How Good Referral Pathways Impact Vascular and Overall Health

Functional, standardized referral pathways can make or break patient outcomes. While this is true in overall health, nowhere has it become more apparent than in vascular health, where many patients in need often don’t make it to the correct specialist, either because of a lack of knowledge that vascular specialists exist or due to a lack of standard networks and connections amongst doctors. Understanding referral pathways and how we, as physicians, contribute to them, can help bridge gaps in the system and permanently improve patient outcomes.  

How integrated and unintegrated systems impact vascular health referral pathways

In the simplest terms, a referral pathway is where a physician, usually a primary care provider, identifies that a patient needs referral to a specialist for a certain problem that they’re having. Sometimes the diagnosis is made by the primary care provider, but in other cases, complete care from diagnosis onward is handled by the specialist.

In highly integrated systems like those at the Mayo Clinic and the Cleveland Clinic, where every provider has the same employer, every provider and thus every patient is on the same EHR, or electronic health record system, making it easy for primary care physicians to identify specialists. For example, a primary care physician at the Cleveland Clinic would have an expectedly easy time identifying and making a patient referral to a vascular surgeon since the world-class hospital boasts a Vascular Surgery specialty department with more than 20 vascular surgeons on staff. This type of integration also allows PCPs to follow their patients’ care, giving them a clear window into patient health over time. Highly integrated healthcare systems like this are common in large cities and other urban areas, making it simple and often quick for patients to get care. That simplicity and speed can make a significant difference in vascular health since symptoms can develop in a matter of weeks or months or go undetected for years until there’s a larger problem.   

Outside of urban areas — in distant suburban, rural, and remote communities, for example — PCPs are typically employed in unintegrated systems. In these cases, referrals are often based on different factors than in an integrated system. These factors may include personal knowledge of the specialist, maybe they went to school together or trained together. Or maybe another provider in the same practice has an established relationship with a specialist and they make the recommendation. Essentially, it is more relationship-based. This doesn’t mean that the standard of care is less for patients in these unintegrated systems, but the referral pathway is less established and more haphazard, and can sometimes take longer, which can be problematic for patients who’ve just found out they have a vascular condition. 

Are current referral pathways getting patients to the right specialists?

While the goal is to get patients to the correct provider for the patient’s needs, referring physicians often don’t have real-time data to use in making that judgment call. What this means is that a referring physician typically doesn’t have any way of quantitatively knowing the quality of care patients will receive from any given specialist; it’s all anecdotal and episodic. And when a patient sees a specialist, their referring physician may not know whether their patient is receiving guideline-based care or the appropriate or recommended care for their specific needs. Referring physicians must trust the specialist to whom they are sending their patient. 

But there are criteria that PCPs and other physicians can use at-a-glance to help determine whether a specialist is the right one for their patient. For example, with vascular health, the specialist should be board-certified in vascular surgery or vascular medicine. There are Board Certified specialists in Interventional Radiology and Interventional Cardiology who treat patients with vascular conditions but they should have a track record of commitment to vascular health by demonstrating continuing education in vascular conditions such as national vascular meeting conference attendance (especially participation as speaker or moderator), participation in vascular research trials, scientific publications on vascular disease and even community educational programs. It can be helpful to look for specialists certified with the American Board of Venous and Lymphatic Medicine (for vein problems) and those who are a Fellow of the Society for Vascular Surgery (for artery and vein problems). 

Where traditional referral pathways break down

Referral pathways typically break down due to a lack of awareness about the full scope of what specialists can do. This is particularly true with vascular surgeons, for example, because it isn’t included in the knowledge scope during medical school. In fact, most physicians can complete medical school and go into their postgraduate training programs without ever hearing about vascular surgery or what these specialists do for patients — which is to manage the health and function of the veins, arteries, and 60,000 miles of blood vessels in every patient’s body. That knowledge deficit can carry on throughout a physician’s career unless they happen to run across a vascular surgeon who is caring for a patient and then start to understand what their capabilities really are. 

Payor prior authorization timelines and procedures can also have a significant impact on getting patients to the right provider in a timely and safe manner. This can lead to alternative, and less favorable pathways. 

Vascular surgery as a case study for the emergence of alternative referral pathways

Although physician-based referrals are the most common referrals for most patients, no matter their condition, this isn’t the only way that patients end up in a specialist’s office. For patients receiving vascular health care, urgent care referrals and self-initiated referrals are also common, in part due to the knowledge deficit in the medical field. 

Referrals through urgent care occur when a patient has an urgent or emergent condition and they end up in an emergency room or urgent care facility. If they’ve experienced a health episode involving aortic aneurysm, blood clot, deep vein thrombosis (DVT), atherosclerosis, or other conditions or incidents involving the vascular system, they may be referred to a vascular surgeon at this time and begin receiving specialized care. 

Other patients self-initiate or rely on friends and family members. Self-initiated referrals often come from patients who’ve had family members with vascular health issues who are seeking to begin early or preventative care. Patients also often refer their friends and family members if they’re already under the care of a vascular surgeon, and they’ve had a good experience and have trust in their provider. 

How we can improve referral pathways and support better patient outcomes

While some providers have promising referral pathways setup, there is a lot of opportunity for improvement. Whether a doctor is on the sending or receiving end of the referral process, there is a need to increase the speed of referrals and get patients in to be seen without undue delay. As with so many other conditions, in vascular health, patients often need to be seen within a few days or weeks, but current referral systems drag on for many weeks and months. This can lead to unnecessary risk and anxiety for patients who deserve compassionate care. 

But what we need most is renewed and invigorated advocacy from within the medical community, speaking out and speaking up for patients; a push for the urgent adoption of complete interoperability in EHRs, and minimization of prior authorization requirements. These changes would create an environment ripe for collaboration between primary care physicians, specialists, and patients to ensure the best possible health outcomes no matter what referral pathway we follow.

Photo: Getty Images, pixelliebe

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