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J Pediatr. 2013 Feb;162(2):409-14.e1. doi: 10.1016/j.jpeds.2012.07.022. Epub 2012 Aug 25.

Barriers to specialty care and specialty referral completion in the community health center setting.

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Division of General Pediatrics, Child and Adolescent Health Measurement Initiative, Oregon Health and Science University, Portland, OR 97239, USA.



To assess the frequency of barriers to specialty care and to assess which barriers are associated with an incomplete specialty referral (not attending a specialty visit when referred by a primary care provider) among children seen in community health centers.


Two months after their child's specialty referral, 341 parents completed telephone surveys assessing whether a specialty visit was completed and whether they experienced any of 10 barriers to care. Family/community barriers included difficulty leaving work, obtaining childcare, obtaining transportation, and inadequate insurance. Health care system barriers included getting appointments quickly, understanding doctors and nurses, communicating with doctors' offices, locating offices, accessing interpreters, and inconvenient office hours. We calculated barrier frequency and total barriers experienced. Using logistic regression, we assessed which barriers were associated with incomplete referral, and whether experiencing ≥ 4 barriers was associated with incomplete referral.


A total of 22.9% of families experienced incomplete referral. 42.0% of families encountered 1 or more barriers. The most frequent barriers were difficulty leaving work, obtaining childcare, and obtaining transportation. On multivariate analysis, difficulty getting appointments quickly, difficulty finding doctors' offices, and inconvenient office hours were associated with incomplete referral. Families experiencing ≥ 4 barriers were more likely than those experiencing ≤ 3 barriers to have incomplete referral.


Barriers to specialty care were common and associated with incomplete referral. Families experiencing many barriers had greater risk of incomplete referral. Improving family/community factors may increase satisfaction with specialty care; however, improving health system factors may be the best way to reduce incomplete referrals.

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