• health care economics
• quality and outcomes of care
• echocardiography

Why do well-meaning cardiologists deviate from practice guidelines? In their  Heart paper, Manja and colleagues tackle this timely topic1 and build on their earlier work evaluating drivers of guideline-discordant care.2 In the first phase of this study, cardiologists reviewed case vignettes and rated how various contextual factors influenced their clinical decisions. Manja et al found that the extent to which participating cardiologists prioritised safety, effectiveness and patient-centeredness in their decisions had little bearing on their adherence to guidelines.2

The second phase of this study uses qualitative methods to delve deeper into this discordance. After conducting standardised interviews with 21 cardiologists in various practice settings, the authors used an ecosystem theory framework to explore why clinicians’ decision-making may not reflect accepted guidelines. This elegant study was methodologically strong and considered patient-level, physician-level, system-level, and cultural-level influences on medical decision-making. In brief, the authors found that cardiologists experience tension between controlling costs through guideline-based care and weighing other factors such as peer pressure, local norms, patient expectations, medicolegal considerations and financial incentives.1 Ultimately, clinicians often succumb to these latter factors despite championing cost-effectiveness and evidence-based medicine.

These findings are at once insightful and perhaps unsurprising. Though few studies have scrutinised decision-making within cardiovascular medicine, a large body of the literature corroborates this study’s conclusions. Synthesising findings from myriad sources, Saini et al previously categorised drivers of poor medical decisions into three domains: (1) economical, financial and organisational structures; (2) failures in the production, dissemination and application of medical knowledge and (3) the distribution of social power and tensions in interpersonal relationships.3 Clearly, the participants in the study by Manja and colleagues echoed how these domains translate into competing value systems that ultimately impact clinicians’ daily decisions.

While Manja et al focused on factors that cardiologists could readily articulate, …