[Referral by a general practitioner versus self-referral to a specialist practice. A comparison using chronic venous...

The gate-keeping role of general practitioners (GPs) is currently the topic of much debate in Germany. Currently it is possible for patients in Germany to see a specialist either through referral by their GP or directly through self-referral. To determine whether the gate-keeping role of GPs has a filtering effect, we compared patients referred by their GPs with self-referred patients presenting with suspected chronic venous insufficiency (CVI) to a specialist practice.

From September to December 2001, we prospectively recruited 316 patients seen for suspected CVI in a specialist practice for vascular surgery and phlebology. Symptoms and clinical findings were recorded using a standardized form.

58.2 % of patients were referred by their GPs. These patients were on average 6 years older and presented at a more advanced stage of disease than self-referred patients. No difference was found between patients with and without referral with respect to the symptoms reported or the therapy recommended by the specialist. CVI was excluded in 7.1 % of patients with a referral and in 6.8 % of those without a referral.

The majority of patients consulting a specialist were referred by their GP. The more advanced disease stage of these patients indicates that a filtering process occurs in referral by GPs. However, the share of patients without referrals in whom CVI could be excluded was low and not significantly different from that of patients with referrals. This indicates that misdiagnosis due to self-referral is relatively modest. A cost reduction effect in a gate-keeper system could therefore only be small.