Such, Monica Van

AbstractRationale, aims and objectivesDiagnostic uncertainty is often encountered in a medical practice. Patients with ambiguous, uncertain, and undiagnosed problems are frequently referred for second opinions. Comparing referral diagnoses to final diagnoses provides an opportunity to determine how frequently final diagnoses vary and changes the direction of medical care.MethodsA retrospective study was done at a single academic medical center using a sample of 286 patients referred by physician assistants, nurse practitioners, and physicians from primary care practices from January 1, 2009 to December 31, 2010. Patients' referral and final diagnoses were compared and classified into 1 of 3 categories: referral diagnosis and final diagnosis the same, referral diagnosis better defined/refined, and referral diagnosis distinctly different from final diagnosis. Episode costs for the respective categories were calculated for the referral visit and services that occurred at our facility within the first 30 days.ResultsIn 12% (36/286) of cases, referral diagnoses were the same as final diagnoses. Final diagnoses were better defined/refined in 66% (188/286) of cases; but in 21% of cases (62/286), final diagnoses were distinctly different than referral diagnoses. Total costs for cases in category 3 (different final diagnoses) were significantly higher than costs for cases in category 1 (P = .0001) and category 2 (P = <.0001).ConclusionReferrals to advanced specialty care for undifferentiated problems are an essential component of patient care. Without adequate resources to handle undifferentiated diagnoses, a potential unintended consequence is misdiagnoses resulting in treatment delays and complications leading to more costly treatments.

The majority of quality measures used to assess providers and hospitals are based on easily obtained data, focused on a few dimensions of quality, and developed mainly for primary/community care and population health. While this approach supports efforts focused on addressing the triple aim of health care, many current quality report cards and assessments do not reflect the breadth or complexity of many referral center practices. In this article, the authors highlight the differences between population health efforts and referral care and address issues related to value measurement and performance assessment. They discuss why measures may need to differ across the three levels of care (primary/community care, secondary care, complex care) and illustrate the need for further risk adjustment to eliminate referral bias. With continued movement toward value-based purchasing, performance measures and reimbursement schemes need to reflect the increased level of intensity required to provide complex care. The authors propose a framework to operationalize value measurement and payment for specialty care, and they make specific recommendations to improve performance measurement for complex patients. Implementing such a framework to differentiate performance measures by level of care involves coordinated efforts to change both policy and operational platforms. An essential component of this framework is a new model that defines the characteristics of patients who require complex care and standardizes metrics that incorporate those definitions.