Psychological determinants of primary care requests for urgent outpatient appointments in elective referrals

Wide variations in referral practice from primary to secondary care have been observed. Clinical, demographic and referrer characteristics explain little of this variation. Patient psychological characteristics have been suggested as a potential explanation of this, biasing referral. The objective of this study is to investigate, in a relatively homogeneous population, the effects of patient's psychological distress and illness beliefs upon GP's requests for urgent outpatient assessment.

An inception cohort of 188 primary care referrals to a UK NHS Trust orthopaedic department for potential lower limb arthroplasty was assessed for disease-related pain and impairment, disability, psychological distress and illness beliefs. Associations between these and primary care requests for urgent outpatient appointments were estimated.

Twenty-two referrals (12%) requested an urgent outpatient appointment. Illness beliefs of greater personal control (OR 2.18, 95% CI 1.18, 4.05) but not psychological distress (OR 0.39, 95% CI 0.11, 1.36) were independently associated with urgent requests. Greater pain and impairment, co-morbidity and disability were univariately associated with this request. In both fully adjusted and parsimonious models, only patient beliefs of greater control and disability were independent determinants of this request for urgency.

Among patients referred for assessment for lower limb arthroplasty primary care practitioner's requests for urgent assessment are influenced by the patient's belief of how well they can control the symptoms, over and above clinical measures, suggesting patients coping better gain faster access. Global disability appears to be the main clinical determinant, which suggests GPs are making urgent referrals appropriately. There is no evidence of any bias on age, gender or socioeconomic status. This request for urgency leads to these patients waiting 2 months less for an outpatient appointment.