A quality improvement program to reduce unnecessary referrals for adolescent scoliosis

Adolescent idiopathic scoliosis (AIS) is a relatively common reason for referral to orthopedic surgery, but most referred patients do not require bracing or surgery. We developed a quality improvement (QI) program within the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, to reduce unnecessary specialty referrals for AIS.

The QI program consisted of physician education, decision support tools available at the point of care, and longitudinal feedback of data on physician referrals for AIS. Referral patterns in the 2-year postintervention period were tracked and compared with those of the 2-year preintervention period. Clinical characteristics of referred patients were compared through claims analysis and chart review.

Initial visits to orthopedic surgery for AIS declined from 5.1 to 4.1 per 1000 adolescents per year, a reduction of 20.4% (P = .01). Process control chart analysis showed a rapid change in referral patterns after the initiation of the program which was sustained over the 2-year postintervention period and demonstrated that 66 initial and 131 total AIS specialty visits were avoided as a result of the program.

A QI program consisting of physician education, decision support available at the point of care, and longitudinal data feedback led to a sustained reduction in unnecessary referrals for AIS. This program can serve as a model for other programs that seek to shift the locus of care from specialists to primary care providers.