Abstract
Objective
To compare the quality of referrals of patients with complex medical problems from
nurse practitioners (NPs), physician assistants (PAs), and physicians to general internists.
Patients and Methods
We conducted a retrospective comparison study involving regional referrals to an academic
medical center from January 1, 2009, through December 31, 2010. All 160 patients referred
by NPs and PAs combined and a random sample of 160 patients referred by physicians
were studied. Five experienced physicians blinded to the source of referral used a
7-item instrument to assess the quality of referrals. Internal consistency, interrater
reliability, and dimensionality of item scores were determined. Differences between
item scores for patients referred by physicians and those for patients referred by
NPs and PAs combined were analyzed by using multivariate ordinal logistical regression
adjusted for patient age, sex, distance of the referral source from Mayo Clinic, and
Charlson Index.
Results
Factor analysis revealed a 1-dimensional measure of the quality of patient referrals.
Interrater reliability (intraclass correlation coefficient for individual items: range,
0.77-0.93; overall, 0.92) and internal consistency for items combined (Cronbach α=0.75)
were excellent. Referrals from physicians were scored higher (percentage of agree/strongly
agree responses) than were referrals from NPs and PAs for each of the following items:
referral question clearly articulated (86.3% vs 76.0%; P=.0007), clinical information provided (72.6% vs 54.1%; P=.003), documented understanding of the patient's pathophysiology (51.0% vs 30.3%;
P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001), appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient to referring health care professional (67.8%
vs 41.4%; P<.0001). Referrals from physicians were also less likely to be evaluated as having
been unnecessary (30.1% vs 56.2%; P<.0001).
Conclusion
The quality of referrals to an academic medical center was higher for physicians than
for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology,
and adequate prereferral evaluation and documentation.
Abbreviations and Acronyms:
NP (nurse practitioner), PA (physician assistant)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: October 11, 2013
Footnotes
Grant Support: This work was financially supported by the Department of Internal Medicine, Mayo Clinic, Rochester, MN.
Identification
Copyright
© 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
