Barriers to referral in patients with angina: qualitative study Commentary: Generalisability and validity in qualitative research

Abstract

Abstract Objectives: To explore barriers to patients being referred for possible revascularisation. Design: Qualitative study using semi-structured interviews. Participants: 16 patients aged under 75 years with stable angina and their doctors. Setting: General practice in Toxteth, Liverpool. Results: Fear of both hospitals and medical tests was common and largely hidden from the doctors. Patients felt they were old, had low expectations of treatment, viewed angina as a chronic illness, and knew little about new developments in angina treatment. Patients and doctors had difficulty in recognising angina symptoms that were not textbook definitions amid multiple comorbidity. Patients saw doctors as busy and did not want to bother them with their condition. Cultural gaps and communication difficulties existed despite all but one patient having English as their first language. Conclusions: Listening to patients is vital to address inequitable access to health services: how patients are treated by doctors today affects acceptability of referral tomorrow. Primary care groups in deprived areas should work with communities to address local fears. This will involve collaboration between primary, secondary, and tertiary care Cultural gaps exist between patients and doctors in deprived areas, and diagnostic confusion can occur particularly in the presence of other psychological and physical morbidity. Adequate time and resources—for example, education for doctors and patients and provision of interpreters—need to be provided if inequitable access to revascularisation procedures is to be addressed. Key messages In different communities and patient groups different myths and fears operate and need to be addressed, as experiences of hospital can profoundly affect patients9 confidence Patients in deprived areas with high mortality rates perceive themselves as “old” at a young age, and expectations of treatment are limited Angina symptoms in inner city primary care may not be the same as those in a textbook, and this has implications for care of patients Cultural gaps exist even between committed doctors and their patients in deprived areas—time and resources are needed to address these gaps Qualitative studies are necessary to understand quantitative evidence of inequitable access to specialist health services