Co-author
Dr Asad Ali Khawaja MBBS
Resident, pediatric emergencies
Ministry of health, Kingdom of Saudi Arabia

Referral decision by a family physician has an enormous impact on the cost and quality of care that a patient receives^1-2. Family physicians usually make specialty referrals to obtain advice for clinically uncertain diagnostic evaluations or treatment plans that fall outside their scope of practice. High rates of referral to specialists may reflect excessive use of expensive resources, but it may be that lower referral rates reflect a family physician's lack of sensitivity to the needs of patients for specialist care. Appropriate referral to specialist care may lead to prompt diagnosis and treatment of conditions that are beyond the immediate expertise of a family physician; whereas, inappropriate referral may lead to a chain of events initiated by unnecessary testing and/or procedure³.

There is a sizeable variation in referral rates between family physicians, among different practices and different regions of countries⁴. In a survey from Alexandria, referral rates from primary care physicians to specialists was found to have a 6.6-fold variation among clinics and a 54.8-fold variation among individual general practitioners⁵.

It is reported from the UK that, each year 10 million new patients are referred from primary to secondary care⁶. Moreover, it has been reported that only 10 % or less of the patients are in need of specialist care, whereas 90 % or more could be looked after by family physicians in the primary health care setting⁷. Overall rate of referral by primary care physicians in medicare current beneficiary survey (MCBS) is approximately 10 percent8. In a survey of Israeli family practice, 10.5 % (1,140 of 10,896 visits) patients were referred to specialist care9; whereas, 8.4 % of office visits were referred in Alexandria⁵. Franks and Clancy¹⁰ used data from 1985-1992 National Ambulatory Medical Care Survey (NAMCS) which showed a 4.5 % referral to specialty care. Referral rate of 5.1 % was found by Christopher Forrest¹¹ in a survey of 141 family physicians that had about 35 thousand office visits and made more than 2,000 referrals in 87 practices located in 31 states during 1997-1999.

Referral rates show clear relationships to several factors. Shortell¹² reported third-party coverage and severity of illness as two important associated factors for more frequent referrals. Franks and Clancy¹⁰ identified male gender and health insurance as two key patient factors increasing the likelihood of referral to specialty care. Christopher Forrest et al¹³ also found a strong positive effect of insurance on referral rates. Christensen investigated more than seventeen thousand referrals from 141 general practitioners to specialists in Denmark which revealed that referral rate increased both with a better access to specialists and with an increasing number of consultations per practitioner per year¹⁴. Catherine O'Donnell also proved that, availability of specialist care does affect the referral rate¹⁵. A cross-sectional interview survey of 125 Family Physicians of Nova Scotia reported significant non-medical factors affecting referral decisions¹⁶. In another study, malpractice fear was associated with greater likelihood of referral¹⁷.

Several authors in the United Kingdom and United States have examined physicians' other reasons for consultation and referrals. These include diagnosis or confirmation of diagnosis; diagnosis and treatment recommendations; advice or treatment; treatment of a previous condition; reassurance of patient, relative, or referring physician; specific investigations or specialty procedure; routine specialty examination; referring physician's education; specific request by patient; medico-legal reasons^11,18-20.

Family medicine at King Khalid University Hospital demonstrates the key rolein providing optimal care for all employees and is a gateway for referral to specialty care. Referrals from employee's health clinic settings are of significant interest to administrators. It is of interest to have insight into up-to-date information on family physician's referral rates and to know which health related problems are managed predominantly by family physicians and therefore seldomly referred. High referral rates could increase the costs to the organization as well as increase the burden on specialty care. The present study aimed to analyze the referral patterns of King Khalid University Hospital employees from employee's health clinic to specialists by family physicians and compare these data between both sexes and Saudi nationals versus expatriates.

Design: This is a retrospective design using cross-sectional descriptive and multivariate co-relational analysis.

Setting: King Khalid University Hospital (KKUH) is a tertiary care teaching hospital of 860 beds having all the medical and surgical subspecialties, established in 1982 in Riyadh city, Kingdom of Saudi Arabia. It is essentially a tertiary referral centre but operates an active primary health care unit and a 24 hours emergency service. Shift work for staff working in emergency and for in-patients care is organized as three shifts per day, each of 8 hours. All full time employees working at KKUH are medically covered. In order to provide a comprehensive and integrated health service for the employees, hospital administration has introduced an employee's health clinic (EHC), which operates during working hours (7:30 AM - 4:30 PM) from Saturday till Wednesday. EHC at KKUH, involving well trained and highly qualified family medicine doctors also act as a gatekeeper to further services.

Although the vast majority of health problems of KKUH employees presented to EHC are managed by the family physicians themselves, a part of family physician's treatment of employees involve referrals. A referral system is one of the strategies to make the best use of specialist care. In this system, all patients should first be seen by primary health care physicians at EHC who decide whether a referral to specialty care is necessary, so that access to the specialist care is limited to those patients who are referred by their family physicians. In other words, access to specialty care is through the employee's health care clinic, except for emergency cases which employees can access directly through the accident and emergency department.

Study population: The total number of full time personnel employed during the six month study period was 3117. Data on the distribution of the hospital employees according to their work category, gender and nationality was obtained from the personnel department's computerized files.
Records of full time hospital staff attending to EHC over a period of 6 months from 1st July to 31st December, 2007 were reviewed. Records of referrals by a family physician to specialty care were selected for detailed analysis. We extracted the information of each with regard to their gender, nationality (Saudi nationals Vs Non Saudi / Expatriate) and diagnosis. Record of teaching staff (faculty members) was not reviewed due to their separate highly privileged health care clinic (VIP clinic).

Statistical analysis: We entered the data into a spreadsheet and processed it with SPSS-9 package. The diagnosis of the illness was coded according to the international classification of diseases (WHO, 10th Revision, Version for 2007). Our descriptive analyses include cross-tabulation of referrals and targeted specialty care. For this article, we merely present some summary information on the total number of referrals and rate of referrals across the targeted specialty. Multivariate logistic regressions predicting the likelihood that the patient had a referral during the study period were estimated to identify important predictors of referral.
Ethics: Approval of the hospital ethic committee was obtained for the study.

Definition of referral: Referral is defined as a process in which the treating physician at a lower level of the health service, who has inadequate skills by virtue of his qualification or fewer facilities to manage a clinical condition, seeks the assistance of a better equipped or specially trained person, with better resources at a higher level, to guide him in managing or to take over the management of a particular episode of a clinical condition in a beneficiary²¹.

During the study period of six months (July 1st - December 31st), a total of 4315 employees visited the employee's health clinic (EHC) and 301 were referred to various specialty care clinics, giving a referral rate of 6.98 %.

Monthly outcome of employees who visited EHC and break up of referrals with regard to gender and nationality is shown in Figures 1 and 2.
Fewer referrals during the month of September was due to the holy month of Ramadan (fasting month), when almost all Saudi nationals and half of the expatriates remain on official leave for about 10 days.

Figure 1 Outcome of employees, who visited employee's health clinic during July to December, 2007

Figure 2 Break up of referrals from employee's health clinic to specialty care by nationality and gender, during July to December, 20

Sick leave certificates were issued on 416 occasions to 377 employees during the study period of 6 months.

A higher proportion of Saudi nationals visited EHC, than expatriates, also population based referrals were higher among Saudis than expatriates. Episode based referral rate among expatriate females was higher than other subgroups of interest. Overall the population based referral rate was 9.66 % during the study period (Table 1).

The correlation of referrals among referred employees was not associated with gender (p = 0.237) or nationality (p = 0.969).

There were a variety of diagnoses of referred patients and because patient's diagnoses were diverse, they were tabulated according to the International Classification of Diseases (ICD 10th revision, version for 2007).

The common diagnostic category presented to EHC was acute upper respiratory infection (31%) followed by chronic problems (Diabetes Mellitus, Hypertension, Bronchial asthma; 12 %), diseases of the musculoskeletal system (9%), diseases of the digestive system (6 %), diseases of the ear and mastoid process (5%), diseases of the skin and subcutaneous tissue (3 %), diseases of the eye and adnexia (3%) and others.

The types of specialists to whom patients were referred from EHC were varied and the number of times each illness was selected for referral by EHC doctor is shown in Table 2. The specialists to whom employees referred most frequently were ophthalmologist (16.6%), Dermatologist (15.9%), General surgeon (14.3%), Otolaryngologist (11.6%) and Orthopedician (8.6%).

The percentage of the top three diseases referred to specialist care were; diseases of the eye and adnexia (82 cases and referred 50; referral rate of 61%), diseases of the skin and subcutaneous tissue (91 cases and referred 48; 53%) and diseases of the ear and mastoid process (131 cases and referred 35; 27%).

It is clear from review that the variation of referrals does exist worldwide and that a large proportion cannot be explained easily. However, until the underlying issues are better understood, the use of referral rates to measure the performance of a family physician will be misguided.

Overall referral rate from EHC to specialty care among KKUH employees in the present study is 6.98%, and appears to be lower than family practice in Israel's⁹, Alexandra5 and MCBS survey8 but higher than the NAMS survey¹⁰ and ASPN referral study by Christopher Forrest and others¹¹.

Population based referral rate of 9.66 % in this study of 6 months, was higher than MCBS8 (< 5%) and UK patients (13.9 % in a year) but much lesse than across the five US health plans22 (30 - 36.8% in a year).

The present study shows that Saudi nationals visit more frequently due to health related problems than expatriates. Population based referral rate in this study was higher among Saudi nationals than expatriates, which could be due to their pension-able appointments guided by different conditions of service; whereas an expatriate employee's contract is renewable on an annual basis. Hence, expatriates usually avoid administrative sanctions for renewal of contracts, on health grounds.

Although the proportion of female expatriates had fewer visits, they were higher among episode based referrals. Possible explanations for this finding is that the majority of females work as nurses and are exposed more to occupational hazards and had moderate to severe sprains or strains due to faulty techniques during lifting, moving or changing the position of patients.

Non-medical reasons for referrals were not assessed in this study. Medical reasons of referral were similar to those reported in Israel, Alexandria and elsewhere^5,9,11.

Although the most frequent health problems presented to EHC for consultation were acute respiratory tract infection followed by follow up of chronic problems (i.e. Diabetes, hypertension, bronchial asthma), diseases of the musculoskeletal system and diseases of the digestive system; the most referrals were made to ophthalmologists, dermatologists, general surgeons, otolaryngologists, orthopedicians, Obstetricians and gynecologists and dental surgeons. This shows that, family physicians were more likely to send patients with uncommon problems to specialists and retain those with the most common conditions. This finding highlights the responsible judgment of family physicians in recognizing the boundaries of their scope of practice. The types of specialist to whom the most referrals were made are almost the same as in Israeli's family practice, in Alexandria and in other studies^5,9,11.

In this study we found that the chance of referral to specialist care for a disease related to eye and adnexia is 61%, diseases of the skin and subcutaneous tissue 53 % and diseases of the ear and mastoid process 27%. This shows that, there is a need for further training in these subjects, so that a family physician can minimize the burden on these specialties.

Several limitations in our study's data source warrant consideration. First, we only studied referrals from the perspective of a source (office of a family physician) and did not review the perspective of a target (i.e., a physician receiving a referral). Secondly, the sample was restricted to visits made at EHC, excluding employees eligible (faculty/teaching staff and high rank administrators) for the VIP clinic, or employees referred to specialty care through the emergency department. Thirdly, the unit of analysis was the visit rather than the patient. The advantage of focusing on the visit is that family physician referral decisions can be examined rather than specialists. Fourthly, we could not study the variation of referrals among family physicians working in EHC. Fifthly, we could not source the opinion of family physicians about non medical causes of their referrals.

The author wishes to thank the management of the hospital for providing updated information of employee's distribution in the hospital.

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