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Family Practice Advance Access originally published online on April 12, 2006
Family Practice 2006 23(4):427-436; doi:10.1093/fampra/cmi125
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© The Author (2006). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Variations in cardiac interventions: doctors' practices and views

Ann Bowlinga, Clare Harriesb, Damien Forrestb and Nigel Harveyb

a Department of Primary Care and Population Sciences, University College London Royal Free Campus, London, UK
b Department of Psychology, University College London Royal Free Campus, London, UK

Correspondence to Professor Ann Bowling, Department of Primary Care and Population Sciences, University College London, Royal Free Campus, Rowland Hill St, London NW3 2PF, UK; Email: a.bowling{at}ucl.ac.uk

Objectives. To investigate referral rates for cardiac interventions by clinical specialty, to document doctors' reasons for referrals and to explore doctors' perceptions of the factors that influenced their clinical decisions.

Study design. Doctors completed a clinical decision-making exercise involving, in total, 6093 electronic patients with cardiac disease, and subsequently took part in the semi-structured interviews about influences on their decisions. Interviews were audio-recorded, transcribed and coded using a thematic approach, with the coding categories derived from the data.

Study setting. Eighty-eight doctors (GPs, care-of-the-elderly specialists, cardiologists) participated in the full study, in seven areas in southern, central and northern England. Complete interview data were analysed for 76 of these.

Principal findings. Not all patients who were eligible for specific investigations or treatment received these. The extent of variations in clinical decisions differed by type of intervention. Apart from the general reasons for referrals, doctors raised nine main influences on their actual decision making. The most commonly reported influence (‘barrier’) was poor access to equipment for intervention, which increased thresholds for investigation and treatment.

Conclusions. The current emphasis on achieving targets in the British NHS has led to a focus on easily measurable, but crude, process targets such as waiting lists. This study points to the need to include a broader quality assurance element to investigate the cluster of system failures which lead to variations in clinical decisions and thereby to inequitable treatment.

Keywords. barriers, cardiology, clinical, equity, referral rates.


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