Patient Perspectives on Delayed Specialty Follow-Up After a Primary Care Visit

Patients are often referred for important diagnostic tests or consultations after a concerning symptom or finding is identified at a primary care visit, but many referrals are delayed or not completed.

In this qualitative study, we reviewed electronic health record data to identify patients who did not have timely completion of a recommended referral at an academic primary care hospital-based practice and an affiliated community health center. Using semistructured interview guides, we interviewed 15 patients who did not complete a cardiac stress test within 28 days of a primary care visit associated with a diagnosis of chest pain, and 15 patients who did not complete a dermatology referral within 90 days of identification of a concerning skin lesion.

Thematic analysis highlighted 3 areas: 1) Patients desired clear communication to inform, equip and empower them, 2) Clinician-patient communication regarding a referral's rationale and value is key, and 3) Referral appointment processes were often challenging and/or delayed. Patients wished to understand why they were being referred, the specific value and reason for the referral, and what to expect. We developed a conceptual model describing how the initial clinician-patient communication may influence referral completion.

Failure to close diagnostic loops may be more likely when a patient is not given sufficient meaningful information, particularly if there is health system "friction" that reduces the patient's ability and ease to obtain a timely diagnostic referral appointment. Clinicians should use accessible language to communicate why a diagnostic referral is useful and important for the patient's health, and include a specific optimal time frame. The initial communication and the ease of the subsequent appointment booking both matter, and may compound or mitigate each other's effect. To reduce diagnostic referral failures and delays. clinicians should advocate for consistent appointment booking processes that systematically inform, equip, and empower patients with clear and meaningful referral information and timely appointments.