NR 715 Week 4 Discussion Qualitative Study Critique

Qualitative Article Critique

Article Reference

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

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Background of the Study

Chronic illnesses such as coronary artery disease (CAD) continue to increase globally and remain among the leading causes of morbidity and mortality. This growing burden has placed considerable strain on healthcare systems, especially regarding coordination between primary care providers (PCPs) and specialists. Effective patient management requires timely and appropriate referrals; however, delays or inappropriate referrals may negatively affect patient outcomes.

Existing studies emphasize the need for improving referral systems to enhance patient safety and healthcare efficiency. For instance, Greenwood et al. (2018) found that poor referral practices often lead to inefficiencies, missed diagnoses, and increased mortality rates.

This article explores how PCPs decide when to refer patients with suspected CAD, focusing on decision thresholds and influencing factors. The study reveals that delayed or missed referrals often lead to poor patient outcomes and that previous clinical experiences significantly shape future referral decisions.

Personal Reflection

One noteworthy observation from the study is the evident mistrust between PCPs and specialists. Some PCPs expressed hesitation or reluctance to refer patients due to fears of over-intervention or unnecessary procedures. This dynamic created ethical challenges and posed risks to patient safety, highlighting potential conflicts of interest.

It was commendable that the participants candidly reflected on their professional challenges and uncertainties. Their openness enriched the study’s authenticity and underlined the importance of self-reflection in clinical practice. Such transparency supports ongoing professional growth and strengthens patient-centered care.

Method and Design

The researchers adopted a qualitative study design utilizing semi-structured interviews to investigate referral behaviors among PCPs. A distinctive aspect of the methodology was the use of “stimulated recall”, which encouraged participants 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 until thematic saturation was achieved.

Analytical Framework: The Pauker and Kassirer decision threshold model guided the analysis, offering a structured framework for interpreting PCPs’ reasoning and referral thresholds.

Interview Content: The interviews covered topics such as individual referral choices, collaboration with specialists, system-level challenges, and patient factors. This multi-dimensional approach offered a comprehensive understanding of the influences affecting referral practices.

Aim and Purpose

The primary aim of the study was to investigate how PCPs determine whether to refer patients with suspected CAD to specialists. Specifically, it sought to identify the determinants shaping these decisions.

The conversational and reflective tone of the interviews encouraged openness and authenticity, enabling participants to share real-world clinical experiences. This approach highlighted the complexity of clinical judgment in referral decision-making.

Sample Size and Characteristics

The study involved nine PCPs from Germany, collectively discussing 26 patient cases. The sample was deliberately diverse across several dimensions to ensure representativeness.

Each PCP discussed three recent patient cases in which referral decisions were uncertain.

Research Findings

The study identified four key categories influencing PCPs’ referral decisions for suspected CAD.

One of the most critical findings was the mistrust between PCPs and specialists, where PCPs feared unnecessary invasive interventions. This mistrust often delayed referrals, compromising patient care. Systemic issues, including poor regulation of the specialist workforce, also weakened the gatekeeping role of primary care.

Strengths and Limitations

Evidence Appraisal

According to the Johns Hopkins Appraisal Tool, this study is classified as Level III evidence, representing non-experimental, qualitative research.

• Strength of Evidence: Moderate to strong (rated between A and B)

• Quality Assessment: The study exhibits methodological rigor despite contextual and sample-size limitations.

Overall, it provides valuable insights into how clinical, interpersonal, and systemic factors influence referral decisions in CAD management.

Conclusion

This qualitative study offers a nuanced understanding of how PCPs navigate referral decisions for suspected CAD. The findings demonstrate that clinical judgment, patient presentation, inter-professional trust, and systemic constraints collectively shape referral thresholds.

The study underscores the importance of:

• Strengthening referral pathways to prevent delays or inappropriate referrals.

• Promoting trust and collaboration between PCPs and specialists.

• Reinforcing gatekeeping functions within primary care.

Implementing these recommendations can help improve the timeliness and appropriateness of referrals, ultimately enhancing patient outcomes in CAD management.

References

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

NR 715 Week 4 Discussion Qualitative Study Critique

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