NR 715 Week 4 Discussion Qualitative Study Critique

Student Name

Chamberlain University

NR 715 Week 1 The Theory- Practice Gap and Nursing Research

Prof. Name:

Date

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

Permalink: Chamberlain Library AccessBackground of the Study

Chronic illnesses, particularly coronary artery disease (CAD), are on the rise globally and pose a significant burden on healthcare systems. Ensuring timely and appropriate referrals from primary care providers (PCPs) to specialists is a critical component of managing these patients effectively. Inappropriate or delayed referrals increase the risk of severe complications, including fatal outcomes. Previous research has shown that strengthening referral processes contributes to better care delivery and improved patient safety (Greenwood-Lee et al., 2018).

This article is particularly meaningful as it explores the decision-making processes of PCPs regarding referrals for suspected CAD and identifies the determinants that influence those decisions. By examining the thresholds at which PCPs decide to refer, the study provides a clearer picture of the challenges that may hinder timely interventions. It also emphasizes how PCPs’ past experiences shape their clinical judgment and subsequent care strategies.

Personal Reflection

What stood out in the article?
The most striking element in this article was the issue of mistrust between PCPs and specialists. Some PCPs intentionally delayed or withheld referrals due to concerns that specialists might proceed with invasive procedures prematurely. This not only reflects professional disagreements but also introduces ethical challenges in patient care.

The candid nature of participants’ reflections made the study more authentic. Their willingness to openly share both frustrations and ethical dilemmas highlighted the importance of reflective practice in clinical decision-making. For me, this transparency demonstrated a valuable step toward addressing referral barriers and improving collaboration across the healthcare continuum.

Method and Design

The researchers employed a qualitative research design using semi-structured interviews with PCPs. A “stimulated recall” technique was applied, where participants reviewed specific cases of suspected CAD patients and reflected on the reasoning behind their referral choices.

Interviews were recorded, transcribed verbatim, and analyzed using a combination of inductive and deductive thematic content analysis. This ensured that both existing theoretical frameworks and new themes emerging from the data were addressed. The Pauker and Kassirer decision threshold model was used to interpret PCPs’ referral thresholds.

The interviews also addressed broader topics, including interprofessional collaboration, system-level influences, and patient perspectives. The thematic coding framework was guided by both previous literature and the research team’s collective expertise.

Aim and Purpose

The primary purpose of the study was to analyze how PCPs determine referral thresholds for suspected CAD cases and what factors influence these decisions. By allowing participants to speak in a natural, conversational tone, the researchers encouraged richer descriptions of real-world challenges, professional reasoning, and experiential reflections. This approach provided deeper insights into the complexity of decision-making in primary care.

Sample Size and Characteristics

The study involved nine PCPs from Germany, contributing reflections on 26 patient cases. Participants represented both urban and rural settings, had varied professional experience, and included a balanced representation of gender. All participants were affiliated with a university research network, which likely enhanced motivation and engagement in the study.

Each PCP was asked to recall three patients from the previous two weeks where they had considered—but were uncertain about—referrals for coronary angiography. Patient ages ranged from 40 to 90 years, with an average age of 68 years. Interviews took place in PCPs’ offices and lasted between 26 and 62 minutes.

Research Findings

The study identified a range of factors that shaped PCPs’ referral decisions. These were categorized into patient-related, provider-related, practice environment, and system-level determinants.

Key Influencing Factors:

Patient-Related Factors: Symptoms, comorbid conditions, prior medical history.
Practice Environment: Resource availability and accessibility of specialist services.
Provider-Related Factors: PCPs’ personal clinical judgment, degree of trust in specialists, and concerns regarding unnecessary invasive interventions.
System-Level Factors: Oversupply of specialists, weak gatekeeping systems, and poor coordination across healthcare levels.

One critical finding was that mistrust between PCPs and specialists sometimes discouraged timely referrals. PCPs expressed worry that some cardiologists were too quick to recommend invasive procedures, which influenced their hesitation to refer. The study thus pointed to the need for stronger system-level oversight and better communication between providers.

Strengths and Limitations

Strengths	Limitations
Inclusion of nine PCPs with diverse demographics and practice settings	Potential social desirability bias influencing participant responses
Recruitment through a university research network ensured high participant motivation	Reliance on self-reported data instead of direct observation
Achieved variation in gender, age, and clinical experience	Consideration of selected cases rather than consecutive patients
Use of “stimulated recall” improved depth of reflection	Findings limited to German healthcare context
Application of the Pauker and Kassirer Threshold Model	Small sample size reduces generalizability

Evidence Appraisal

Using the Johns Hopkins Evidence Appraisal Tool, this qualitative study is classified as Level III evidence, given its non-experimental design. The quality rating is between A and B, which indicates that the research maintains a strong methodological framework while being subject to some limitations inherent to qualitative inquiry.

Conclusion

This study sheds light on the multifaceted nature of referral decisions in suspected CAD cases. It demonstrates that PCPs’ decisions are shaped not only by clinical symptoms but also by interpersonal trust, past experiences, and systemic healthcare challenges. The findings underscore the urgent need for improved collaboration between PCPs and specialists, stronger gatekeeping roles for primary care, and system-level reforms to streamline referral pathways. Addressing these areas could minimize delays, prevent missed diagnoses, and ultimately improve patient outcomes in the management of CAD.

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