658328 centralization versus decentralization a

8/12/2019 658328 Centralization Versus Decentralization A

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support for our hypothesis on the effect of GP-specialist relationship on referral rate: doctors

who had high confidence in their referral decision making referred significantly fewer patients

under the close-relationship condition in comparison with the centralized referral condition.

1.2Research HypothesisOur research hypothesis is that:

Hypothesis.Participants who have a close relationship with the specialist to whom they

refer will refer significantly fewer patients in comparison with the participants in a centralized

referral system.

1.5 Participants and Procedure

The online survey was emailed to family practice residents through the Departments of

Family Medicine in seven Canadian Universities. The participants were randomly assigned to the

conditions of a 2 (social relationship: close relationship vs. centralized referral system) x 2 (test

type: rheumatology vs. respirology) between subjects factorial design. At first, participants read

a survey description which consisted of information on the survey purpose, its content, the

approximate length of time it took to complete the survey, and the possibility of taking part in a

draw for an Apple iPad 3 (worth of $550) after completing the survey. The purpose of the survey

as explained to participants was to understand the factors affecting priority setting in the patient

referrals from general practitioners to specialists.

In section 1, participants answered a preliminary questionnaire including questions on

their level of knowledge and confidence in answering questions in two areas of rheumatology

and respirology.

Section 2 included the case test which consisted of 12 patient case descriptions developed

based on real patients who were referred by general practitioners to specialists in two areas of


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rheumatology and respirology. In order to manipulate the relationship between the participant as

the general practitioner and the specialist to whom they might refer their patients, we provided a

written description of the relationship between the participant and the specialist. In close

relationship conditions, participants read an explanation about a specialist in their town to whom

they had developed a close professional relationship after having referred many of their patients

to this specialist over the past few years. In the centralized referral system conditions, on the

other hand, participants were provided with an explanation of a centralized referral system to

which they would refer their patients. After reading the treatment description, participants were

asked to read each patient case description and answer three referral-related questions: 1.

whether they would refer the patient to the specialist, 2. the urgency or relative priority of the

patient for referral on a scale from 0 (Not Urgent) to 10 (Very Urgent), and 3. a brief explanation

about the reasons for their referral or non-referral decision.

Finally, in section 3 participants answered an after-the-test questionnaire that consisted of

questions on mood (PANAS, Watson et al., 1988), risk attitude, geographic location of residency

program, and demographic data. Data on factors including age, gender, ethnicity, and primary

language were also collected.

1.3Manipulating GP-Specialist RelationshipsIn order to manipulate social relationships between the participant as a GP and the

specialist in each treatment condition, we provided an explanation of the type of relationship at

the beginning of the case test section of our experiment. Table 1 presents the manipulation for

social relationship in each of the four treatment conditions.

Table1. GP-specialist relationship manipulation

a) Rheumatology/close relationship conditionThe following case describes one of your patients who you may consider referring to a


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rheumatologist. The rheumatologist to whom you may refer the patient is Dr. Lee. Havingreferred many of your patients to Dr. Lee over the past few years, you consider yourself to have aclose professional relationship with Dr. Lee. You trust and feel comfortable with Dr. Lee as aspecialist. Please read the case and answer the questions below.

b) Respirology/close relationship conditionThe following case describes one of your patients who you may consider referring to arespirologist. The respirologist to whom you may refer the patient is Dr. Lee. Having referredmany of your patients to Dr. Lee over the past few years, you consider yourself to have a closeprofessional relationship with Dr. Lee. You trust and feel comfortable with Dr. Lee as aspecialist. Please read the case and answer the questions below.

c) Rheumatology/no relationship conditionThe following case describes one of your patients who you may consider referring to arheumatologist. The referral system to which you refer the patient is a centralized referralsystem in which the patients are referred to different rheumatologists through a centralized

system that allocates the patient to the rheumatologist that has the next available time slot. Pleaseread the case and answer the questions below.

d) Respirology/ no relationship conditionThe following case describes one of your patients who you may consider referring to arespirologist. The referral system to which you refer the patient is a centralized referral systemin which the patients are referred to different respirologists through a centralized system thatallocates the patient to the respirologist that has the next available time slot. Please read the caseand answer the questions below.

1.4Main Statistical Analyses and ResultsIn order to test our hypothesis regarding the effect of social relationships and other

related independent variables on referral rate, we ran a multiple regression analysis. It was

predicted that the interaction between the participant's referral self-confidence and type of

relationship may affect referral behavior among participants. In order to test the interactions

between independent variables of interest, we included all the two-way and three-way

interactions between the type of relationship, test type and confidence in the model.

We did not find any significant effect of relationship type on referral rate to support our

first hypothesis. Interestingly, we found a significant interaction between relationship type and

referral self-confidence in the main test (= -2.239;p< 0.025).


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Other variables that had a significant effect on referral rate consist of test type,

knowledge, and loss aversion: First, there was a higher referral rate for rheumatology cases in

comparison with respirology ones. Residents referred rheumatology cases significantly more

than respirology ones (= 4.346;p< 0.001). Second, knowledge had a significant positive effect

on referral rate (= 0.586;p< 0.025). Interestingly, residents who had more knowledge referred

more patients to specialists in comparison with those who had less knowledge of the area. This

result is in line with the previous empirical studies on referral rate (Newton et al., 1991;

Reynolds et al., 1991; Evans & McBride, 1968). Third, loss aversion had a positive relationship

with referral rate. Those who were loss averse referred significantly more patients (= 1.146;p

< 0.025). This result was in line with the results of Nightingale's studies on the effect of loss

aversion on laboratory use and referral to hospitals (Nightingale, 1988; 1987 a; 1987 b).

In order to follow up the interaction between relationship type and referral confidence

and to test the difference between close relationship and centralized referral system among high

confidence and low confidence individuals, we ran two separate multiple regressions to examine

the effect of relationship type on refferal rate among participants with low referral self-

confidence and those with high referral self-confidence.

The results of the multiple regression for highly confident individuals showed that

participants in the close relationship treatments referred significantly fewer patients in

comparison with participants in the centralized referral system: Relationship type was significant

among high-confidence individuals ( = -1.385,p

658328 centralization versus decentralization a

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