Triage of general practitioner referrals to internal medicine: identifying unnecessary referrals and exploring underlying referral reasons

IntroductionAccess to specialist care in the Netherlands requires a general practitioner (GP) referral, yet referrals to secondary care keep rising. Triage has been proposed to manage this demand and may be relevant for internal medicine, which addresses diverse and increasingly complex conditions. This study aimed to identify the internal medicine healthcare needs which were redirected to the GP after triage and to explore the factors driving GP referral behaviour. MethodsThis multi-method study combined quantitative referral data with qualitative insights from GP focus groups. Data were extracted from a hospital in an urban region, including adults with non-acute complaints referred for outpatient consultation to internal medicine between August 2019 and July 2021. Referrals were triaged for appropriateness and redirected where possible. Focus groups explored GPs perspectives on referral practices. ResultsOf 5,826 referrals triaged, 998 (17%) were redirected to the GP with advice and guidance. Endocrinology accounted for 35% of redirected cases, followed by nephrology (8.6%). Focus groups revealed underlying drivers of referral behaviour, identifying four themes: medical factors; GP-related factors, including professional uncertainty and autonomy; patient-related factors; and external factors, such as contextual and regulatory influences. ConclusionThis study demonstrates that triage is a feasible strategy for managing referral volumes, particularly within domains such as endocrinology where many medical problems can be managed in primary care. However, referrals are shaped by more than clinical need, reflecting uncertainty, emotional considerations, patient expectations and systemic factors. Strengthened collaboration between primary and secondary care, alongside pre-referral consultation strategies, is essential to ensure appropriate, high-quality patient care.