Although the vast majority of referrals were scored as medically necessary, patients' preference for referral was concurrently given as a reason in 43.7%, and 27.5% of the referrals were effectuated to avoid overlooking anything.
This commitment became especially apparent during discussions of case scenarios describing patients with mild symptoms but with strong preference for referral or patients with severe symptoms with strong preference against referral.
The patient profiles that the group agreed should not be referred were those with mild symptoms and either no or strong preference against referral and those with moderate symptoms and a strong preference against referral.
Moreover, a lack of consensus for patients with severe symptoms and a strong preference against referral was due to some group members proposing that these patients might benefit from referral as they believed a surgeon could persuade them of the benefits of surgery.
Unlike many Western countries, after implementation of the NHI in Taiwan, the medical treatment-seeking behavior of patients changed because of freedom to select any healthcare provider or hospital based on preference without referral; on average, a person had 15.1 physician consultations per year in 2013[20].
Some guideline development group members felt that such a recommendation risked ignoring a patient's preference for referral.
The decision-making process for referrals is complex; increased consumerism in health care 3 and increased legal rights of patients may increase patients' preference for referral.
There was consensus that patients with severe knee symptoms who want to be referred should be referred and that patient with moderate or mild symptoms and strong preference against referral should not be referred.
Dental and medical practices accessed tend to be Jewish run, although whether this is through preference, lay referral systems within the community, geography, or a lack of choice is unclear and will be explored further.
We also designed case scenarios based on five patient characteristics presented: age, symptom severity, body mass, co-morbidity and patients' preference for referral (see Table 2 and Box 1).
