Pediatric Referral Rates Higher for Patients with Mental Health Diagnosis and Public Health Insurance

Suk­fong S. Tang, Kandyce Larson, William L. Cull.

Presented at the 2017 Pediatric Academic Societies Annual Meeting.

Background: Primary care doctors serve as the primary gateway through which subspecialty care is accessed. Little is known about what proportion of primary care visits by pediatric patients result in a referral and whether the increase in pediatric mental health visits over the last decades has been associated with a rise in referrals.

Objective: Investigate potential time trend and factors associated with referrals to other physicians by primary care doctors who provide visits to pediatric patients in office settings from 2004­2013.

Methods: Based on nationally representative non­hospital based ambulatory visit data from the 2004­13 National Ambulatory Medical Care Survey (NAMCS) for patients ages 0 through 18 (N=36,223 visits), multivariable logistic regressions were used to determine if survey year, insurance type (Medicaid/CHIP vs other), physician specialty (pediatrician vs other), nature of visit (problem­focused vs preventive), mental disorder diagnosis (ICD­9 codes 290­319 vs all other codes) and other patient and geographic characteristics affected the likelihood of referral by office­based primary care physicians. SPSS Complex Sample was used for all statistical analyses.

Results: Across all years, 2004­13, the portion of primary care office visits resulting in a referral to another physician averaged 5.4%, with no significant trends over time in referral rates. Visits by patients with public health insurance were more likely to result in a referral (AOR = 1.23, 95% CI: 1.05­1.43). Referrals were more likely for problem­focused visits (AOR = 1.31, CI: 1.12­1.52) and visits recorded with a mental disorder diagnosis (AOR = 1.87, CI: 1.52­2.30). Referrals also increased with age (AOR = 1.06, CI: 1.05­1.07). Patient gender and race/ethnicity, geographic region and metropolitan location did not affect the likelihood of referrals for the study population, nor did referring physician specialty.

Discussion: About 1 in 20 pediatric visits to physician offices resulted in a referral to another physician, and this rate remained stable over the 10­year period through 2013. Office­based primary care physicians were more likely to refer pediatric patients with public health insurance and those diagnosed with mental disorders to other physicians. Future studies can explore what additional factors may be associated with pediatric referrals and if referrals result in specialist/subspecialist care.