Referrals and Black-White Coronary Heart Disease Treatment Disparities: A Qualitative Study of Primary Care Physician Perspectives.

Background: Black-White coronary heart disease (CHD) treatment disparities are well documented, especially regarding the use of high-quality hospitals. Physician referral networks may play a role.

Objective: To understand how primary care physicians (PCPs) make specialty referrals for CHD treatment and how referrals may contribute to treatment disparities.

Design: Qualitative study using semi-structured interviews and focus group discussions.

Participants: We purposively recruited 45 PCPs (50 invited, 90% response rate) in three metro areas with high Black-White segregation of cardiac care networks (New York City; Chicago; Atlanta).

Approach: We developed the focus group discussion guide from interviews and current literature. We conducted two focus groups per metro area via Zoom. Two expert team members independently coded the transcripts using inductive techniques and analyzed focus group content and themes using Dedoose.

Key results: Most participants were male (62.2%), White (57.8%), and practiced for at least 23 years. We identified several recurrent themes for factors influencing cardiology referrals. The most frequently mentioned themes were heavy reliance on professional networks, specialist availability, timeliness, communication style, patient geographic and economic constraints, and patient preferences. PCPs used anecdotal and not data-driven evidence to assess hospital quality and viewed Black-White differences in high-quality hospital use as due to patient economic status and preferences or differences in hospital access and provider referral bias.

Conclusion: PCPs' referral decisions for CHD treatment are primarily driven by access to specific professional networks and the socioeconomic circumstances of their patients. Nevertheless, PCPs strive to make the best available decisions, leaning into their networks and honoring patient preferences. While PCPs acknowledged existing disparities, they attributed them to patient and system factors rather than provider referral bias. Mitigating disparities will require interventions to improve minority-serving providers' formal and informal connections with high-quality specialists and hospitals, address patient socioeconomic constraints, and train providers to recognize their potential biases and misconceptions.