The Referral from Family Practice to GI Specialty: The Concordance of Diagnosis and Propriety of Consultation

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Sangsulee Thamakaison
Dumrongrat Lertrattananon
Saisunee Tubtimtes
Taratip Pumkompol
Salika Somsri


Background: Appropriateness of the consultation for specialty is necessary in Primary care which resulted in positive or negative consequences for patients.There were lot of consultations from family medicine to medicine department especially gastroenterologists.  However, few studies have assessed the quality of referral between primary care physicians and GI specialists.

Objective: To study the appropriateness and quality of referrals between the two departments in the area of referral reasons, processes, and communications.

Methods: Cross-sectional descriptive study. 2,714 medical records of patients who were referred from Department of Family Medicine to Medicine between 1 January 2010 and 31 December 2010, 483 (17.8%) patients were randomly sampled and reviewed for  health problems, reasons and appropriateness of referral and concordance of diagnosis. Among these, 106 referrals to GI specialists were collected data by medical reviews and analyzed.

Results: The most consultation to gastroenterologists(n = 106; 21.95%) were viral hepatitis (30.6%), GI malignancy suspicion (20.4%), resistant dyspepsia (18.4%), cirrhosis (9.2%), resistant GERD (8.2%), unspecific chronic abdominal pain (4.1%) and others (9.2%; GI bleeding; abnormal liver function test; and patients’ preference 12.26%). However, 12.3% of referred cases had not been recorded the health problems intended to refer. Only 90 referred patients (84.9%) was seen by GI specialists. Moreover, gastroenterologists noted more details regarding history taking (33.3%), physical exam (16.7%) and investigations (65.6%) than primary doctors in outpatient documentation cards. There were disagreements in diagnoses between family physicians and specialists (n = 18;20%).The common lessons were: (1)  initial diagnoses as GERD but finally dyspepsia and vice versa; (2) initially suspected GI malignancy, finally just functional dyspepsia with one case diagnosed as Graves’ disease. For the referral groups that suspected GI malignancy (n = 20), there was only 50% concordance in diagnosis. Forty percent of referrals were inappropriate for reasons such as too early referral (n = 28; 77.8%; especially dyspepsia or suspected GI malignancy), delayed consultation (n = 1; 2.78%), and requiring more history taking, physical examination, investigations before referrals (7 cases; 19.4%). Most untrained GPs made unspecific diagnosis before consultation e.g. unspecific abdominal pain, fever with splenomegaly, positive stool occulted blood, dysphagia, weight loss and abnormal liver function tests. From the author’s view, 32.2 % of referred cases could be able to manage in primary care. Astoundingly, 83.3% of referrals were lack of communication between specialists back to primary care

Conclusions: There should be training programs for family physicians in common gastroenterological topics and implementing intervention for better referral communication to improve quality of referrals and patients’ cares.


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Thamakaison S, Lertrattananon D, Tubtimtes S, Pumkompol T, Somsri S. The Referral from Family Practice to GI Specialty: The Concordance of Diagnosis and Propriety of Consultation. Rama Med J [Internet]. 2015 Dec. 29 [cited 2024 May 21];38(4):294-306. Available from:
Original Articles


Sewell JL, Day LW, Tuot DS, Alvarez R, Yu A, Chen AH. A brief, low-cost intervention improves the quality of ambulatory gastroenterology consultation notes. Am J Med. 2013;126(8):732-8. doi:10.1016/j.amjmed.2013.02.017.

Jaturapatporn D, Hathirat S. Specialists' perception of referrals from general doctors and family physicians working as primary care doctors in Thailand. Qual Prim Care. 2006;14(1):41-8.

Donohoe MT, Kravitz RL, Wheeler DB, Chandra R, Chen A, Humphries N. Reasons for outpatient referrals from generalists to specialists. J Gen Intern Med. 1999;14(5):281-6.

Starfield B, Forrest CB, Nutting PA, von Schrader S. Variability in physician referral decisions. J Am Board Fam Pract. 2002;15(6):473-80.

Tabenkin H, Oren B, Steinmetz D, Tamir A, Kitai E. Referrals of patients by family physicians to consultants: a survey of the Israeli Family Practice Research Network. Fam Pract. 1998;15(2):158-64.

Ely JW, Kaldjian LC, D'Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97. doi:10.3122/jabfm.2012.01.110174.

Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care--a systematic review. Fam Pract. 2008;25(6):400-13. doi:10.1093/fampra/cmn071.

Pleyer C, Bittner H, Locke GR, et al. Overdiagnosis of gastro-esophageal reflux disease and underdiagnosis of functional dyspepsia in a USA community. Neurogastroenterol Motil. 2014;26:1163-71.

Vakil N, Halling K, Ohlsson L, Wernersson B. Symptom overlap between postprandial distress and epigastric pain syndromes of the Rome III dyspepsia classification. Am J Gastroenterol. 2013;108(5):767-74. doi:10.1038/ajg.2013.89.

Quigley EM, Lacy BE. Overlap of functional dyspepsia and GERD--diagnostic and treatment implications. Nat Rev Gastroenterol Hepatol. 2013;10(3):175-86. doi:10.1038/nrgastro.2012.253.

Xiao YL, Peng S, Tao J, et al. Prevalence and symptom pattern of pathologic esophageal acid reflux in patients with functional dyspepsia based on the Rome III criteria. Am J Gastroenterol. 2010;105(12):2626-31. doi:10.1038/ajg.2010.351.

Yarandi SS, Christie J. Functional dyspepsia in review: pathophysiology and challenges in the diagnosis and management due to coexisting gastroesophageal reflux disease and irritable bowel syndrome. Gastroenterol Res Pract. 2013;2013:351086. doi:10.1155/2013/351086.

The Gastroenterological Association of Thailand. Guideline for the management of Dyspepsia and Helicobacter pylori 2010.

The Gastroenterological Association of Thailand. Guideline for the management of gastroesophageal reflux disease.

Ali T, Roberts DN, Tierney WM. Long-term safety concerns with proton pump inhibitors. Am J Med. 2009;122(10):896-903. doi:10.1016/j.amjmed.2009.04.014.

Yang YX, Metz DC. Safety of proton pump inhibitor exposure. Gastroenterology. 2010;139(4):1115-27. doi:10.1053/j.gastro.2010.08.023.

Lodato F, Azzaroli F, Turco L, et al. Adverse effects of proton pump inhibitors. Best Pract Res Clin Gastroenterol. 2010;24(2):193-201. doi:10.1016/j.bpg.2009.11.004.

Fashner J, Gitu AC. Common gastrointestinal symptoms: risks of long-term proton pump inhibitor therapy. FP Essent. 2013;413:29-39.

Savarino V, Di Mario F, Scarpignato C. Proton pump inhibitors in GORD An overview of their pharmacology, efficacy and safety. Pharmacol Res. 2009;59(3):135-53. doi:10.1016/j.phrs.2008.09.016.

Abraham NS. Proton pump inhibitors: potential adverse effects. Curr Opin Gastroenterol. 2012;28(6):615-20. doi:10.1097/MOG.0b013e328358d5b9.

Sheen E, Triadafilopoulos G. Adverse effects of long-term proton pump inhibitor therapy. Dig Dis Sci. 2011;56(4):931-50. doi:10.1007/s10620-010-1560-3.

Shah NH, LePendu P, Bauer-Mehren A, et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One. 2015;10(6):e0124653. doi:10.1371/journal.pone.0124653.

Thai Association for the Study of the Liver. Thailand Practice Guideline for Management of Chronic Hepatitis B and C 2015.

O'Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med. 2011;171(1):56-65. doi: 10.1001/archinternmed.2010.480.