Brief ReportBrief Report

Patient Perspectives on Delayed Specialty Follow-Up After a Primary Care Visit

Leonor Fernández, Dru Ricci, Amie Pollack, Maelys J. Amat, Meghan Drielak, Talya Salant, Gordon D. Schiff, Umber Shafiq, Scot B. Sternberg, James Benneyan, Mark Aronson, Erin Sullivan and Russell S. Phillips
The Journal of the American Board of Family Medicine January 2025, 38 (1) 139-153; DOI: https://doi.org/10.3122/jabfm.2024.240063R3

Article Figures & Data

Tables

  • Table 1.

    Demographics of Patients with Dermatology and Stress Test Referral Open Loops * (Total n = 305)

     Dermatology
    Open Loops
    (n = 143)    		Stress Test
    Open Loops
    (n = 162) 
    Mean age, n (SD) 57.9 (15.7) 55.8 (11.7) 
    Gender, n (%)     
     Male78 (55.5) 65 (40.1) 
     Female 65 (45.5) 97 (59.9) 
    Race, n (%)     
     White 112 (78.3) 78 (48.1) 
     Black 15 (10.5) 54 (33.3) 
     Asian 5 (3.5) 11 (6.8) 
     Other/Mixed race 6 (4.2) 16 (9.9) 
     Unknown 5 (3.5) 3 (1.9) 
    Ethnicity, n (%)   
     Hispanic 11 (7.7)  21 (13.0) 
     Non-Hispanic/Not  indicated 132 (92.3) 141 (87) 
    Preferred spoken language, n (%)    
     English132 (92.3) 138 (85.2) 
     Spanish2 (1.4) 9 (5.6) 
     Cape Verdean 2 (1.4) 5 (3.1) 
     Other 6 (4.2) 10 (6.2) 
     Unknown 1 (0.7)   
    Education, n (%)     
     Less than high school 6 (4.2) 11 (6.8) 
     High school 44 (30.8) 67 (41.4) 
     College 71 (49.7) 63 (38.9) 
     Unknown 22 (15.4) 21 (13.0) 
    Health insurance, n (%)     
     Commercial 68 (47.6) 73 (45.1) 
     Medicaid 26 (18.2) 47 (29.0) 
     Medicare 46 (32.2) 31 (19.1) 
     Unknown 3 (2.1) 11 (8.6) 
    Site of care, n (%)     
     Hospital based clinic136 (95.1) 147 (90.7) 
     Community health  center  7 (4.9) 15 (9.3) 

    • *Dermatology referrals for lesions suspicious for skin cancer not completed at 90 days, and stress test referrals for chest pain not completed within 28 days based on EHR clinician orders and EHR documented appointments.

    • Abbreviations: SD, standard deviation, EHR, electronic health record.

  • Table 2.

    Demographics of Interviewed Patients (Recruited from Patients with Open Loops)

      Dermatology
    Open Loop
    (n = 15)    		Stress Test
    Open Loop
    (n = 15)
    Mean age, (SD) 65.0 (11.9) 55.0 (9.8) 
    Gender,* n (%)   
     Male9 (60.0) 7 (46.7) 
     Female 6 (40.0) 8 (53.3) 
    Race-Ethnicity* n (%)     
     White 14 (93.3) 6 (40.0) 
     Black –3 (20.0) 
     Asian 1 (6.7) –
     Other/More than one  race –1 (6.7) 
     Hispanic –5 (33.3) 
    Language Spoken at Home*   (some patients spoke more than one),  n
     English 15 10 
     Spanish –6
     Cape Verdean/Kriolu–1
     Other language2 3
    Education,* n (%)     
     Some high school––
     High school –1 (6.7) 
     Some college 5 (33.3) 5 (33.3) 
     College 2 (13.3) 4 (26.7) 
     Post-college 8 (53.3) 4 (26.7) 
    Primary insurance, n (%)    
     Commercial 4 (26.7) 7 (46.7) 
     Medicare 7 (46.7) 4 (26.7) 
     Medicaid 4(26.7) 4 (26.7) 
    Confidence filling out forms, n (%)
     Not very confident––
     Confident 8 (53.3) 5 (33.3) 
     Very confident 7 (46.7) 10 (66.6) 
    Site of care, n (%)    
     Hospital based clinic 15 (100.0) 14 (93.3) 
     Community based clinic –1 (6.7) 

    • *Elicited during interview.

    • Abbreviation: SD, standard deviation.

  • Table 3.

    Domains, Major Themes, and Representative Quotes Regarding Diagnostic Referrals

    DomainThemeIllustrative Quote
    Cross-CuttingClear Communication as EmpoweringThey sometimes (ask): ‘Do you have any questions?’ But some people don’t really know what to ask…, about (the topic). I say, no, I don't have no question, because I don't know what to ask. And when I get home, some people ask me questions. I say, hmm…it’s true: I should have asked that. You know …they should give more information. 
    Importance of Clinician-Patient Communication about the ReferralAgreement with Referral  My primary care physician took a look at it and said she would feel much better having a dermatologist look at it, and we both agreed that she would make a … referral  
    Unclear Rationale for ReferralThey said they needed to do a stress test to see what was going on. To define what was going on. But they didn’t explain what the test is, what they were going to do, nothing. I just got there and I went to the machine and you're going to do this, you're going to do that, that’s it.
    She felt that she couldn't tell me exactly what was going on and that the expertise of a dermatologist would probably be better. 
    Ambiguous Urgency and Time Frame   I felt that they never thought it was a life-threatening situation. So it was more like: Is (it) convenient for you to have this done?
    I kind of had a sense that it wasn't extremely urgent, or else he would have said, like go to the emergency room right now.   
    Desire for Transparency and Clear Language  I would ask them to be 100% transparent and communicate to the best of their knowledge how risky the condition is, to allow me to figure out how much concern I should or should not have.
    If someone could have said: “Well, here's the process that we go through. You'll be examined, your physician will be so and so, followed by discussion of what the physician perceives to be the cause of my skin outbreaks and comment about how concerned I should be about them.” But I didn't get any of that stuff. 
    I would’ve appreciated more information about it… in layman's terms" 
    Emotional Context- Fears, Concerns, and Anxiety  My worry was the injection they were going to give me (for the stress test) (translated from Spanish)
    In other words, as soon as you run the test I’m scared. The essential thing is that the distance between point A and point B be as short as possible, even if B is bad news. I just can’t handle the wait.
    My primary said that probably is nothing to be scared of. I was calm, you know, but I feel scared, because when it's the heart it’s the heart. You don't know…”  
    Challenges in Arranging the ReferralHealth System Delays and Challenges  They tell you (that) you may have skin cancer, and it's taken forever to get an appointment"
    It just seems like the medical professionals are overwhelmed and short staffed. There's a long wait, you know… it shouldn't be that way.  
    Trust in Physician and Health System They sometimes act like they don't believe what you're saying
    Logistical and other Barriers  The only problem (is distance) and it's our fault because we live far away…So it’s logistics.
    So I'm definitely going to pursue it. It's just you know, life got in the way. (….)Dermatology calling me would have made it easier.
    Inconsistent Referral Processes, Diffuse Responsibility, and Uncertainty I thought that he was gonna take care of booking it, and then I found out later that he (…) wanted me to actually do the booking, …the call.
    There were…at least five things that I was responsible to get taken care of. I guess it wasn't clear enough. …All the other things were taken care of by the office. 
Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools

Jump to section

Keywords