Which doctors are influenced by a patient's age? A multi-method study of angina treatment in general practice, cardiology and gerontology

BACKGROUND: Elderly patients with cardiovascular disease are relatively undertreated and undertested. OBJECTIVES: To investigate whether, and how, individual doctors are influenced by a patient's age in their investigation and treatment of angina. DESIGN: Process-based judgment analysis using electronic patients, semistructured interviews. SETTING: Primary Care, Care of the Elderly and Cardiology in England. PARTICIPANTS: Eighty five doctors: 29 cardiologists, 28 care of the elderly specialists and 28 general practitioners (GPs). MAIN OUTCOME MEASURES: Testing and treatment decisions on hypothetical patients. RESULTS: Forty six per cent of GPs and care of the elderly doctors, and 48% of cardiologists treated patients aged 65+ differently to those under 65, independent of comorbidity. This effect was evident on several decisions: elderly patients were less likely to be prescribed a statin given a cholesterol test, referred to a cardiologist, given an exercise tolerance test, angiography and revascularisation; more likely to have their current prescriptions changed and to be given a follow-up appointment. There was no effect of specialty, gender or years of training on influence of patient age. Those doctors who were influenced by age were on average five years older than those who were not. Interviews revealed that some doctors saw old age as a contraindication to treat. CONCLUSIONS: Age, independent of comorbidity, presentation and patients' wishes, directly influenced decision-making about angina investigation and treatment by half of the doctors in the primary and secondary care samples. Doctors explicitly reasoned about the direct influence of age and age-associated influences.