Background
Methods
Study design
Sampling and recruitment
Data collection
Qualitative analysis
Application of threshold model
Results
Sample
PCPs’ characteristics | Number of PCPs |
---|---|
Gender | |
Male | 6 |
Female | 3 |
Age group | |
< 50 y | 1 |
50 – 59 y | 6 |
60 – 69 y | 2 |
Experience (years since establishment) | |
< 10 y | 1 |
10—14 y | 1 |
15—19 y | 3 |
> 20 y | 4 |
Type of practice | |
Single-handed | 4 |
Group practice | 5 |
Area of practice | |
Large city: > 100 000 inhabitants | 1 |
Medium-sized town: 20 000–100 000 inhabitants | 1 |
Small-sized town: 5000–20 000 inhabitants | 6 |
Rural community: > 5000 inhabitants | 1 |
Availability of exercise ECG | |
Conducted in own practice | 2 |
Not available in own practice | 7 |
Factors influencing referral thresholds
Social and geographic environment
“So, I work [...] with both big [cardiology] practices here, so it is a very good and trusting relationship, and they [the cardiologists] react immediately if we have the impression that there is an urgent need for action. So, I get an appointment immediately [...]. We also have personal phone numbers of our colleagues and can reach them directly.” [P-04, 47]
“The barrier is greater for me. I do not know my colleague [cardiologist], just over the phone. Calling him, until I get to him, through practice staff, takes quite a while. It costs me time, it costs me effort. I do not have a phone number of anyone to make things shorter. That means that there is a greater barrier. For me, for the patients. They must get there, [...] they must ask their children to drive, they must take time off, and so on." [P-08, 154]
“I advised him [the patient] that he should see a cardiologist, I think you have to do an exercise ECG, just because of this presentation. Consequently, he also needs a cardiac ultrasound [...]Basically, he goes to the [non-interventional] cardiologist, because I do not really think he needs a coronary angiogram. “[P-07, 8]
“If he keeps besieging me and says he wants that, I will send him to the cardiologist and say, then the cardiologist has to struggle with him. Then, I do not send him to the cardiac catheter, I send him to the [non-interventional] cardiologist.” [P-07, 116]
“And then I picked up the phone directly, […], told myself that it [the artery] might have been clogged again, […] and then registered him [for the coronary angiography].” [P-08, 78ff.]
“I knew that the colleague [cardiologist] would do an ergometry anyway. I can save myself the effort.” [P-03, 21]
“The hospital has formed a group of established practitioners and their chief physicians who meet once a quarter in the hospital and talk about the problems of the established with the hospital. […] Such things are also discussed, including procedures [regarding CAD], and we have - the hospital issues so-called newsletters, where recommendations are suggested for the established colleagues in the whole district, yes. And every established colleague gets that, all PCPs, this is such a guideline, which concerns the current diseases.” [P-05, 38ff.]
Practitioner-related factors
“That affected me very deeply. I must say. [...] Because I did not expect it, yes. [...] So that is why I am particularly careful with women, if they have retrosternal pain and also with nausea and back pain, then I always think of the worst case. […] I no longer take any risks, better to admit once too often [...]. And even if I have the slightest suspicion, they go to the hospital.” [16ff.]
“She would be alive for sure if she hadn't been privately insured and if she hadn't gone to the cardiologist. She might need four breaks to get up those stairs now, but she would still be alive. And that is the reason for my attitude: wait and see first. I'm not a fan of too many technical investigations." [P-08, 138]
“But these are the young colleagues who have faith in laboratories and technology [...]. Especially when they come out of the hospital [training]. And then, as, yes, experienced colleagues, we can say: Take it easy. If the patients are doing as they always are, there is no reason to send them to the hospital for catheters or because of decompensated diabetes. There is no reason, we just have to take a close look at our patients." [P-08, 94]
“If I were to evaluate that statistically, I probably wrote most of the referrals to cardiac catheter on Monday morning. Because the practices are usually all jam-packed. And because I have less time and less desire to deal that intensively with patients, whether they really have a hard indication for a catheter. […] So, when the waiting room is full outside, the referrals are in there. That goes in no time. On Friday morning I talk to the patient for half an hour and then we decide whether it makes sense or not.” [P-08, 114ff.]
Patient-related factors
“For how long I have known him, whether this is a patient who always comes for all sorts of things or whether someone comes rarely, that matters. So if someone is not here that often and then comes with such complaints, then […] the warning lights are more likely to go off.” [P-09, 40]
“In the end I gave her painkillers, told her she had nothing heart-related, and wrote down for me to do an exercise ECG. But more from the point of view that I do not know her, that I did not want to do anything wrong to her, that one does not want to overlook anything.” [P-07, 70]
“If I had missed something there [with the patient who is the local mayor], I would not have been able to go out on the street. [...] Well, there are patients who expect a bit more from me because they are in public. Whether this is our pastor or a local mayor here. Yes, they are more likely to be sent to the catheter than I might have done for myself or my father.“ [P-08, 26ff.]
"If she [the patient] has had an inconspicuous exercise ECG, that happens occasionally, especially with the fifty-year-old female patients [...], then they get the diagnosis of somatization disorder, meaning psychosomatic, and they never go to the cardiologist or get a catheter […]. Such a female clientele. […] They are usually more sensitive." [P-08, 26f, 100f.]
P-04: “I referred her[...].” I: “What led you to this decision?” P-04: “Yes, the pre-existing illness [diabetes mellitus II] and her non-compliance [...]. And of course, the fact that the symptoms of heart attacks in women are often very mild or not so typical; so you always have to be more careful.” [P-04, 25ff.]
“So it is also a reassurance for the patient if she is sent to the cardiologist. That means that maybe there does not have to be anything, but she knows that she can always have the referral to the cardiologist, and that ultimately gives her a piece of security.” [P-03, 96]
“So, if a patient exerts pressure, if he says, "I want to see a cardiologist", of course, I do not start discussing. Well, I would refer him, I would say "I don't think you have anything, but then go".“ [P-01, 116]