Variations in cardiac interventions: doctors' practices and views.
OBJECTIVE
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.


METHODS
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.


METHODS
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.


RESULTS
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.
Bowling
Ann
A
Department of Primary Care and Population Sciences, University College London, Royal Free Campus, London, UK. a.bowling@ucl.ac.uk
Harries
Clare
C
Forrest
Damien
D
Harvey
Nigel
N
D002309:Cardiology / Q000592:standards; D017023:Coronary Angiography; D003657:Decision Making; D005080:Exercise Test; D005194:Family Practice / Q000592:standards; D006331:Heart Diseases / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D007407:Interviews as Topic; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000592:standards; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D006113:United Kingdom; D014850:Waiting Lists