What is an "appropriate" referral?

One of the cornerstones of my business is the concept of generating appropriate referrals, as opposed to just getting more butts in waiting room seats. Uninformed or ill-informed referrals are counter-productive for everyone involved: specialists waste time seeing patients that do not truly need their services, patients waste time seeing specialists, and the cost of treating the patients' non-surgical condition increases.

But how does one determine which referrals are appropriate and which are not?

The authors of a recent article published in The Foot Journal evaluated foot and ankle referrals based on whether or not the condition directly led to surgical treatment. (Hewitt. A prospective audit of referral patterns to a dedicated Foot and Ankle surgical service. Foot. 1 December 2011 (volume 21 issue 4 Pages 166-171)  They determined that only 65% of referrals were appropriate based on this criteria. I found it interesting to note that 13% of the referred patients had a condition that warranted no treatment at all from the specialists.

In an ORTHOSuperSite summary of the above journal article, Dr. Carol Frey published an interesting perspective. She argues that surgical rates are not an accurate measure of referral appropriateness. "The best way to judge an appropriate referral is by the outcome," she writes. "Since managed care does not have disparate charges for similar levels of care, it seems that any referral that can obtain a good outcome, is appropriate. Another way to judge an appropriate referral is by cost savings. One recent study in California pointed out that 59% of referrals for foot and ankle care were to podiatrist (as opposed to an orthopedic foot and ankle specialist), and although they cost less per individual treatment, they had significantly more treatments, procedures and visits associated with treatment."

Regardless of the criteria on which we judge appropriate referrals, I think we can all agree with the study authors: "Referral pathways could be improved by greater communciation between [general practitioners] and foot and ankle service with the construction and implementation of referral guidelines which would enhance the referral and treatment pathway to the service.”

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