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Case-mix and variation in specialist referrals in general practice
Caoimhe O Sullivan1, Rumana Z Omar, Gareth Ambler
1University College London Hospital NHS Trust. caoimhe.osullivan@uclh.nhs.uk
Summary
Patient morbidity significantly influences specialist referrals more than age or sex. This study highlights that while morbidity is a key factor, much variation in general practice referrals remains unexplained.
Area of Science:
- Health Services Research
- General Practice
- Healthcare Management
Background:
- Variation in specialist referrals from general practice is a significant concern in healthcare.
- Previous studies have not comprehensively assessed the role of patient morbidity in explaining these referral variations within the UK.
- Understanding referral drivers is crucial for efficient healthcare resource allocation.
Purpose of the Study:
- To investigate the relative importance of patient age, sex, and morbidity in explaining variations in specialist referrals from general practice.
- To quantify the proportion of referral variation attributable to patient-level factors versus practice-level factors.
- To utilize the Johns Hopkins ACG Case-Mix System for a comprehensive assessment of patient morbidity.
Main Methods:
- A retrospective cohort study analyzed data from 202,000 general practices in the UK, covering over 1.1 million patients.
- Patient morbidity was categorized using the Johns Hopkins ACG Case-Mix System, incorporating diagnoses, age, and sex.
- Multilevel logistic regression models were employed to differentiate referral variation between practices and within practices.
Main Results:
- Patient morbidity emerged as a stronger predictor of specialist referrals compared to age and sex.
- Morbidity accounted for 30.4% of the total variation in referrals, whereas age and sex explained only 5.3%.
- Practice-level variations contributed approximately 5% to referral differences, indicating most variation occurs within practices.
Conclusions:
- Patient morbidity is a substantially larger driver of general practice referrals than age and sex, explaining nearly six times more variation.
- Despite the significant role of morbidity, approximately two-thirds of referral variation remains unexplained.
- Findings suggest caution when interpreting referral data, even after adjusting for demographic and morbidity factors, due to substantial unexplained within-practice variation.