According to the Goldberg and Huxley model,5 a patient must pass through a number of filters in order to arrive at the specialized mental health care level. First, the patient must decide to seek help. Then, the “second filter” occurs in the office of the primary care provider (PCP), and the outcome depends on the PCP’s ability to recognize psychiatric disorders, to integrate them with the patient’s total profile of health care needs, and to assess the need for specialized mental health services. If the PCP decides that the patient requires specialized care (“third filter”), the PCP must recommend the type of specialized care the patient should seek. Several factors influence the outcome of the third filter, including the characteristics of the patient, community, provider, and system.6,7 This paper focuses on the third filter and its issues such as the relationship and influence at the provider and system levels, particularly with regard to how providers interact at the referral interface (labeled as the “communication interface”) for specialized mental health care from a psychiatrist. In designing this study, we identified several factors from the psychiatrists’ point of view that impinge on the communication interface between primary care physicians and psychiatrists. These factors include patient factors (e.g., the diagnosis, the patient’s relationship with the primary care physician, the patient’s beliefs/attitudes, and the perceived goals of mental health care); health care environment factors (e.g., health plan, setting, community resources, availability/accessibility of care); and physician factors (knowledge/skills, pressures, perceived goals, time/ economic pressures, collegial relationship with one or more patients). The success of the communication interface will depend on how these factors interact and the compatibility between primary care physician factors and psychiatrist factors. Our research asked the following questions. How do the providers who make and receive referrals interact and what are the outcomes (e.g., satisfaction, treatments provided, etc.) for the physician and patient? How can systems and providers be influenced to interact more successfully and improve patient care? This report describes the first phase in our efforts to understand this communication interface. Data are presented on psychiatrists’ aggregate communication experiences with referrals from non-psychiatric physicians. The data we present describe current experiences from the psychiatrists’ point of view and generate additional hypotheses regarding factors that may affect the communication interface. 246
METHODS Study Population This study uses data collected from the American Psychiatric Association’s (APA) Practice Research Network (PRN). At the time of the study, the PRN consisted of 542 APA members who report spending at least 15 hours per week in direct patient care. Forty-two percent of PRN members had been randomly selected and invited to join the network; the remaining members are self-identified volunteers. The randomly selected cohort was recruited from among respondents to the 1996 National Survey of Psychiatric Practice. The survey was conducted among a random sample (n⳱1,481) of the 40,866 psychiatrist members of the APA at that time (representing approximately 70% of the psychiatrists in the United States). Of those deemed eligible (i.e., still in psychiatric practice; n⳱1,375), 970 psychiatrists (70.55%) responded, and 693 (50.40%)of them met the PRN eligibility criteria.8 The selfidentified volunteer component of the network was recruited through advertisements in APA publications and at national psychiatric conferences.7 Analytic comparison of 78 sociodemographic and practice variables (e.g., sex, age, board certification in general and/or child psychiatry, and practice variables, such as setting and patients’ type of health plan) have shown that PRN members are representative of the full APA. Only 4 variables showed statistically significant differences: the percentage of psychiatrists who were board certified in geriatric psychiatry, the percentage affiliated with a medical school, the percentage residing in the Midwest, and the percentage of those who indicated “other” or “mixed race.” Furthermore, we compared univariate distributions for 33 demographic, clinical, and treatment variables to identify any differences between patients of volunteers vs. randomly selected PRN members. Only 2 variables were significantly different (P⳱ 0.05): use of psychotherapy without medications (17.1% random vs. 11.0% volunteer) and the mean number of medications prescribed per patient (1.9 random vs. 2.2 volunteer). Given the few statistical differences, the 2 groups were combined for our analyses. The PRN will continue to expand over the next several years and the proportion of randomly selected members will increase over time, thereby enhancing the network’s representativeness.7 All PRN members were asked to participate in the Study of Outpatient Referral Patterns, a cross-sectional, observational study. Of the 542 sampled, 534 were eligible Psychosomatics 41:3, May-June 2000
Tanielian et al. for participation. Eight psychiatrists were ineligible because of retirement, closing of practices, or insufficient clinical hours. Of those who were eligible, 435 (81.5%) completed the study. Other publications have described the rationale and infrastructure of the PRN, the professional characteristics of psychiatrists, and the characteristics of their patients.7–9 PRN members spend an average of 32 hours providing direct patient care and treat an average of 43 patients during a typical work week. PRN members report spending a little over half their patient care time in an office practice (54%, see Table 1). The results presented in this article are based on psychiatrists who spend at least some patient care time in an outpatient setting (95%; n⳱413) and who received at least one new outpatient referral in the past 60 days (82%; n⳱340) Data Sources and Measures Psychiatrists were asked to complete a 10-item selfreport survey. The survey was designed by a multidisciplinary panel that included PCPs and mental health specialists. The survey contained several questions regarding the frequency and nature of new outpatient referrals during the previous 60 days. For this study, referral is defined as “any new outpatient directed to a psychiatrist for any psychiatric purpose” (e.g., for consultation, psychotherapy, psychopharmacology, or other treatment) and whether the recommendation TABLE 1.
Characteristics of the practice research network respondents (Nⴔ435)
Demographic
% Psychiatrists
% Male Mean age White, non-Hispanic International medical graduates Board certified in psychiatry Patient Care Setting Office practice Hospital Clinic/outpatient facility Staff/group model HMO Other
66.4 49.5 years 73 15 72 % of Time 54 25 14 1 7 % Psychiatrists
Spend any direct patient care time in an outpatient setting Received new outpatient referral from non-psychiatric physician in past 60 days
95 82
* Percentages may add to more than 100% because of rounding
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to the patient was general (“You should seek psychiatric care for this mental health issue.”) or specific (“You should see Dr. Jones for medication.”). The survey focused specifically on new outpatient referrals that involved a nonpsychiatric physician anywhere in the referral process. The survey also gathered information on the psychiatrists’ experiences and satisfaction with the referral and communication process with non-psychiatric physicians. In particular, data were collected on the frequency and source of outpatient referrals, the types of information received from the referring physician before the first visit, the frequency of communication or information provided by the referring physician, and the type and frequency of feedback given to the referring physician. Response choices for satisfaction with communication were “poor,” “fair,” “very good,” “excellent,” and “can’t rate.” For nature and frequency of communication choices were “never,” “almost never,” “sometimes,” “often,” and “always.” Data were also collected on whether confidentiality concerns influenced the exchange of treatment information between the psychiatrist and non-psychiatric physician. In addition, the study gathered information on psychiatrists’ overall satisfaction with the communication process for referrals with non-psychiatric physicians. Implementation Survey materials were mailed to all PRN members. Before the first mailing, a study alert was faxed or mailed to all PRN members. Post card and fax reminders were sent to encourage the submission of survey responses. Non-respondents to the first mailing were sent a second mailing 3 weeks later. Thank-you letters and a token gift were sent to all PRN members who completed the study. All methods for data collection were approved by the American Psychiatric Association Institutional Review Board. Analytic Methods Summary statistics to describe referral patterns between psychiatry and non-psychiatric physicians were generated. Because psychiatrists who receive a higher number of referrals from non-psychiatric physicians may be more satisfied with the referral process, we partitioned psychiatrists according to the number of new outpatient referrals for analyses. Psychiatrists were divided into three groups (low, moderate, and high), according to the number of new outpatient referrals received during the previous 60 days. 247
Referral to Psychiatrists The “low referrals” received fewer than 5, “moderate referrals” received between 5 and 19, and “high referrals“ received 20 or more. In addition, to examine whether the psychiatrists more satisfied with non-psychiatric referrals might use verbal forms of communication, we categorized psychiatrists according to their satisfaction level with the overall communication process. Psychiatrists who rated the overall quality of interactions with nonpsychiatric physicians “very good” or “excellent” were included in the “very satisfied” group. Psychiatrists who rated the overall quality “poor” or “fair” were included in the “not satisfied” group. Potential relationships among the frequency of referrals, the psychiatrists’ satisfaction, and the types of communication received, and among the psychiatrists’ satisfaction and types of communication used were assessed with Chi-square tests. RESULTS Responding psychiatrists who spent time in an outpatient setting (n⳱413) indicated that they saw an average of 24 new outpatients during the previous 60 days (range⳱0– 160, median⳱16). Based on the psychiatrists’ report, an average of 42% of their new outpatients had a nonpsychiatric physician involved at some point in the referral process and 35.8% were directly referred to the psychiatrist by a non-psychiatric physician. The remaining results are presented for psychiatrists who received at least 1 new outpatient referral directly from a non-psychiatric physician during the previous 60 days (n⳱340). Figure 1 displays the percentage of patients referred directly to psychiatrists, sorted by physician specialty. As shown, 82% of the patients referred to psychiatrists by nonpsychiatric physicians were from primary care physicians. Forty-three percent of psychiatrists reported that they actively seek referrals or consultations from primary care physicians. Fifty-one percent of psychiatrists reported that they often or always receive the reason for the referral, 32.6% often or always receive the patient’s demographic information, and 26.2% often or always receive the patient’s medical history before their visit with the referred patient (See Table 2). Only 17.2% of psychiatrists reported that they often or always receive the patient’s treatment history, and 33.0% indicated that they often or always receive no information from the referring physician before the first visit. As shown in Table 2, a telephone call was the most 248
common mode of transmission of information from nonpsychiatric physicians regarding the patient, with 35.3% of psychiatrists reporting that they often or always receive information in this manner. Use of a standard referral/authorization form was the second most common mode of communication, with 18.8% of psychiatrists reporting that they often or always receive a copy of this form before the first visit. Psychiatrists Who Report Back to the Referring Physician Table 2 also details the proportion of psychiatrists who report sending information back to the referring physician after their evaluation by type and mode of communication. As noted, a majority of psychiatrists report often or always sending diagnostic (79.6%) and treatment (79.3%) information back to the referring physician. A letter was the most common form of transmission; 49.1% of psychiatrists reported often or always sending this form of communication after their evaluation of the patient. Almost two-thirds (63.8%) of psychiatrists reported never or almost never having been prevented by confidentiality concerns or patients’ request from sharing information that might help the other physician treat the patient. Thirty percent responded sometimes, and 4.5% of the psychiatrists responded as often having been prevented by confidentiality concerns or patient requests. FIGURE 1.
Percentage of patients referred directly to psychiatrists by physician speciality
Other/Speciality Unknown OB/GYN 5% 5% Medical/Surgical 8% General Pediatrics 9%
General/Internal 40%
Family Practice 33%
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Tanielian et al. Psychiatrists’ Satisfaction With Their Interactions With Primary Care Physicians Although 63.5% of psychiatrists reported that the accessibility/ availability of primary care physicians was very good or excellent, 68.5% reported that the communication with primary care physicians regarding follow-up for care was poor or fair (Table 3 shows the proportion of psychiTABLE 2.
atrists by level of satisfaction). The level of satisfaction with interactions was lowest for adequacy and sufficiency of patient information provided (69.7% of psychiatrists reported poor or fair). However, half (50.0%) of psychiatrists indicated that their level of satisfaction with the overall quality of interactions with primary care physicians was very good or excellent. No significant differences were observed among psy-
Characteristics of communication transfer (Nⴔ340 psychiatrists)
Type of information received from non-psychiatric physician Demographic Reason for referral Medical history Treatment history No information Mode of communication received from non-psychiatric physician Letter Telephone Standard form Copy of medical records In-person discussion Other (e.g., e-mail) Types of information sent to referring physician by psychiatrists Diagnostic information Treatment information Educational information Results of psychological or neuropsych tests Recommendations for specific actions/treatments Mode of communication used by psychiatrists to referring physician Letter Telephone Standard form Copy of medical records In-person discussion Other (e.g., email)
Never 16.1 3.0 8.1 9.5 10.7 Never 24.6 6.2 28.3 17.1 14.8 10.0 Never 0.3 0.3 6.0 15.4 0.9 Never 6.3 0.6 56.5 29.6 11.6 8.2
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 23.9 13.7 25.5 30.6 33.0
27.5 32.3 40.4 42.7 21.4
23.0 33.8 21.7 14.2 33.0
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 37.0 18.1 25.5 34.2 39.5 3.2
30.0 40.4 27.4 36.3 37.7 4.4
8.2 30.3 16.4 10.5 6.9 4.7
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 2.4 3.3 26.2 29.9 12.8
17.8 17.2 44.1 29.5 33.3
34.9 35.8 17.6 15.7 31.0
Percentage of Psychiatrists Reporting Almost Never Sometimes Often 22.9 9.5 16.7 25.1 30.5 2.1
21.7 43.9 11.6 24.8 42.4 2.4
23.5 35.9 10.3 12.7 13.7 2.1
Always 9.6 17.2 4.5 3.0 1.8 Always 0.3 5.0 2.4 1.8 1.2 1.5 Always 44.7 43.5 6.3 9.5 22.0 Always 25.6 10.1 4.9 7.9 1.8 0.9
* Percentages do not add up to 100% because of rounding
TABLE 3.
Psychiatrists’ satisfaction with experience communicating with non-psychiatric physician
Overall quality of interactions Accessibility/availability of non-psychiatric physicians Sufficiency of background patient-information provided Nonpsychiatric physicians’ communication of expectations Communication with nonpsychiatric physicians regarding follow-up care
Poor
Percentage of Psychiatrists Reporting Fair Very Good Excellent
5.3 3.8 19.7 19.4 30.0
42.4 30.0 50.0 47.6 38.5
35.9 37.9 21.5 26.2 19.4
14.1 25.6 6.5 3.5 4.4
Can’t Rate 0.9 1.2 1.2 2.4 6.5
* Percentages will not add to 100% because of missing data
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Referral to Psychiatrists chiatrists who received a low, moderate, or high number of referrals in the reporting of the frequency of receiving demographic, reason for referral, medical history, and treatment history from the referring physician (data not shown) (Table 4 shows the distribution of psychiatrists according to level of referrals). However, significant variation by level of referrals was observed in the reporting of the frequency of receiving different modes of communication. For example, psychiatrists who reported receiving a letter or receiving a telephone call from the referring physician varied by level of referrals (v2⳱15.8, df⳱8, P⳱0.045; 3.6%, v2⳱23.9, df⳱8, P⳱0.002; respectively). A higher proportion of psychiatrists who received a high level of referrals reported that they often or always receive a letter and a higher proportion of psychiatrists who receive a low level of referrals reported that they often or always receive a telephone call. Significant differences were also observed in the reported frequency of receiving information from the nonpsychiatric physician according to the psychiatrists’ reported level of satisfaction with the communication process (see Table 5). Psychiatrists who reported being satisfied with the overall communication with non-psychiatric physicians were more likely to report receiving a telephone call from the non-psychiatric physician before the patient’s first visit (v2⳱41.941, df⳱4, P⬍0.0001). Psychiatrists who were satisfied with the communication process were also more likely to report receiving information regarding the reason for referral, the patient’s medical history, and the patient’s treatment history before the first visit (v2⳱20.12, df⳱4, P⬍0.0005; v2⳱32.25, df⳱4, P⬍0.0001; v2⳱31.52, df⳱4, P⬍0.0001; respectively). Psychiatrists who were unsatisfied were more likely to report receiving no information (v2⳱38.195, df⳱4, P⬍0.0001). DISCUSSION Primary care physicians represent a major source of referrals to psychiatrists. Given the increasing complexity of psychiatric patients and the treatments they receive, it is TABLE 4.
imperative to understand the interface between primary care and psychiatry, particularly with regard to the various types of relationships psychiatrists and primary care physicians can have with regard to referrals and patient care.6 Overall, psychiatrists’ perceptions of communications with primary care physicians are positive. There appears, however, to be some inconsistency depending on the domain of communications measured. Psychiatrists also identify the inadequacy of information and communication from primary care physicians to psychiatrists as a major problem. This is especially true regarding previously provided medical and treatment history and communication of expectations. These data also indicate that psychiatrists who are most satisfied with the referral interface with primary care physicians are receiving more information regarding the patients that are referred to them. Psychiatrists who receive a high number of referrals tend to use written forms of communication. Practitioners with a high volume of patients in their practice may find it difficult to arrange schedules, telephone calls, etc. to establish in-person discussions. Written communications may provide a mechanism that is more effective and efficient for psychiatrists with a high volume of referrals. Study Strengths and Limitations Previous reports have demonstrated the generalizability of PRN findings to APA psychiatrists with regard to demographic and practice characteristics.2 However, generalizations regarding these data can only be made to psychiatrists who spend at least 15 hours per week providing direct patient care and who spend at least some time practicing in an outpatient setting. This represents approximately 95% of patient care time.7 These findings are also limited to the extent that they are based on physician-reported aggregate experiences. In particular, the validity of psychiatrists reporting back to referring physicians may be questioned. Responding psychiatrists may have exaggerated how much they reported back because of a social pressure to report communicating
Referral characteristics of study psychiatrists (Nⴔ340)
Level of New Outpatient Referrals Received
% of Psychiatrists
Number of Referrals
Low (fewer than 5 in past 60 days) Moderate (between 5 and 19 in past 60 days) High (20 or more in past 60 days)
33.1 44.8 22.1
mean⳱2.3, median⳱2 mean⳱9.4, median⳱10 mean⳱34.7, median⳱30
* Overall number of referrals: mean⳱12.7, median⳱8.0, range: 0-98
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Tanielian et al. with the referring physician more often than psychiatrists actually do. This study did not assess the role of the nonpsychiatric physician in the care of patients who self-refer to psychiatrists. Also, electronic interaction may be a growing mode of communication between physicians; however, this survey did not inquire specifically about electronic communication. This study did not assess the possible relationships among clinician, patient, system, and setting factors, all of which may have an important contribution to the success of the communication and referral interface in mental health. Implications and Future Research In general, psychiatrists reported that they are satisfied with the communication and referral interface with primary TABLE 5.
care physicians despite primary care physicians’ reports of dissatisfaction. We can only speculate why psychiatrists’ satisfaction is positive despite reports of insufficient information from primary care physicians. Psychiatrists may not expect communication back from referring physicians and may see it as a bonus when it does occur. Concerns with patient confidentiality, lack of direct doctor-to-doctor referrals caused by carve-outs, and the difficulty of timely contact by letter, telephone, or in-person all present barriers to successful communication between physicians. Although communication gaps between psychiatrists and primary care physicians may interfere with patient care (only 17.2% of psychiatrists report often or always receiving the patient’s treatment history before the first visit), these data indicate that communication occurs at some level. Thus, it
Variation in communication by level of psychiatrist satisfaction
Type of Information Received From Non-psychiatric Physician Demographic Satisfied psychiatrists Non-satisfied psychiatrists Reason for referral Satisfied psychiatrists Non-satisfied psychiatrists Medical history Satisfied psychiatrists Non-satisfied psychiatrists Treatment history Satisfied psychiatrists Non-satisfied psychiatrists No information Satisfied psychiatrists Non-satisfied psychiatrists
Never
Percentage of Psychiatrists Reporting Almost Never Sometimes Often
Always
Statistic (Chi-square, df, P-value)
6.3 9.9
11.6 12.2
14.0 13.4
11.9 11.0
7.2 2.4
11.25, df⳱4, P⳱0.0252
1.8 1.2
4.8 8.9
12.8 19.6
19.9 14.0
11.6 5.6
20.12, df⳱4, P⳱0.0005
2.7 5.3
8.9 16.6
19.9 20.5
15.7 5.9
3.6 0.9
32.25, df⳱4, P⬍0.0001
3.3 6.2
10.4 20.2
24.6 18.1
9.8 4.5
2.7 0.3
31.519, df⳱4, P⬍0.0001
7.7 3.1
22.6 10.4
8.9 12.5
10.7 22.3
0.6 1.2
38.195, df⳱4, P⬍0.0001
10.6 13.9
17.0 20.0
18.5 11.5
4.9 3.3
0.0 0.3
9.920, df⳱4, P⳱0.0418
1.8 4.5
5.3 12.8
17.8 22.6
21.4 8.9
4.2 17.7
41.941, df⳱4, P⬍0.0001
13.4 14.9
13.7 11.9
13.4 14.0
9.1 7.3
0.9 1.5
1.88, df⳱4, P⳱0.7563
8.7 8.4
15.3 18.9
17.4 18.9
7.5 3.0
1.5 0.3
11.015, df⳱4, P⳱0.0264
6.3 8.4
17.2 22.3
22.0 15.7
4.2 2.7
1.2 0.0
13.293, df⳱2, P⳱0.0099
18.5 23.5
4.9 8.6
3.7 14.8
14.8 4.9
3.7 2.5
10.864, df⳱4, P⳱0.0281
Mode of Communication Received from Non-psychiatric Physician Letter Satisfied psychiatrists Non-satisfied psychiatrists Telephone Satisfied psychiatrists Non-satisfied psychiatrists Standard form Satisfied psychiatrists Non-satisfied psychiatrists Copy of medical records Satisfied psychiatrists Non-satisfied psychiatrists In-person discussion Satisfied psychiatrists Non-satisfied psychiatrists Other (e.g., email) Satisfied psychiatrists Non-satisfied psychiatrists
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Referral to Psychiatrists will be important to improve the quantity and quality of the flow of information between psychiatrists and primary care physicians. Some authorities advocate that the on-site presence of mental health providers in primary care settings will improve communication and patient care.10 Because this is not always feasible, communication by in-person contact, email, telephone, or letter should be a priority for physicians, including psychiatrists seeking more physician referrals and more information regarding patients. It is also possible that psychiatrists present an overly favorable picture with regard to their own actions particularly, with regard to communicating back to the referring physicians (nearly 80% of psychiatrists reported often or always sending back information regarding the diagnosis and treatment of the patients) because this is not necessarily what primary care physicians report.4 It is important to acknowledge that the referral process is a two-way street. Previous studies have addressed the PCPs’ perspectives regarding the communication interface with referrals. However, the current study focuses only on the psychiatrists’ point of view. The data reported here characterize psychiatrists’ aggregate experience of receiving referrals from primary care physicians and what communication occurs at the interface.11 To follow up on these findings with patient-level data, the PRN is conducting a second phase survey to gather detailed patient-level data on the actual practices of psychiatrists in the referral interface. This second survey will
characterize the nature, frequency, and type of communication regarding specific patients who were referred by a non-psychiatric physician and examine variation in the patients’ demographics, clinical/diagnostic, treatment, and reimbursement characteristics. The PRN patient-level study is designed to complement efforts by other physician practice based-research networks, such as the Ambulatory Sentinel Practice Network and the Pediatric Research in Office Settings who have conducted similar studies to characterize the referral interface between primary and specialty care. In addition, studies such as the Physician Referral Study12 will help us understand the dynamics of the referral process to specialty care and the impact of health care system factors on outcomes. Ultimately, these data will inform all of the design of an educational intervention or development of new systems aimed at improving the quality of interactions, the level of physician satisfaction with the interface, and patient outcomes. Findings from this study were presented in part during the National Institute on Mental Health Conference “Interventions in Primary Care,” July 1998, in Baltimore, Maryland. Work on this article was supported in part by the John D. and Catherine T. MacArthur Foundation and the federal Center for Mental Health Services. The authors acknowledge the PRN members who participated in this study and the APA staff who contributed to the project, including Deborah A. Zarin, M.D., Eve Kupersanin, and Heather Cohen.
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7. Zarin DA, Pincus HA, West JC, et al: Practice-based research in psychiatry. Am J Psychiatry 1997; 154:1199–1208 8. Zarin DA, Pincus HA, Peterson BD, et al: Characterizing psychiatry with findings from 1996 national survey of psychiatric practice. Am J Psychiatry 1998; 155:397–404 9. Pincus HA, Zarin DA, Tanielian TL, et al: Psychiatric patients and treatments in 1997: findings from the American Psychiatric Practice Research Network. Arch Gen Psychiatry 1999; 56:441–449 10. Katon W, Van Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995; 273:1026–1031 11. Little DN, Hammond C, Kollisch D, et al: Referrals for depression by primary care physicians: a pilot study. J Fam Pract 1998; 47:375–377 12. Grembowski DE, Cook K, Patrick DL, et al: Managed care and physician referral. Med Care Res Rev 1998; 55:3–31
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