Paediatrician perceptions of patient referral and dischargeGary L. Freed A B , Erin Turbitt A , Sarah Gafforini A and Marina Kunin A
A Health Systems and Workforce Unit, Centre for Health Policy, Melbourne School of Population and Global Health, Level 4, 207 Bouverie Street, The University of Melbourne, Vic. 3010, Australia. Email: firstname.lastname@example.org; email@example.com; firstname.lastname@example.org
B Corresponding author. Email: email@example.com
Australian Health Review - https://doi.org/10.1071/AH16077
Submitted: 4 April 2016 Accepted: 23 August 2016 Published online: 26 September 2016
Objective The aim of the present study was to determine the factors involved in the decision of paediatric specialists to discharge patients back to their primary care provider following referral. Return of patients to primary care, when medically appropriate, is essential to provide efficient care to children given the limited workforce of paediatric subspecialists in Australia.
Methods Data were compiled from a self-completed mail survey of all paediatricians in five specialties at two children’s hospitals in Melbourne (n = 81). Analysis involved frequency distributions and descriptive analyses, followed by bivariate analyses to determine the differences, if any, among respondents based on the demographic variables collected.
Results The response rate was 91%. Most paediatricians (73%) believed that at least sometimes referrals were for a condition general practitioners (GPs) should be able to manage themselves. However, only 36% reported that they frequently or almost always provided the referring GP with information on how to care for the particular condition without a referral. Concerns regarding whether a patient would receive required care following discharge were felt to be important by most paediatricians. Further, many paediatricians reported that their discharge decision is affected by concerns it would be too complicated to arrange for a GP to take over the care of a patient.
Conclusions Understanding the factors involved in the referral process and the decision to discharge patients from speciality care clinics to primary care is essential to develop strategies to address long waiting times. Ensuring appropriate referral of children involves the participation of GPs, parents and specialists.
What is known about the topic? Most paediatric subspecialists practice in paediatric hospitals, where there is a sufficient volume of patients requiring their services. There have been reports across Australia of increased referrals to general and subspecialist paediatricians, with subsequent increases in waiting times and difficulties accessing timely care for children. There are anecdotal reports of inappropriate referrals to paediatric subspecialty clinics.
What does this paper add? There is broad sentiment among paediatric specialists that they receive many referrals from GPs without either a clear rationale for the referral and/or sufficient information regarding the clinical history of the patient. Few paediatricians report contacting the referring GP to obtain additional information. Paediatricians believe parents are a frequent driver of both necessary and unnecessary referrals.
What are the implications for practitioners? Understanding the factors involved in the referral process and the decision to discharge patients from speciality care clinics to primary care is essential to develop strategies to address long waiting times.
Additional keywords: general practice, paediatrics, parents, specialist.
References Van Cleave J, Gortmaker SL, Perrin JM. Dynamics of obesity and chronic health conditions among children and youth. JAMA 2010; 303 623–30.
| Dynamics of obesity and chronic health conditions among children and youth.CrossRef | 1:CAS:528:DC%2BC3cXitlCqtbs%3D&md5=65b62022c554b725d4032308c6a916c7CAS | 20159870PubMed |
 Australian Institute of Health and Welfare. Australia’s health system. Australia’s health 2014. 2014. Available at: http://www.aihw.gov.au/australias-health/2014/health-system/ [verified 20 January 2016].
 Queensland Government, Queensland Health. Outpatient appointment waiting lists. 2014. Available at: https://www.health.qld.gov.au/goldcoasthealth/apptwaitingtimes/ [verified 20 January 2016].
 Freed GL, Sewell J, Spike N, Brooks P, Moran L. Changes in the demography of Australia and therefore general practice patient populations. Aust Fam Physician 2012; 41 715–19.
| 22962651PubMed |
 Freed GL, Spike N, Magin P, Morgan S, Fitzgerald M, Brooks P. The paediatric clinical experiences of general practice registrars. Aust Fam Physician 2012; 41 529–33.
| 22762075PubMed |
 Jiwa M, Arnet H, Bulsara M, Ee HC, Harwood A. What is the importance of the referral letter in the patient journey? A pilot survey in Western Australia. Qual Prim Care 2009; 17 31–6.
| 19281672PubMed |
 Piterman L, Koritsas S. Part 1. General practitioner–specialist relationship. Intern Med J 2005; 35 430–4.
| Part 1. General practitioner–specialist relationship.CrossRef | 1:STN:280:DC%2BD2MzhtFegtw%3D%3D&md5=8d46f6a39f3707c3ced2f02ae08de98bCAS | 15958116PubMed |
 Jiwa M, Dhakiwal S. Referral writer: preliminary evidence for the value of comprehensive referral letters. Qual Prim Care 2012; 20 39–45.
| 22584366PubMed |
 Smith P. Poor referral letters harming GP brand. Austr Doctor 2014. Available at: http://www.australiandoctor.com.au/news/latest-news/poor-referral-letters-harming-gp-brand [verified 20 January 2016].
 Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q 2011; 89 39–68.
| Dropping the baton: specialty referrals in the United States.CrossRef | 21418312PubMed |
 Ong SP, Lim LT, Barnsley L, Read R. General practitioners’ referral letters – do they meet the expectations of gastroenterologists and rheumatologists? Aust Fam Physician 2006; 35 920–2.
| 17099816PubMed |
 Stille CJ, Fischer SH, La Pelle N, Dworetzky B, Mazor KM, Cooley WC. Parent partnerships in communication and decision making about subspecialty referrals for children with special needs. Acad Pediatr 2013; 13 122–32.
| Parent partnerships in communication and decision making about subspecialty referrals for children with special needs.CrossRef | 23356961PubMed |
 Aarthun A, Akerjordet K. Parent participation in decision-making in health-care services for children: an integrative review. J Nurs Manag 2014; 22 177–91.
| Parent participation in decision-making in health-care services for children: an integrative review.CrossRef | 23406447PubMed |