SMJ 2003: 48(1) 13-16
Andrew
D McGavigan, Paul E Begley, Joanne Moncrieff, Kerry
Address for correspondence
Andrew McGavigan
Department
of Cardiology
Stobhill
Hospital
Glasgow
G22
3UW
Email: amcgav@hotmail.com
Abstract
Rapid
access chest pain clinics are expanding across the country with marked resource
implications despite a paucity of data regarding their efficacy. Early
assessment of patients in this manner potentially delays review of patients
referred via the traditional route. We conducted a prospective observational
study of patients referred with chest pain to the Cardiology Outpatient
Department over a four-week period in a District General Hospital to compare
demographics and outcomes in patients referred to the rapid access with those
referred to the general cardiology clinics. There were no significant
differences in baseline demographics, exercise test result or clinic outcome.
Both populations were low risk. Discussion is needed between primary and
secondary care to achieve a consensus as to the purpose of a rapid access system
and how best to utilise the service appropriately. Further studies are required
to assess the efficacy and health economics of this system.
Key
words: Rapid
access; National Service Framework; Chest pain
Introduction
Coronary heart disease (CHD) is the single biggest contributor to morbidity and mortality in the UK (1) . It accounts for over 300,000 myocardial infarctions every year in the United Kingdom and over 2 million patients have angina (2) . The assessment of patients with chest pain has considerable resource implications for inpatient, outpatient and emergency services with over 22,000 patients presenting with new onset exertional chest pain each year in the UK (3) . The recent National Service Framework (NSF) for England and Wales proposed a series of guidelines for the investigation and management of angina (4) . A key component of this framework is the establishment of rapid access chest pain clinics where patients with exertional angina can be investigated and treated without delay. The maximum waiting time has been arbitrarily decided as 14 days from referral (4) . Although there is no formal framework for services in Scotland at present, some hospitals have adopted rapid access chest pain clinics and it is likely that a formal policy shall be announced in the near future.
The rationale for such clinics seems clear. Exertional chest pain is a common complaint and it is often difficult to differentiate between cardiac and non-cardiac pain, even with the help of a resting ECG. Furthermore, the natural history following a presentation with cardiac chest pain can be sinister with more than 10% of patients developing a myocardial infarction or death within one year of initial presentation (3) . It would seem logical that rapid access clinics would achieve early identification of those patients at high risk of an adverse outcome in the short to medium term and allow appropriate invasive investigation (5) , revascularisation (6) and initiation of evidence based therapies (7,8) . However, many view a rapid access clinic as a way to rule out cardiac disease. There is a paucity of evidence to support either viewpoint and this subject remains a topic of considerable debate (9) . However, it is clear that without an increase in resources, including extra staffing levels and out patient places, patients who are fast tracked are seen earlier at the expense of those referred via the traditional route. This is true of many fast track systems in other specialties (10) . In the cardiological setting, many centres stipulate a typical history of exertional chest pain must be present for referral to try and increase yield of patients at high risk of an adverse outcome referred through the rapid access system and to minimise those at risk having assessment delayed by being referred via the conventional referral route. This policy has been adopted at our centre.
Stobhill Hospital is a District General Hospital in the North of Glasgow. The rapid access chest pain clinic was established in November 1995 with 12 available spaces per week for assessment of rapid access referrals. Since its inception, there has been an increase in demand for the service. Between 1999 and 2000 alone, there was a 14.4% increase in the number of patients seen at the clinic (rising from 480 patients in 1999 to 549 patients in 2000) resulting in failure to meet the previously agreed 2-week target. Referral guidelines were established with local primary care and it was agreed that patients with a stable history of chest pain precipitated by exertion or emotion were suitable for referral. Patients with suspected myocardial infarction or unstable angina were excluded from the service and managed through acute General Medical Receiving. No additional funding for this service was made. Given the limitation in resources, it is imperative that these slots are utilised appropriately. We sought to characterise the population referred to the rapid access clinic with regard to demographics, subjective assessment of risk, results of non-invasive stress testing and clinic outcomes and to compare them to the population with chest pain referred as a routine new appointment.
Methods
Patient
Population
A prospective, observational study was performed of all referrals to the Rapid Access Chest Pain clinic (RACP) and new referrals with chest pain to the general Cardiology Outpatient Department (COPD) over a four-week period, 15th January to 9th February 2001.
Data collection
A proforma was designed specifically for completion at the outpatient clinics by middle grade and consultant cardiology staff. All staff were informed of the study protocol and agreed to participate. The proforma was attached to the front of the case notes of all patients to be included in the audit (all rapid access chest pain patients and all new patients with chest pain referred by the conventional route). The proforma was in two sections. The first was completed prior to investigation and included baseline demographics and asked the cardiologist to subjectively score the patient at low, intermediate or high likelihood of their symptoms being due to coronary artery disease on the basis of history and examination alone. The second was completed following non-invasive investigations and included details of exercise test results and planned follow up.
Definition of
appropriateness for referral
A referral was
considered appropriate for the RACP if both these features were present
- the patient had chest pain, and this was precipitated by exertion or
emotion. These criteria were taken
directly from the working definition of "definite or possible angina"
to be found in the guidelines on cardiology outpatient services issued to all
general practices in our catchment area (figure
1).
Grading of
Exercise Tests
All exercise tolerance tests in this study were carried out with a Quinton-450 treadmill utilising the full Bruce protocol. For the purposes of analysis, exercise tests (ETT) were graded as follows:
ˇ Strongly positive - clinically AND electrically positive at < 6 minutes
ˇ Positive - clinically AND / OR electrically positive at > 6 minutes
ˇ Positive - clinically OR electrically positive at < 6 minutes
ˇ Negative clinically and electrically negative at achievement of maximum heart rate
ˇ Suboptimal - those tests for which no definite conclusion could be reached because the patient did not achieve his/her maximum heart rate
ˇ Not done
Statistical analysis
Students T-test was used for comparison of continuous, normally distributed variables, while the chi-square test was used for comparison of categorical variables. A p-value of < 0.05 was taken as significant.
Results
Baseline
Demographics
During the study period, a total of 90 new patients referred with chest pain were seen, of which 46 were referred to the RACP and 44 to the clinic by the conventional route (COPD). Over and above the number seen, an additional 14 patients (5 RACP and 9 COPD) were referred but did not keep their appointments (9.8% and 17% respectively). Proformas were missing or incomplete for 7 patients (2 RACP and 5 COPD). Analysable and complete data was collected for a total of 83 patients 92.2% - 44 RACP and 39 COPD. The basic demographic details of the two patient groups are outlined in table I. The mean number of days waited from referral to attendance at the RACP clinic was 22 (+/-5.5), while only one patient was seen within the recommended 14 days. The time waited for routine new COPD referrals was on average 3 months.
Appropriateness
of referral
Only 26 (59%) of the 44 patients referred to the RACP clinic fulfilled the appropriate criteria for referral to this service. Of the 18 patients who did not meet the criteria, 5 (11.4%) had no chest pain and 13 (29.6%) had chest pain which was not precipitated by exertion of emotion. This is compared to 19 (48.7%) of the 39 patients referred to the COPD with chest pain who met the criteria for the RACP. There was no significant difference in the numbers fulfilling the referral criteria between the groups.
Subjective
assessment and ETT results
Table II shows the subjective assessment of likelihood of symptoms being due to coronary artery disease by the interviewing cardiologist prior to non-invasive investigations. 12 patients (27.3%) in the RACP group were thought to have a history typical of ischaemic heart disease as were 8 (20.5%) in the COPD group. This compares to 21 patients (47.7%) in the RACP group and 22 (56.4%) in the COPD group thought to have a low likelihood of their symptoms being due to cardiac ischaemia, p=0.69. The majority of patients underwent exercise testing 39/44 RACP and 32/39 COPD. The remainder were felt to be too frail undertake treadmill assessment (2 patients) or had no chest pain (3 patients) and were therefore not exercised. ETT was performed on the other two patients without chest pain due to their history of dyspnoea on exertion. The results of ETT for both groups are illustrated in table II. The results of exercise testing are similar in both groups with no statistically significant difference detected. Only 3 patients (6.8%) had a strongly positive test at less than 6 minutes in the RACP group. No patients in the COPD group had a strongly positive test. This is compared to a negative ETT in 24 patients (54.5%) of the RACP group and 14 (35.5%) in the COPD group, p=NS.
Clinic outcome
Outcome from the clinic visit is illustrated in table III. Very few patients were referred for coronary angiography, 4 (9.1%) in the RACP group, 2 (5.1%) in COPD, p=NS. The discharge rates from the clinic visit were 20 (45.5%) in RACP group and 10 (26.6%) in COPD. There were a high number of return appointments made in both groups. A diagnosis was made in 29 patients (66%) in the RACP group compared to 22(56%) in COPD group. Diagnoses made are shown in table III.
Discussion
It is clear from this study that the patients referred for urgent assessment via the rapid access clinic were a low risk population. Although coronary artery disease is more prevalent in men in the general population (1) , women comprised 57% of the patients referred. The difficulty in assessing chest pain in women has long been recognised and this may account for a higher than expected proportion of women being referred. However, even accepting this, only 26 (59%) of patients referred to the rapid access clinic fulfilled the pre-determined referral criteria. Indeed, five patients did not have a history of chest pain at all With regard to subjective assessment of the likelihood of symptoms being due to ischaemic heart disease, nearly half were felt to have an atypical history and only a quarter felt to have a typical story. Similar findings of a low risk population were seen in the results of exercise testing with the majority (61.5%) having a negative test at good workload. Of those who had a diagnosis made at the clinic visit, two thirds had a diagnosis other than angina and nearly half of the patients were discharged. Only 4 patients (9.1%) were referred for coronary angiography.
In seeking to achieve early risk stratification of patients with anginal type symptoms it is important that investigation of these patients is not delayed (5) . It was therefore surprising to find a large number of patients referred by the conventional route who actually meet the criteria for the fast track service (49%), a similar figure to those referred to the RACP clinic. The patient demographics were similar in the two groups, as were subjective assessment, ETT results, diagnoses and clinic outcomes. This raises the question of how General Practitioners are deciding on which patients to fast-track. It is outwith the scope of this study to determine if there are different referral practices between surgeries. However, one explanation may be that patients previously diagnosed with angina were more likely to be sent through the normal non-fast track route, 38% vs. 13.6%, p<0.01, and the NSF does recommend new onset chest pain be fast tracked.
As with all changes in delivery of care, the establishment of rapid access chest pain clinics should ideally reduce morbidity and mortality compared to usual practice or deliver as least equivalent health care provision in a more rapid and cost efficient manner with improved convenience to the patient. Although there is no data to suggest an improved mortality or morbidity with the use of rapid access chest pain clinics, this could be achieved if the referral criteria for any rapid access clinic identifies those patients most at risk of an adverse outcome. Importantly the absence of the features meriting a rapid access appointment should be highly predictive of a reasonable outcome. This would allow targeting of invasive investigations, revascularisation and early initiation of therapy to those at highest risk. In this study the patients referred were a low risk group and many had atypical histories for ischaemic heart disease. This may reflect the different expectations and requirements from such a service between primary and secondary care. General Practitioners may see the service primarily as a means of reassurance (to exclude the presence of disease) (11) . Indeed, studies of open-access electrocardiography and exercise testing have shown that GPs refer only a small proportion of patients for a specialist opinion, even after a positive exercise test (11,12) . It is therefore essential for full discussion between primary and secondary care as to the needs, objectives and referral criteria of a rapid access service. We have demonstrated that even when formal criteria have been agreed, many patients are referred outwith these criteria. It is also essential that re-enforcement of the objectives and criteria for referral is made regularly, as is continual audit to ensure that they are being achieved.
With regards to the economics of rapid access chest pain clinics, same day clinics have been shown to reduce the need for hospitalisation in the short term (13,14) . Clinics not run on a daily basis do not have the same benefits with regard to hospitalisation. Indeed, there may be some detrimental effects of rapid access clinics. To achieve rapid assessment, many centres have transferred resources form routine referrals, leading to increased waiting times for routine referrals. In our study, patients referred to RACP and to the routine clinic were almost identical in demographics, risk and outcome. However, the corresponding wait for assessment was 3 months compared to 22 days. It is perhaps the case that urgent referral of the low risk group demonstrated in this study may delay investigation of a similar group referred by conventional means.
Despite little evidence of the efficacy of rapid access clinics, it is likely that such services will increase throughout the country. Centres in England and Wales already are being audited with their performance in this regard. The Clinical Standards Board for Scotland is likely to make similar recommendations. However, it is imperative that if a fast track system is to be adopted that additional resources are made available. As such systems become more widespread, studies of the impact of rapid access clinics on the morbidity and mortality of coronary disease are not likely to be easily performed. Justification of such clinics must come from further studies which should focus on determining the referral criteria which best identifies those most at risk of an adverse outcome and with the best negative predictive value.
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