Which doctors are influenced by a patient's age? A multi-method study of angina treatment in general practice, cardiology and gerontology

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.

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

“…Physicians saw old age as having an influence because of its association with frailty, co-morbidity, the nature and duration of potential benefit of the treatment and patient's wishes regarding intervention. 58 In contrast, a study from Germany found that older patients were more likely than younger patients to be diagnosed with coronary heart disease and had a greater likelihood of receiving appropriate medication. 45 This German study used hypothetical experimental scenarios with primary care physicians and so the results may not be generalizable.…”

“…57 There is a direct influence of patient's age on decision-making about angina investigation and treatment. 58 Older patients were less likely to be referred to cardiologists and if referred were less likely to receive cardiovascular interventions. Physicians saw old age as having an influence because of its association with frailty, co-morbidity, the nature and duration of potential benefit of the treatment and patient's wishes regarding intervention.…”

Ageism in the Health Care System: Providers, Patients, and Systems

“…Further, in a sample of junior doctors in Singapore, personal and professional background characteristics such as age, marital status, living arrangements and years in medical practice were not associated with attitudes towards older adults (Lui and Wong 2009). Harries and colleagues (Harries et al 2007) found no effect of medical specialty on attitudes and clinical decision making in response to patient vignettes. However, other researchers report such differences, e.g.…”

Pharmacotherapy in the ageing patient: The impact of age per se (A review)

“…Thirteen studies focussed on cardiac conditions, of which ten specifically explored medication underutilisation in atrial fibrillation. Four studies investigated the influence of patient age on clinicians' treatment decisions (Hajjar et al, 2002;Fraenkel et al, 2006;Harries et al, 2007;Kievit et al, 2010).…”