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

Abstract

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.