Open Access Research article

What is the impact of primary care model type on specialist referral rates? A cross-sectional study

Clare Liddy12*, Jatinderpreet Singh1, Ryan Kelly1, Simone Dahrouge123, Monica Taljaard45 and Jamie Younger3

Author Affiliations

1 C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Room 369Y, Ottawa, Ontario K1N 5C8, Canada

2 Department of Family Medicine, University of Ottawa, 43 Bruyère St. Room 369Y, Ottawa, Ontario K1N 5C8, Canada

3 Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada

4 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

5 Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada

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BMC Family Practice 2014, 15:22  doi:10.1186/1471-2296-15-22

Published: 3 February 2014



Several new primary care models have been implemented in Ontario, Canada over the past two decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three primary care models: 1) Enhanced Fee-for-service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation – Interdisciplinary (CAP-I).


We conducted a cross-sectional study using health administrative data from primary care practices in Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A multivariable clustered Poisson regression analysis was used to compare referral rates between models while adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex, income, rurality, health status) characteristics.


Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI (719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681-707) models and the interdisciplinary CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002). Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were more likely to be referred.


Primary care model is significantly associated with referral rate. On a study population level, these differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively – a difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or not is not known and requires further investigation. Physician remuneration and team structure likely account for the differences; however, further investigation is also required to better understand whether other organizational factors associated with primary care model also impact referral.

Primary care; Specialist referral; Capitation; Primary care model