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Referral of Children to Specialists in the United States and the United Kingdom
Christopher B. Forrest, MD, PhD;
Azeem Majeed, MD, MRCGP;
Jonathan P. Weiner, DrPH;
Kevin Carroll, MB, MFPHM;
Andrew B. Bindman, MD
Arch Pediatr Adolesc Med. 2003;157:279-285.
Objective To compare the rates and patterns of children's specialty referrals in the United States (US) and the United Kingdom (UK).
Design Retrospective cohort analysis of health care claims/encounter data obtained in 1996 (US) and 1997 (UK).
Setting Children in the US were selected from 5 managed health plans that used primary care physicians as gatekeepers: 2 health maintenance organizations and 3 point-of-service plans. Point-of-service plans allow patient self-referral at increased out-of-pocket costs. In the UK, the General Practice Research Database provided data from 211 general practices.
Participants Children, from birth to the age of 17 years, with no cost sharing for physician services in the US (n = 135 092) and who were registered with general practitioners, all of whom authorize patients' access to specialty care, in the UK (n = 221 312).
Main Outcome Measure Annual percentage of children referred to a specialist.
Results Across the 5 US plans, 18.6% to 28.8% of the patients per year were referred vs 8.7% of the patients per year in the UK sample. Referral rates were not significantly different between a health maintenance organization and a point-of-service plan administered by a single insurer. Compared with patients in the UK sample, those in the US plans were 1.9 times more commonly referred to medical specialists and 3.2 times more commonly referred to surgical specialists. There was considerable cross-national variation in specialty-specific referral rates for children with selected conditions.
Conclusions Children in US managed care plans are between 2 and 3 times as likely to be referred to specialists compared with counterparts in the UK. Although these referral rate differences are substantial, our findings cannot be construed to mean that the US referral rates are too high or that the UK rates are too low. The greater supply of specialists and higher expectations for direct access to specialty care in the US, compared with the UK, are likely explanations for these differences in children's specialty referral rates.
From the Department of Health Policy and Management, Health Services Research and Development Center, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Md (Drs Forrest and Weiner); the School of Public Policy, University College London (Dr Majeed), and the Office for National Statistics (Drs Majeed and Carroll), London, England; and the Division of General Internal Medicine, the Department of Medicine, University of California, San Francisco (Dr Bindman). Drs Forrest and Weiner are developers of the Adjusted Clinical Group system used to control for health status in some analyses in this study. The Johns Hopkins University has copyrighted this software and receives royalties from its sale, which are used toward ongoing developmental work. None of these royalties were used to fund this study.
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