Table 1.

Published Studies on Inappropriate Referrals (overreferrals)

Study	Inappropriate Referrals (%)	Condition(s)	Term Used to Define Inappropriate	Definition of Inappropriate
Lawler et al. 1990	19.2	All conditions	Elective	Judgment of external expert (scale of 1 to 4, 4 being extremely unlikely to suffer harm without referral and could be managed by PCP).
Donohoe et al. 1999	30	All conditions	Inappropriate	Judgment of specialist physician (scale of 1 to 9 scale, 1 being “highly inappropriate”; 9 being “highly appropriate”).
Albertson et al. 2000	17.4	All conditions	Not indicated	Judgment of referring physician (e.g., comfortable treating, patient seeking additional reassurance not indicated).
Harrington and Walsh 2001	41	Rheumatology	Inappropriate	Judgment of specialist receiving referral (e.g., already receiving appropriate care, no autoimmune symptoms, prior complete evaluation, no prior evaluation by referring physician).
Wallerstein and Seshadri 1994	0.7	Pediatric developmental disability	Unnecessary	Judgment of specialist receiving referral (no evidence of chronic developmental disability and no need for further testing or services).
Forrest et al. 2003	12.4	All conditions	Discretionary	Four predefined criteria: common condition, high certainty, low urgency, cognitive assistance only.
Forrest et al. 2006	17	All conditions	Discretionary	Four predefined criteria: common condition, high certainty, low urgency, cognitive assistance only.
Warren 1994	16	Strabismus	Inappropriate, invalid, excessive	Change in management (excessive referrals when >30% of referrals for strabismus are not found to have strabismus).
Reeder et al. 2004	42–65	Pediatric musculoskeletal disorders	Inappropriate	Guidelines (2002 AAP Surgical Advisory Panel guidelines for referral to surgical subspecialties).

Note: Limited to studies published in the United States.