Referral management: Which patients are deemed not appropriate for neurologic consultation, and what happens to them?

Objective: In many if not most institutions in the US, demand for neurology services exceeds the supply, resulting in poor access. This study examines whether the use of a limited resource - time for outpatient neurology consultation - can be optimized by screening referrals for appropriateness and whether it is safe to do so. Patients and methods: An established triage activity at an academic outpatient clinic - experienced nurses flagging possibly inappropriate outpatient referrals and a group of neurologists triaging them - was examined by obtaining referral characteristics and detailed one year follow up for patients that were referred but not scheduled, over a period of 6 months. A narrative of issues related to this activity is provided as well. Results: 180 Declined referrals were identified. Most frequent reason for declined referral were pain, headache and dizziness. The most frequently recommended disposition was follow up with the referring primary care physician (32%), pain or spine clinic (11%) or reevaluation by a previously involved outside neurologist (12%). Review of follow up care - as far as available - indicated that in the majority of cases (52%), no further neurologic evaluation was pursued. Triage was considered reasonably safe (i.e. very little if any pathology was missed or work up delayed). In 15%, referring providers tried to circumvent the triage system by various means; we also felt that the option to reach the triaging neurologist was rather underused and that at least a fraction of referring physicians disapproved of triage efforts. Conclusions: Triaging referrals by chart review appears to be safe, but its effectiveness is limited by the time investment, limited acceptance by some referring providers and other factors.