Bowling Ann, Harries Clare, Forrest Damien, Harvey Nigel
Department of Primary Care and Population Sciences, University College London, Royal Free Campus, London, UK.
Fam Pract. 2006 Aug;23(4):427-36. doi: 10.1093/fampra/cmi125. Epub 2006 Apr 12.
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.
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.
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.
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.
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.
按临床专科调查心脏介入治疗的转诊率，记录医生转诊的原因，并探究医生对影响其临床决策因素的看法。
医生完成了一项临床决策练习，总共涉及6093名患有心脏病的电子病历患者，随后参与了关于影响其决策因素的半结构化访谈。访谈进行了录音、转录，并采用主题方法进行编码，编码类别源于数据。
88名医生（全科医生、老年护理专家、心脏病专家）参与了在英格兰南部、中部和北部七个地区进行的全面研究。对其中76名医生的完整访谈数据进行了分析。
并非所有符合特定检查或治疗条件的患者都接受了这些检查或治疗。临床决策的差异程度因干预类型而异。除了转诊的一般原因外，医生还提出了对其实际决策的九个主要影响因素。最常报告的影响因素（“障碍”）是干预设备获取困难，这提高了检查和治疗的门槛。
英国国民医疗服务体系（NHS）目前对实现目标的强调导致了对易于衡量但粗略的过程目标（如等候名单）的关注。本研究指出，需要纳入更广泛的质量保证要素，以调查导致临床决策差异从而导致治疗不公平的一系列系统故障。
