Background

Preconsultation exchange is an emerging model of specialty care proposed by the American College of Physicians that seeks to answer a clinical question without a formal patient visit to the specialty clinic. This form of specialty care has been little studied. We sought to determine the appropriateness of preconsultation exchange for ambulatory hepatology consultations within our urban health care system.

Methods

Retrospective study of referrals for ambulatory hepatology consultation in the safety net health care system of San Francisco, Calif from January 2007 through April 2010.

Results

Of the 500 referrals reviewed, 87 were excluded as repeat requests. The most common reasons for referral were hepatitis B (34.9%) and hepatitis C (32.0%). Fifty-six referrals (13.6%) were appropriate for preconsultation exchange, and 190 (46.0%) were inappropriate for preconsultation exchange. One hundred sixty-seven (40.4%) referrals did not include enough information to determine appropriateness for preconsultation exchange. Most of these (83.8%) were made for hepatitis B or hepatitis C, despite the presence of explicit referral guidelines. Midlevel providers were more likely than physicians to provide enough information to determine appropriateness for preconsultation exchange.

Conclusion

In our urban health care system, preconsultation exchange appears to be an appropriate form of specialty care for some ambulatory hepatology consultations. Communication between primary care provider and specialist appears to be an important barrier to broader implementation of preconsultation exchange. Optimizing the preconsultation exchange is critical to improve the primary-specialty care interface, and to build a true Patient-Centered Medical Home Neighborhood.