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Centralization versus Decentralization and Referral Rate: A Behavioral Perspective 1.1 Introduction
In recent years, there has been a shift from decentralized referral systems towards centralized ones in order to decrease patient waiting time and increase the flexibility of the referral processes. From a queuing theory perspective, a centralized referral system characterized by a central queue for all the referrals reduces waiting time variation in the queue by mitigating the variability in the appointment schedules of specialists (Dijk & Sluis, 2008; Rothkopf & Rech, 1987; Smith & Whitt, 1981). However, the existence of social relationships between general practitioners (GPs) and specialists in decentralized referral systems may decrease the total number of referrals in decentralized referral systems. In common decentralized referral systems, GPs refer patients directly to the specialists whom they know. Knowing the specialist can influence GPs referral decision making about cases which fall into the uncertain category: Such social relationships can motivate the GPs to be more careful about their referrals; the GP is mindful of not wasting specialists time or feels guilty about referring patients who they might be able to manage themselves (Newton et al., 1991). Therefore, GP-specialist relationship which is a characteristic of decentralized referral systems may decrease referral rate. In this research, we designed a survey to investigate the effect of GP-specialist relationship on referral rate. Using an online survey, we examined how a shift from a decentralized referral system, characterized by a close relationship between general practitioners and specialists, to a centralized referral system, where there is no relationship between the referring general practitioner and the specialist, would affect referral rate. We found partial

2 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.

1.2 Research Hypothesis

Our 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

3 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.

1.3 Manipulating GP-Specialist Relationships

In 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 condition The following case describes one of your patients who you may consider referring to a

4 rheumatologist. The rheumatologist to whom you may refer the patient is Dr. Lee. Having referred many of your patients to Dr. Lee over the past few years, you consider yourself to have a close professional relationship with Dr. Lee. You trust and feel comfortable with Dr. Lee as a specialist. Please read the case and answer the questions below. b) Respirology/close relationship condition The following case describes one of your patients who you may consider referring to a respirologist. The respirologist to whom you may refer the patient is Dr. Lee. Having referred many of your patients to Dr. Lee over the past few years, you consider yourself to have a close professional relationship with Dr. Lee. You trust and feel comfortable with Dr. Lee as a specialist. Please read the case and answer the questions below. c) Rheumatology/no relationship condition The following case describes one of your patients who you may consider referring to a rheumatologist. The referral system to which you refer the patient is a centralized referral system 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. Please read the case and answer the questions below. d) Respirology/ no relationship condition The following case describes one of your patients who you may consider referring to a respirologist. The referral system to which you refer the patient is a centralized referral system in which the patients are referred to different respirologists through a centralized system that allocates the patient to the respirologist that has the next available time slot. Please read the case and answer the questions below.

1.4 Main Statistical Analyses and Results

In 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).

5 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 selfconfidence 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 < 0.025). The second multiple regression for low-confidence individuals showed no significant relationship between relationship type and referral rate.