Variations in use of cardiac services in England: perceptions of general practitioners, general physicians and cardiologists.

OBJECTIVE: To explain why those who live some distance from tertiary cardiac centres make less use of coronary angiography and revascularisation than those who live close by, and why people living in particular wards within certain districts make less use of services than might be expected from their level of need.
METHOD: Semi-structured interviews with 24 general practitioners (GPs) in two English health districts (Morecambe Bay and East Lancashire), five general physicians working in district general hospitals, and four interventional cardiologists working in tertiary centres. Transcripts of audiotape recordings were analysed using the constant comparative method.
RESULTS: Those living far from tertiary centres are usually referred to general physicians before they are referred for angiography. The general physicians tend to be more conservative in their approach to treatment than interventional cardiologists. GPs working near tertiary centres are able to refer directly to interventional cardiologists. There are also logistical and economic reasons for inequitable use of services. Some GPs perceived that patients of South Asian descent undergo fewer investigations than might be expected because of communication or other difficulties.
CONCLUSION: Use of cardiac services would be more equitable if there were interventional cardiologists based in district general hospitals who could perform angiograms for their own patients in the tertiary centres. Patients might also benefit in angiograms could be conducted in selected district general hospitals. Further qualitative research, involving both doctors and patients, is needed to explore other reasons for relatively low rates of investigation and revascularisation in certain groups of patients.