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Reasons Why Physicians Choose Not to Refer Their Patients

Cindy H. Lee, MD; Mary Tan, BSc; Andrew T. Yan, MD; Raymond T. Yan, MD; David Fitchett, MD; Etienne A. Grima, MSc; Anatoly Langer, MD, MSc; Shaun G. Goodman, MD, MSc; for the Canadian Acute Coronary Syndromes (ACS) Registry II Investigators

Arch Intern Med. 2008;168(3):291-296.

Background  Despite the recommendation for an early invasive strategy in the treatment of patients who present with non–ST-segment elevation (NSTE) acute coronary syndromes (ACS), referral for cardiac catheterization is suboptimal; the reasons why some patients are not referred remain unclear.

Methods  Patients were recruited into the prospective, observational Canadian ACS Registry II between October 1, 2002, and December 31, 2003; 2136 patients with NSTE ACS identified through the registry were divided into tertiles according to the Thrombolysis in Myocardial Infarction risk score and the rates of catheterization compared. In addition, the most responsible physicians were asked to indicate the main reason they did not refer their patients for catheterization.

Results  The rate of referral for catheterization was 64.7%. Patients who underwent catheterization had lower in-hospital (0.8% vs 3.7%; P < .001) and 1-year mortality rates (4.0% vs 10.9%; P < .001) compared with those who did not. Higher-risk patients were referred at a similar rate as low-risk patients (62.5% vs 66.9%; P = .25). Among the reasons provided by the most responsible physician as to why patients were not referred for catheterization, 68.4% of patients were thought to be "not at high enough risk"; however, 59.1% of these patients were found to be at intermediate to high risk according to their baseline Thrombolysis in Myocardial Infarction risk score.

Conclusions  Cardiac catheterization is not used optimally in patients who present with NSTE ACS. Despite better in-hospital and 1-year outcomes in those patients who are referred for catheterization, many higher-risk patients are not being referred because of the perception that they are not at high enough risk. A significant opportunity remains to improve on accurate risk stratification and adherence to an early invasive strategy for higher-risk patients.

Author Affiliations: The Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto (Drs Lee, A. T. Yan, R. T. Yan, Fitchett, and Goodman), and the Canadian Heart Research Centre (Ms Tan, Mr Grima, and Drs A. T. Yan, Fitchett, Langer, and Goodman), Toronto, Ontario.
Group Information: A list of participating Canadian ACS Registry II Investigators and Coordinators was published in Arch Intern Med. 2007;167:1009-1016.

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