Pattern and content of neuropsychological referral questions across 25 years of outpatient visits in a hospital-based clinic.

Much of the practice is clinical neuropsychology is performed in the role of consultant and although the neuropsychologist is dependent upon referrals made from outside sources, relatively little attention has been devoted to the investigation of the referral process. Surveys of clinicians and referral sources have reported breakdowns of referral sources by discipline and general topics of referral questions based on recollection, but direct analysis of referral patterns across the same period has not been undertaken.

The purpose of the study is to document the advancement of neuropsychology from providing psychological testing to establishing itself as a multifaceted discipline with a significant diagnostic purview that is regularly relied upon to contribute to important decisions in the lives of patients. By examining the referral questions rather than neuropsychologists' or referral sources' recollection of referrals, this study expands what is known about referral content and patterns. In an effort to explain question content without relying upon recollection, a coding rubric was designed to capture the breadth of presenting problems and requests seen in the original referral questions.

Two-thousand-six-hundred referral questions were selected from the odd year over the 25 year period from 1983 to 2007, yielding a total of 2600 referral questions. Cochran's Kappa was used to conduct interrater reliability analyses in three stages across the entire rating process. Content analysis showed that 79.1% of all questions had at more than minimal content. The most common request was for assistance with diagnostic considerations, which was present in 66.4% of all cases. Assistance with differential diagnoses was requested in 27.4% of all cases with the majority of these composed of requests for assistance in differentiating between psychiatric and neurological or other medical considerations. There was evidence for a trend over time in the gradual decline of requests for assistance with psychiatric differential diagnosis and requests for the MMPI from 1993 to the present. Memory problems and dementia are the most common presenting problems, although there is evidence of a slight decline in these evaluations beginning in 1997. Requests for specific recommendations, particularly those related to making recommendations regarding treatment planning were found to steadily increase across the sampling period. Limitations and implications for practice were discussed.