Article Text

Original research article
Qualitative study of cardiologists’ perceptions of factors influencing clinical practice decisions
  1. Veena Manja1,
  2. Gordon Guyatt2,
  3. John You3,
  4. Sandra Monteiro2,
  5. Susan Jack4
  1. 1Department of Surgery, University of California Davis, Davis, California, USA
  2. 2Department of Health Research Methods, Evidence and Impact McMaster University, Hamilton, Ontario, Canada
  3. 3Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  4. 4School of Nursing, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr Veena Manja, Department of Surgery, University of California Davis, Sacramento, CA 95817, USA; vmanja{at}


Background Healthcare costs are increasing in the USA and Canada and a substantial portion of health spending is devoted to services that do not improve health outcomes. Efforts to reduce waste by adopting evidence-based clinical practice guideline recommendations have had limited success. We sought insight into improving health system efficiency through understanding cardiologists’ perceptions of factors that influence clinical decision-making.

Methods In this descriptive qualitative study, we conducted in-depth interviews with 18 American and 3 Canadian cardiologists. We used conventional content analysis including inductive and deductive approaches for data analysis and mapped findings to the ecological systems framework.

Results Physicians reported that major determinants of practice included interpersonal interactions with peers, patients and administrators; financial incentives and system factors. Patients’ insurance status represented an important consideration for some cardiologists. Other major influences included time constraints, fear of litigation (less prominent in Canada), a sense that their obligation was never to miss any underlying pathology, and patient demands. The need to bring income into their health system influenced American cardiologists’ practice; personal income implications influenced Canadian cardiologists’ practice. Cardiologists reported that knowledge limitations and logistical challenges limit their ability to assist patients with cost considerations. All these considerations were more influential than guidelines; some cardiologists expressed a high level of scepticism regarding guidelines.

Conclusions Clinical decision-making by cardiologists is shaped by individual, interpersonal, organisational, environmental, financial and sociopolitical influences and only to a limited extent by guideline recommendations. Successful strategies to achieve efficient, evidence-based care will require addressing socioecological influences on decision-making.

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

Statistics from


  • Contributors VM contributed to the conception, and all authors to the planning and design of the work. VM contributed to acquisition, VM and SJ to the analysis and all authors to the interpretation of data. VM drafted the initial draft of the manuscript which was revised based on extensive input from all authors. All authors give final approval of the version published. VM is responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The Institutional Review Board at the University at Buffalo, Buffalo, New York, USA and the Hamilton Integrated Research Ethics Board at McMaster University, Hamilton, Ontario, Canada.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles