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Abstract
Background: Elderly patients with cardiovascular disease are relatively undertreated and undertested.
Objectives: To investigate whether, and how, individual doctors are influenced by a patient’s age in their investigation and treatment of angina.
Design: Process-based judgment analysis using electronic patients, semistructured interviews.
Setting: Primary Care, Care of the Elderly and Cardiology in England.
Participants: Eighty five doctors: 29 cardiologists, 28 care of the elderly specialists and 28 general practitioners (GPs).
Main outcome measures: Testing and treatment decisions on hypothetical patients.
Results: Forty six per cent of GPs and care of the elderly doctors, and 48% of cardiologists treated patients aged 65+ differently to those under 65, independent of comorbidity. This effect was evident on several decisions: elderly patients were less likely to be prescribed a statin given a cholesterol test, referred to a cardiologist, given an exercise tolerance test, angiography and revascularisation; more likely to have their current prescriptions changed and to be given a follow-up appointment. There was no effect of specialty, gender or years of training on influence of patient age. Those doctors who were influenced by age were on average five years older than those who were not. Interviews revealed that some doctors saw old age as a contraindication to treat.
Conclusions: Age, independent of comorbidity, presentation and patients’ wishes, directly influenced decision-making about angina investigation and treatment by half of the doctors in the primary and secondary care samples. Doctors explicitly reasoned about the direct influence of age and age-associated influences.
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Footnotes
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↵i Where appropriate, information was tailored: alcohol consumption and specifics of blood tests were related to patient sex, town of birth to ethnic origin, retirement to age, and, where a patient’s notes suggested they were allergic to aspirin, clopidogrel was listed as the antiplatelet medication.
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↵ii Angiogram levels, 12 lead electrocardiogram (ECG) levels, thallium scan levels, exercise tolerance test (ETT) levels, echocardiogram, chest x ray (male and female different), abdominal ultrasound (male and female different), barium swallow (one, normal), and computed tomography (CT) scan (one, normal).
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↵iii Department of Health statistics on sex and age group only were obtained from the RCGP website20 and on sex, age and ethnic group from the Department of Health Medical and Dental Workforce Census. To avoid low cell counts, age was categorised as <40 years and 40+ years.
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↵iv Two other doctors (n = 87) also participated in the study but their data files became corrupted and their responses on the Clinical Judgment Analysis (CJA) exercise are not included in our analyses. Two cardiologists, and three care of the elderly doctors completed all but 4, 7, 4, 7 and 5 cases respectively on the CJA task. The rest of their data are included in the analyses.
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Funding: This project was funded by the Economic and Social Research Council grant R000238247. The funding body made no contribution to the design, analysis, interpretation of data, write-up of the report, nor the decision to submit it for publication.
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Competing interests: none.
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Ethics approval: not required.
Contributors: Clare Harries is guarantor of this paper: She accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. CH, NH, DF and AB designed the study materials; CH, with input from DF, carried out the programming for the CJA task; DF conducted the fieldwork and the interviews; CH, with advice from AM, analysed the CJA data. AB categorised the interview data by theme and analysed it. CH and AB planned the analyses and wrote the final draft of this paper. All co-investigators contributed intellectually to this paper.
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