Name
Chamberlain University
NR-715: Scientific Underpinnings
Prof. Name
Date
Winkler, K., Gerlach, N., Donner-Banzhoff, N., Berberich, A., Jung-Henrich, J., & Schlößler, K. (2023). Determinants of referral for suspected coronary artery disease: A qualitative study based on decision thresholds. BMC Primary Care, 24(1), 110. https://doi.org/10.1186/s12875-023-02064-y
Permalink: Chamberlain Library Access
Chronic illnesses such as coronary artery disease (CAD) continue to rise globally and remain one of the leading causes of morbidity and mortality. This ongoing increase has placed significant strain on healthcare systems, particularly in the coordination between primary care providers (PCPs) and specialists. Optimal patient care requires seamless referrals; however, delayed, unnecessary, or inappropriate referrals may put patients at risk for worsened health outcomes.
Existing literature emphasizes the importance of strengthening referral systems to improve patient outcomes. For example, Greenwood et al. (2018) noted that poor referral practices lead to increased system inefficiencies, missed diagnoses, and higher patient mortality.
This study is particularly relevant because it explores the decision-making process of PCPs in determining when to refer patients with suspected CAD. By examining thresholds for referral, the study sheds light on both systemic and individual-level factors that affect patient care. Notably, the findings indicate that missed or late referrals often result in negative outcomes, and PCPs’ prior experiences significantly shaped their future decisions.
One striking observation in the article is the reported mistrust between PCPs and specialists, where some PCPs hesitated or even avoided making referrals. Such reluctance created ethical dilemmas and raised concerns about patient safety. It also highlighted potential conflicts of interest, as some PCPs prioritized avoiding unnecessary procedures over timely diagnosis.
I found it commendable that participants shared honest reflections about their challenges and uncertainties. Their willingness to express personal experiences added authenticity to the study’s findings. This openness underscores the importance of self-reflection in clinical practice, where transparency can serve as a tool for professional growth and the advancement of patient-centered care.
The researchers employed a qualitative study design using semi-structured interviews to explore referral practices. A distinctive feature of the study was the use of “stimulated recall”, which encouraged PCPs to revisit specific patient cases involving suspected CAD.
Data Collection: Interviews were audio-recorded, transcribed verbatim, and analyzed thematically using both inductive and deductive coding strategies until thematic saturation was achieved.
Analytical Framework: The Pauker and Kassirer decision threshold model was utilized to interpret PCPs’ clinical reasoning and referral thresholds.
Content of Interviews: In addition to individual referral decisions, the interviews examined clinical strategies, inter-professional collaboration, healthcare system influences, and patient perspectives.
This multi-layered approach provided a comprehensive understanding of referral dynamics and illuminated how different levels of influence interact in real clinical settings.
The primary aim of the study was to examine how PCPs determine whether to refer patients with suspected CAD to specialists. Specifically, it sought to identify the determinants that shaped their decisions.
The conversational tone of the interviews allowed participants to share candid stories and reflections, thereby ensuring authenticity in the data. This design emphasized both clinical judgment and the real-world complexities of referral decision-making.
The study recruited nine PCPs from Germany, who collectively shared 26 patient cases. The sample was selected for diversity across several dimensions:
Geographic Location: Both rural and urban practices were represented.
Demographics: Participants varied in gender and professional experience.
Recruitment Source: All PCPs were part of a university research network, which likely contributed to high levels of engagement and credibility.
Interviews, lasting 26 to 62 minutes, were conducted in the participants’ workplaces. Each provider discussed three patients from the past two weeks where referral decisions were uncertain. The patient cases ranged in age from 40 to 90 years, with an average age of 68.
The study identified four major categories of determinants influencing PCPs’ referral decisions:
| Category | Key Factors |
|---|---|
| Patient-Related | Symptom presentation, comorbidities, past medical history, and patient preferences |
| Provider-Related | Clinical judgment, risk perception, experience, trust (or mistrust) in specialists |
| Practice Environment | Accessibility to diagnostic resources, proximity to cardiologists, availability of support staff |
| System-Level | Oversupply of specialists, weak gatekeeping roles, fragmented communication, lack of coordinated pathways |
One of the most significant findings was the mistrust between PCPs and specialists. PCPs often feared that referrals would result in unnecessary invasive interventions rather than appropriate diagnostic testing. This concern frequently delayed referrals, potentially putting patients at risk.
The results also highlighted systemic weaknesses, such as insufficient regulation of the specialist workforce, which undermined PCPs’ effectiveness as gatekeepers.
| Strengths | Limitations |
|---|---|
| Inclusion of nine diverse PCPs from different settings | Risk of social desirability bias in participant responses |
| Recruitment from a university research network, ensuring motivated participants | Reliance on self-reported cases rather than real-time observation |
| Variation in demographics (age, gender, and clinical experience) | Consideration of selected cases instead of consecutive patient encounters |
| Use of “stimulated recall” enhanced reflective depth | Findings restricted to the German healthcare context |
| Application of Pauker and Kassirer Threshold Model strengthened interpretation | Small sample size, limiting generalizability |
Using the Johns Hopkins Appraisal Tool, this study was classified as Level III evidence, reflecting its non-experimental, qualitative design.
Strength of Evidence: Moderate to strong (rated between A and B).
Quality Assessment: The study demonstrates methodological rigor but is limited by sample size and contextual restrictions.
Despite these limitations, the research contributes valuable insights into the clinical decision-making process in CAD referral practices.
This study offers critical insights into the complex decision-making processes of PCPs regarding referrals for suspected CAD. It emphasizes how patient presentation, provider judgment, interpersonal trust, and systemic healthcare factors collectively shape referral thresholds.
The findings underscore the need for:
Strengthened referral pathways to avoid delayed or inappropriate referrals.
Enhanced collaboration and trust between PCPs and specialists.
Greater emphasis on gatekeeping roles within primary care.
Improving these aspects may significantly reduce missed opportunities for timely diagnosis and improve overall patient outcomes in CAD management.
Greenwood-Lee, J., Jewett, L., Woodhouse, L., et al. (2018). A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC Health Services Research, 18, 986. https://doi.org/10.1186/s12913-018-3745-y
Winkler, K., Gerlach, N., Donner-Banzhoff, N., Berberich, A., Jung-Henrich, J., & Schlößler, K. (2023). Determinants of referral for suspected coronary artery disease: A qualitative study based on decision thresholds. BMC Primary Care, 24(1), 110. https://doi.org/10.1186/s12875-023-02064-y
