Patterns of Avoidable Pediatric General Surgical Referrals in a Rural State

Avoidable referral of children for outpatient pediatric general surgical evaluation creates inefficient healthcare utilization and unnecessary social and financial burdens for patients and families. We sought to characterize patient and referring provider characteristics associated with avoidable patient referrals for outpatient pediatric general surgical evaluation in a rural state.

This is a multisite retrospective cohort study including patients <18 y referred for outpatient pediatric general surgical evaluation between November 2017 and July 2024. Avoidable referrals were defined as patients who attended pediatric general surgery clinic but did not require an in-clinic procedure, imaging, operation, or clinic follow-up within 1 y. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between patient and provider factors and avoidable referral.

We included 5966 patients. One-quarter of referrals were identified as avoidable (n = 1402, 24%), with children 0-3 y more commonly identified as avoidable (P < 0.001). Umbilical hernia was the most common referral (n = 917); 39% of these were avoidable. Pectus excavatum was most likely to be avoidable (n = 188; 46% avoidable). Referrals for self-pay patients and those placed by emergency medicine providers were more likely to be avoidable [odds ratio 2.5, 95% Confidence Interval (CI) (1.5-4.1) P < 0.001; odds ratio 1.8, 95% CI (1.3-2.7) P < 0.001]. Avoidable referrals had a shorter average time from referral to outpatient pediatric general surgery clinic visit (34 versus 41 d, P < 0.001).

Nearly one-quarter of referrals were identified as avoidable. Development of targeted screening prior to outpatient pediatric general surgical evaluation may improve access to pediatric specialty care for indicated referrals and appropriate healthcare utilization.