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

Content Provider	Springer Nature : BioMed Central
Author	Winkler, Katja Gerlach, Navina Donner-Banzhoff, Norbert Berberich, Anika Jung-Henrich, Jutta Schlößler, Kathrin
Abstract	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.
Related Links	https://bmcprimcare.biomedcentral.com/counter/pdf/10.1186/s12875-023-02064-y.pdf
Ending Page	11
Page Count	11
Starting Page	1
File Format	HTM / HTML
ISSN	27314553
DOI	10.1186/s12875-023-02064-y
Journal	BMC Primary Care
Issue Number	1
Volume Number	24
Language	English
Publisher	BioMed Central
Publisher Date	2023-05-02
Access Restriction	Open
Subject Keyword	General Practice Family Medicine Primary Care Medicine Consultation and Referral Primary Health Care Myocardial Ischemia Chest Pain Qualitative Research
Content Type	Text
Resource Type	Article
Subject	Family Practice
Journal Impact Factor	3.2/2023
5-Year Journal Impact Factor	3.3/2023

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1	Ministry of Education (GoI), Department of Higher Education	Sanctioning Authority	https://www.education.gov.in/ict-initiatives
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