Specialty referral communication and completion in the community health center setting.
ABSTRACT Parent and provider disagreement about children's care at the time of specialty referral may lead to incomplete referral, ie, not attending a specialty visit when referred. This study's objectives were first to assess parent-provider correlation in perspectives on referral necessity, seriousness of child's health problem, and parental understanding of referral among children referred to pediatric specialists, and second to assess whether these perspectives are associated with incomplete referral.
Two months after specialty referral, parents and primary care providers completed a survey rating referral necessity, seriousness of problem, and parental understanding on a 4-part scale ("definitely yes" to "definitely no"). Parents were surveyed by telephone; providers completed one self-administered survey per referral. Using z tests and Pearson correlation coefficients, we summarized parent-provider agreement about referral necessity, seriousness of problem, and parent understanding. We applied logistic regression to test associations of parent and provider ratings for each variable with incomplete referral.
A total of 299 (60.0%) of 498 matched parent and provider surveys were included in the analysis. Parents had low correlation with providers in perspectives of referral necessity and seriousness of problem. Parents reported that referral was necessary more often than providers, and providers underestimated parents' self-reported understanding of the referral. Nearly 1 in 3 children had incomplete referral, and both parent and provider reports of lower necessity were associated with incomplete referral.
Parents and providers hold divergent perspectives on referral necessity and seriousness of children's health problems; these perspectives may impact rates of incomplete referral. Improving communication around specialty referral might reduce incomplete referral.
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ABSTRACT: OBJECTIVE:To describe racial differences in use of specialty care among children with autism spectrum disorder.METHODS:We identified patients ages 2 to 21 years with an International Classification of Diseases, Ninth Revision code of autism (299.0) seen from 2000 to 2011 at a major academic health center by using a research patient data repository and determined rates of specialty provider visits and procedures by race. We then used logistic regression to determine the associations of rates of subspecialty visits and procedures with race and ethnicity, controlling for gender, age, and payer type.RESULTS:We identified 3615 patients (2935 white, 243 Hispanic, 188 African American, and 249 other). The most striking differences were in use of gastroenterology (GI)/nutrition services. Nonwhite children were less likely to use GI/nutrition specialty providers (African American, odds ratio = 0.32 [95th percentile confidence interval: 0.18-0.55]; Hispanic, 0.32 [0.20-0.51]; other, 0.56 [0.34-0.92]) as well as neurology (African American, 0.52 [0.33-0.83]; Hispanic, 0.40 [0.27-0.59]) and psychiatry/psychology (African American, 0.44 [0.27-0.72]; Hispanic, 0.60 [0.41-0.88]; other, 0.62 [0.38-0.99]). Nonwhite children were less likely to have had GI studies: colonoscopy (African American, 0.23 [0.10-0.53]; Hispanic, 0.26 [0.14-0.50]), endoscopy (African American, 0.31 [0.16-0.58]; Hispanic, 0.27 [0.16-0.46]; other, 0.53 [0.31-0.90]), and stool studies (African American, 0.49 [0.30-0.91]). Hispanic children had lower rates of neurologic and other testing: EEG (Hispanic, 0.53 [0.35-0.78]), brain MRI (African American, 0.37 [0.22-0.63]; Hispanic, 0.62 [0.42-0.90]), sleep study (Hispanic, 0.18 [0.04-0.76]), and neuropsychiatric testing (Hispanic, 0.55 [0.32-0.96]).CONCLUSIONS:We found racial and ethnic differences among children diagnosed with autism in use of care and procedures. Possible explanations for these findings include differences in presentation, referral rates, or referral follow through.PEDIATRICS 06/2013; 132(1). DOI:10.1542/peds.2012-3886 · 5.30 Impact Factor
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ABSTRACT: To explore medical home attributes of community health centers (CHCs) that provide care to low-income children nationwide compared to other providers for the poor. Cross-sectional study of children aged 0 to 17 years in the Medical Expenditure Panel Survey (MEPS; 2003 to 2009) who resided in families living at <200% of the federal poverty level (FPL) and had visits to a primary care setting. CHC visits were defined as a visit to a neighborhood/family health center, rural health clinic, or community health center. Independent measures included provider type, age, gender, race/ethnicity, insurance, FPL, number of parents at home, language, maternal education, health status, and special health care need. Dependent measures included 4 medical home attributes: accessibility, and family-centered, comprehensive, and compassionate care. CHCs typically serve low-income children who are publicly insured or uninsured, come from racial/ethnic minority groups, and have poorer health status. Eighty percent to 90% of parents visiting both CHCs and other primary care providers rated high levels of family-centered, comprehensive, and compassionate care. However, CHCs had a 10% to 18% lower rating of accessibility (after-hours care, telephone access) even after controlling for sociodemographic characteristics. Racial/ethnic disparities existed at both settings, but these patterns did not differ between CHCs and other settings. On the basis of parental reports, CHCs received similar ratings to other primary care providers for family-centered, comprehensive, and compassionate care, but lower ratings for accessibility. Further studies should examine strategies for practice transformation in CHCs to improve patient satisfaction and accessibility to optimize child health outcomes.Academic pediatrics 09/2013; 13(5):436-42. DOI:10.1016/j.acap.2013.06.006 · 2.23 Impact Factor
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ABSTRACT: Using nationally representative data from the United States, this paper analyzed the effect of a state's medical malpractice environment on referral visits received by specialist physicians. The analytic sample included 12,839 ambulatory visits to specialist care doctors in office-based settings in the United States during 2003-2007. Whether the patient was referred for the visit was examined for its association with the state's malpractice environment, assessed by the frequency and severity of paid medical malpractice claims, medical malpractice insurance premiums and an indicator for whether the state had a cap on non-economic damages. After accounting for potential confounders such as economic or professional incentives within practices, the analysis showed that statutory caps on non-economic damages of $250,000 were significantly associated with lower likelihood of a specialist receiving referrals, suggesting a potential impact of a state's medical malpractice environment on physicians' referral behavior.Health Economics Policy and Law 03/2013; DOI:10.1017/S1744133113000157 · 1.33 Impact Factor