Qureshi Nabeel, Berry Sandra, Damberg Cheryl L, Gibson Ben, Popescu Ioana
RAND Corporation, Los Angeles, USA.
David Geffen School of Medicine, UCLA, Los Angeles, USA.
J Gen Intern Med. 2024 Nov 13. doi: 10.1007/s11606-024-09175-x.
Black-White coronary heart disease (CHD) treatment disparities are well documented, especially regarding the use of high-quality hospitals. Physician referral networks may play a role.
To understand how primary care physicians (PCPs) make specialty referrals for CHD treatment and how referrals may contribute to treatment disparities.
Qualitative study using semi-structured interviews and focus group discussions.
We purposively recruited 45 PCPs (50 invited, 90% response rate) in three metro areas with high Black-White segregation of cardiac care networks (New York City; Chicago; Atlanta).
We developed the focus group discussion guide from interviews and current literature. We conducted two focus groups per metro area via Zoom. Two expert team members independently coded the transcripts using inductive techniques and analyzed focus group content and themes using Dedoose.
Most participants were male (62.2%), White (57.8%), and practiced for at least 23 years. We identified several recurrent themes for factors influencing cardiology referrals. The most frequently mentioned themes were heavy reliance on professional networks, specialist availability, timeliness, communication style, patient geographic and economic constraints, and patient preferences. PCPs used anecdotal and not data-driven evidence to assess hospital quality and viewed Black-White differences in high-quality hospital use as due to patient economic status and preferences or differences in hospital access and provider referral bias.
PCPs' referral decisions for CHD treatment are primarily driven by access to specific professional networks and the socioeconomic circumstances of their patients. Nevertheless, PCPs strive to make the best available decisions, leaning into their networks and honoring patient preferences. While PCPs acknowledged existing disparities, they attributed them to patient and system factors rather than provider referral bias. Mitigating disparities will require interventions to improve minority-serving providers' formal and informal connections with high-quality specialists and hospitals, address patient socioeconomic constraints, and train providers to recognize their potential biases and misconceptions.
黑人和白人在冠心病（CHD）治疗方面的差异有充分记录，尤其是在使用高质量医院方面。医生转诊网络可能起到了一定作用。
了解初级保健医生（PCP）如何进行冠心病治疗的专科转诊，以及转诊如何导致治疗差异。
采用半结构化访谈和焦点小组讨论的定性研究。
我们在心脏护理网络黑人和白人高度隔离的三个大都市地区（纽约市、芝加哥、亚特兰大）有目的地招募了45名初级保健医生（邀请了50名，回复率为90%）。
我们根据访谈和现有文献制定了焦点小组讨论指南。我们通过Zoom在每个大都市地区进行了两个焦点小组讨论。两名专家团队成员使用归纳技术对转录本进行独立编码，并使用Dedoose分析焦点小组的内容和主题。
大多数参与者为男性（62.2%），白人（57.8%），且从业至少23年。我们确定了影响心脏病学转诊因素的几个反复出现的主题。最常提到的主题是严重依赖专业网络、专科医生可用性、及时性、沟通方式、患者的地理和经济限制以及患者偏好。初级保健医生使用轶事证据而非数据驱动的证据来评估医院质量，并将高质量医院使用方面的黑白差异归因于患者的经济状况和偏好，或医院就医机会和提供者转诊偏见的差异。
初级保健医生对冠心病治疗的转诊决定主要受特定专业网络的可及性及其患者的社会经济状况驱动。然而，初级保健医生努力做出最佳决策，依靠他们的网络并尊重患者偏好。虽然初级保健医生承认存在现有差异，但他们将其归因于患者和系统因素，而非提供者转诊偏见。减少差异将需要采取干预措施，以改善为少数族裔服务的提供者与高质量专科医生和医院的正式和非正式联系，解决患者的社会经济限制，并培训提供者认识到他们潜在的偏见和误解。
