Open Access Research article

Performance measures of the specialty referral process: a systematic review of the literature

James P Guevara1234*, Diane Hsu12 and Christopher B Forrest24

Author Affiliations

1 PolicyLab: Center to Bridge Research, Practice, & Policy, The Children's Hospital of Philadelphia, Philadelphia, PA, USA

2 Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA

3 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA

4 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA

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BMC Health Services Research 2011, 11:168  doi:10.1186/1472-6963-11-168

Published: 13 July 2011



Performance of specialty referrals is coming under scrutiny, but a lack of identifiable measures impedes measurement efforts. The objective of this study was to systematically review the literature to identify published measures that assess specialty referrals.


We performed a systematic review of the literature for measures of specialty referral. Searches were made of MEDLINE and HealthSTAR databases, references of eligible papers, and citations provided by content experts. Measures were eligible if they were published from January 1973 to June 2009, reported on validity and/or reliability of the measure, and were applicable to Organization for Economic Cooperation and Development healthcare systems. We classified measures according to a conceptual framework, which underwent content validation with an expert panel.


We identified 2,964 potentially eligible papers. After abstract and full-text review, we selected 214 papers containing 244 measures. Most measures were applied in adults (57%), assessed structural elements of the referral process (60%), and collected data via survey (62%). Measures were classified into non-mutually exclusive domains: need for specialty care (N = 14), referral initiation (N = 73), entry into specialty care (N = 53), coordination (N = 60), referral type (N = 3), clinical tasks (N = 19), resource use (N = 13), quality (N = 57), and outcomes (N = 9).


Published measures are available to assess the specialty referral process, although some domains are limited. Because many of these measures have been not been extensively validated in general populations, assess limited aspects of the referral process, and require new data collection, their applicability and preference in assessment of the specialty referral process is needed.

Primary Care; Specialists; Referral-Consultation; Coordination; Quality of Care