PCPs rely on subjective factors when making surgical referrals

Primary care physicians typically use subjective factors when making surgical recommendations, contrasting the evidence-based practice for prescription recommendations, according to the results of a qualitative study in JAMA Network Open.

Anusha Naik, a medical student at the University of Pennsylvania Perelman School of Medicine, and colleagues wrote that, though they routinely use objective data when recommending prescription drugs, it is unclear what evidence physicians use when making surgical recommendations.

“Primary care physicians (PCPs) initiate more than 51 million referrals annually. With substantial differences in practice patterns, management of the referral process is critical to facilitate advances in patient satisfaction, population health, and cost containment,” the researchers wrote. “Given the variation in quality across surgeons and hospitals in the US, referrals for high-quality surgical care provide an opportunity to improve patient care. Although data on surgeon and hospital performance are publicly available for clinicians at the time of referral decisions, it is not clear if and how such data are applied.”

The researchers compared the factors that physicians considered when making recommendations for prescription medications vs. referral recommendations to hospitals or specific surgeons.

For the qualitative study, Naik and colleagues interviewed 21 PCPs — 14 of whom were women — from a large primary care network in the Northeast United States between April 26, 2021, and May 18, 2021.

For prescription medication recommendations, all the physicians reported using patient attributes and evidence-based decision support tools.

For surgical referrals, though, the physicians reported that they largely relied on personal beliefs about surgical quality, perceived convenience and their own professional training and experience. They said that limitations of existing data on surgical quality was a barrier to using such information when making surgical recommendations.

“When probed on how they determine surgeon and hospital quality, PCPs reported using anecdotal interactions due to existing data limitations,” Naik and colleagues wrote. “This finding is problematic because surgeon or hospital reputation and measured quality are poorly correlated.”

One way to improve the surgical referral process, the researchers wrote, is to develop decision support tools (DSTs) like the ones used for medication selection.

“To be effective, DSTs for surgical referrals will have to overcome PCP concerns regarding data reliability, availability, and accessibility,” they wrote. “Given the variation in surgical outcomes across hospitals and surgeons, data-driven referral practices may improve surgical outcomes by encouraging PCPs to refer to objectively higher-quality clinicians.”

Naik and colleagues wrote that their findings highlight the possibility of improving surgical outcomes by introducing reliable, accessible data “as an imperative step in the surgical referral process.”

“This qualitative study suggests that PCPs’ common practice of using DSTs for medication selection may be transferable to the surgical referral process,'” they wrote. “In the absence of objective data, PCPs rely on professional experiences, personal beliefs about quality, and convenience to guide surgical recommendations. Surgical outcomes data with tools to aid in decision-making may disrupt current physician referral practices and improve access to high-quality surgical care.”