Capsule Commentary on Ackerman et al., When to Repatriate? Clinicians’ Perspectives on the Transfer of Patient Management from Specialty to Primary Care

The question of when patients can stop seeing specialists and instead be managed exclusively by their primary care providers (PCPs) is an important one. Studies have examined the transition of care among patients surviving cancer,^1,2 though the literature on other health conditions is limited.³ In a mixed methods study, Ackermann and colleagues found that there was agreement between the PCP and the specialist co-managing patients for about half of patients, with 16 % of patients deemed appropriate for transfer to primary care and 36 % appropriate for continued co-management.⁴ Among the remaining 48 % of patients in which there was disagreement, specialists were half as likely to deem patients appropriate for transfer back to primary care.

In interviews with PCPs, reasons for this discordance included lack of specialist belief in the PCP’s abilities, financial incentives for specialists to continue to follow stable patients, and patient preference to see specialists. Additional reasons included easing the PCP’s burden for complex patients and difficulty accessing primary care appointments. The PCPs felt uncomfortable initiating conversations with specialists regarding transitioning a patient’s care back to the PCP. Some felt disagreeing with a specialist’s recommendation could offend them, disrupting future professional collaboration. Another barrier to smooth transition is its dependency on the patient’s approval. Patients should be the focus in the decision to transition; however many are misinformed in thinking dual health care is superior to sole care by a PCP.

In this study, there were no interviews with either the specialists or patients involved. It would be helpful to understand patient care transition from these two perspectives. This might provide answers to why transitions are difficult. Currently, there are no guidelines to determine when patients are appropriate to be transferred back to their PCPs. Future studies should explore potential models that physicians can use to determine direction of a patient’s care. Obstacles like medical stability of a patient and the PCP’s experience related to the condition are factors that should be considered. While primary care is much less expensive than specialty care, the growing shortage of PCPs is likely to exacerbate this problem.