Open Access Highly Accessed Research article

Comparative performance information plays no role in the referral behaviour of GPs

Nicole ABM Ketelaar1*, Marjan J Faber2, Glyn Elwyn3, Gert P Westert2 and Jozé C Braspenning2

Author Affiliations

1 Radboud university medical center, Scientific Institute for Quality of Healthcare 114, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands

2 Radboud university medical center, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands

3 The Dartmouth Health Care Delivery Science Center and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, N.H., USA

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BMC Family Practice 2014, 15:146  doi:10.1186/1471-2296-15-146

Published: 27 August 2014



Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient’s needs. We investigated how GPs view their role in using CPI to choose providers and support patients.


We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network.


Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of-care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI.


Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP’s role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs’ ability and willingness to use CPI to guide their patients in the referral process.

Primary care; Doctor-patient relationship; Access to care; Performance information; Quality of care; Qualitative research; Quantitative research; Mixed methods