Cargando…

Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds

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 decision...

Descripción completa

Detalles Bibliográficos
Autores principales: Winkler, Katja, Gerlach, Navina, Donner-Banzhoff, Norbert, Berberich, Anika, Jung-Henrich, Jutta, Schlößler, Kathrin
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10152784/
https://www.ncbi.nlm.nih.gov/pubmed/37131137
http://dx.doi.org/10.1186/s12875-023-02064-y
_version_ 1785035807748259840
author Winkler, Katja
Gerlach, Navina
Donner-Banzhoff, Norbert
Berberich, Anika
Jung-Henrich, Jutta
Schlößler, Kathrin
author_facet Winkler, Katja
Gerlach, Navina
Donner-Banzhoff, Norbert
Berberich, Anika
Jung-Henrich, Jutta
Schlößler, Kathrin
author_sort Winkler, Katja
collection PubMed
description 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. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12875-023-02064-y.
format Online
Article
Text
id pubmed-10152784
institution National Center for Biotechnology Information
language English
publishDate 2023
publisher BioMed Central
record_format MEDLINE/PubMed
spelling pubmed-101527842023-05-03 Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds Winkler, Katja Gerlach, Navina Donner-Banzhoff, Norbert Berberich, Anika Jung-Henrich, Jutta Schlößler, Kathrin BMC Prim Care Research 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. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12875-023-02064-y. BioMed Central 2023-05-02 /pmc/articles/PMC10152784/ /pubmed/37131137 http://dx.doi.org/10.1186/s12875-023-02064-y Text en © The Author(s) 2023 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research
Winkler, Katja
Gerlach, Navina
Donner-Banzhoff, Norbert
Berberich, Anika
Jung-Henrich, Jutta
Schlößler, Kathrin
Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds
title Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds
title_full Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds
title_fullStr Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds
title_full_unstemmed Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds
title_short Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds
title_sort determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10152784/
https://www.ncbi.nlm.nih.gov/pubmed/37131137
http://dx.doi.org/10.1186/s12875-023-02064-y
work_keys_str_mv AT winklerkatja determinantsofreferralforsuspectedcoronaryarterydiseaseaqualitativestudybasedondecisionthresholds
AT gerlachnavina determinantsofreferralforsuspectedcoronaryarterydiseaseaqualitativestudybasedondecisionthresholds
AT donnerbanzhoffnorbert determinantsofreferralforsuspectedcoronaryarterydiseaseaqualitativestudybasedondecisionthresholds
AT berberichanika determinantsofreferralforsuspectedcoronaryarterydiseaseaqualitativestudybasedondecisionthresholds
AT junghenrichjutta determinantsofreferralforsuspectedcoronaryarterydiseaseaqualitativestudybasedondecisionthresholds
AT schloßlerkathrin determinantsofreferralforsuspectedcoronaryarterydiseaseaqualitativestudybasedondecisionthresholds