Key result
Primary care physicians' referral decisions for suspected coronary artery disease are influenced by practice environment, physician experience, and non-diagnostic patient characteristics.
Why the study?
Chest pain is a frequent issue in primary care with CAD as a potential cause, but the determinants influencing PCPs' referral decisions to secondary care needed exploration.
Observational (n=26)
Primary care physicians' decisions to refer patients with suspected coronary artery disease are heavily influenced by non-clinical factors such as local specialist availability, physician experience, and patient social context.
Non-clinical factors may shape CAD referral thresholds in primary care; hypothesis-generating for standardizing decisions across settings.
BACKGROUND: Chest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs' referral decisions, and to investigate determinants which influenced those decisions. METHODS: PCPs working in Hesse, Germany, were interviewed in a qualitative study. We used 'stimulated recall' with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer. RESULTS: PCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited. CONCLUSIONS: We could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.
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Winkler et al. (2023) conducted an observational in Suspected coronary artery disease (n=26). Factors influencing referral thresholds was evaluated on Determinants of referral decisions. Primary care physicians' referral decisions for suspected coronary artery disease are influenced by practice environment, physician experience, and non-diagnostic patient characteristics.
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