Referral of children to specialists in the United States and the United Kingdom

Objective: To compare the rates and patterns of children's specialty referrals in the United States (US) and the United Kingdom (UK). Design: Retrospective cohort analysis of health care claims/encounter data obtained in 1996 (US) and 1997 (UK). Setting: Children in the US were selected from 5 managed health plans that used primary care physicians as gatekeepers: 2 health maintenance organizations and 3 point-of-service plans. Point-of-service plans allow patient self-referral at increased out-of-pocket costs. In the UK, the General Practice Research Database provided data from 211 general practices. Participants: Children, from birth to the age of 17 years, with no cost sharing for physician services in the, US (n=135092) and who were registered with general practitioners, all of whom authorize patients' access to specialty care, in the UK (n=221312). Main Outcome Measure: Annual percentage of children referred to a specialist. Results: Across the 5 US plans, 18.6% to 28.8% of the patients per year were referred vs 8.7% of the patients per year in the UK sample. Referral rates were not significantly different between a health maintenance organization and a point-of-service plan administered by a single insurer. Compared with patients in the UK sample, those in the US plans were 1.9 times more commonly referred to medical specialists and 3.2 times more commonly referred to surgical specialists. There was considerable cross-national variation in specialty-specific referral rates for children with selected conditions. Conclusions: Children in US managed care plans are between 2 and 3 times as likely to be referred to specialists compared with counterparts in the UK. Although these referral rate differences are substantial, our findings cannot be construed to mean that the US referral rates are too high or that the UK rates are too low. The greater supply of specialists and higher expectations for direct access to specialty care in the US, compared with the UK, are likely explanations for these differences in children's specialty referral rates.