Gatekeeping and referrals to cardiologists: general practitioners' views on interactive communications.

OBJECTIVE: Referrals to specialists have not been compulsory in Iceland since 1984. In 2006, referrals were again required for patients to receive reimbursement for part of the cost of appointments with cardiologists. The aim of this study was to explore GPs' attitudes to the referral system and possible professional gain by interactive communications. DESIGN: Cross-sectional questionnaire survey. SETTING, SUBJECTS, AND MAIN OUTCOME MEASURES: This is part of a larger study in 2007 on referrals from GPs to cardiologists. A questionnaire was sent to all working GPs in Iceland (n = 201 and responsible for 307 000 inhabitants) regarding the referral process, reasons for referrals, how often a response letter was received, and GPs' attitudes to the referral system. Responses from doctors working in rural areas were compared with those working in Reykjavik and nearby urban areas. RESULTS: The response rate was 63% (126 answers). The mean age of participants was 51; 89% were GP specialists and 60% worked in Reykjavik and nearby urban areas. Almost all respondents (98%) thought that report letters from cardiologists were helpful; 64% (95% confidence interval 53-73) thought that the recently introduced referral system did increase useful information that was beneficial to their patients. There was a statistically significant difference between colleagues working in rural areas and those working in Reykjavik and nearby urban areas regarding several aspects of the referral process. CONCLUSION: A referral system increases the flow of information and mutual communications between general practitioners and specialists to the benefit of the patients. The geographical location of the health care centre may be of importance regarding the value of the referrals.

[Gatekeeping and referrals from GPs to cardiologists: patients' opinions and registration of information flow]. / Tilvísanir til hjartalaekna. Vidhorf hjartasjúklinga og samskipti laekna.

INTRODUCTION: Formal referrals to medical specialists have not been required in Iceland since 1984. In 2006, however, referrals were required for patients to receive reimbursement for cardiologists fees. We studied patients' experiences and opinions on the referral process and explored the potential for quality improvement related to the increase in written communication between referring GPs and cardiologists. MATERIAL AND METHODS: Based on the electronic medical record system, referrals from GPs at Efstaleiti Health Care Center in Reykjavík to cardiologists between 1 June 2006 and 1 April 2007 were analyzed. A total of 344 patients were referred in this period. 245 agreed to participate in a questionnaire study about their opinions on the referral system and 209 (85%) completed the questionnaire. Relevant data on previous contacts with the health care center and received consultants reports from the years 2005-7 were extracted from the record system. RESULTS: Participating patients had a mean age of 72 years, male/female ratio 1:1. Ninety percent (95% C.I. 86-94) regarded the new referral system as more expensive and troublesome, but 89% (95% C.I. 85-94) wanted their cardiologist to send a formal report to the referring GP. The number of reports from cardiologists to the health centre's GPs increased from 43 in 2005 to 326 in 2007. CONCLUSION: Implementation of a referral system led to some dissatisfaction among the patients. On the other hand, it led to a major increase in the information exchange between GPs and cardiologists, in clear accordance with patients' wishes. It would be of interest to study the impact of the increased information flow influenced on the health care delivered.