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EASING the burden on GPs by providing fast, cheap access to cardiologists could lead to lower mortality rates for patients discharged from emergency departments after experiencing chest pain, according to two leading Australian cardiologists.
Professor Michael Jelinek, former director of cardiology at St Vincent’s Hospital in Melbourne, said follow-up of these patients was best achieved through combined care.
“All serious diseases that involve questions of life expectancy should be handled by the GP in close consultation with a specialist”, he said.
Dr Paul Antonis, acting director of MonashHeart in Melbourne, said the present system of follow-up care placed too much burden on GPs.
Professor Jelinek and Dr Antonis were responding to a research article published in Circulation which found that high-risk patients who presented to the emergency department (ED) with chest pain had significantly fewer adverse outcomes if they were followed up by a cardiologist after discharge. (1)
The observational study examined the relationship between physician follow-up and clinical outcomes for 56 767 patients with diabetes or established cardiovascular disease, who were evaluated in EDs for chest pain and discharged home.
Patients who did not experience any adverse clinical outcomes in the first 30 days after the ED visit were included in the study.
“Transition of care from hospital to home is an emerging focus for quality-of-care improvement because it has been shown to reduce repeat admissions and to improve clinical outcomes”, the authors wrote.
They found that 17% of patients saw a cardiologist within 30 days of release from the ED, 58% saw a GP, and 25% did not seek follow-up from any doctor.
One year after discharge, unadjusted rates of all-cause mortality or hospitalisation with myocardial infarct (MI) were 5.5% in the group who saw a cardiologist, 7.7% for those who saw a GP and 8.6% for those who had no follow-up.
“Not having follow-up care was strongly associated with an increased risk of dying at 1 year”, the authors wrote. “In addition, we found that patients who were cared for by a cardiologist had the lowest risk of adverse clinical outcomes, with a 21% reduced hazard of death or MI compared with those with no physician follow-up and a 15% reduced hazard compared with those with [GP] follow-up.”
Professor Jelinek told MJA InSight that, while he found the results “unsurprising”, they highlighted the “huge burden which is thrown upon primary care providers”.
“GPs might see three patients with a heart attacks each year”, he said. “Asking them to take on the follow-up care after discharge is too great a burden. With all due respect, they’re dealing with things they can’t handle. I’m not a GP, because it’s too hard. It’s tough stuff.”
Dr Antonis agreed, saying GPs did a “phenomenal job” but there was enormous pressure on them to maintain competence in every area, “and that becomes more difficult as medical knowledge expands, as it is, exponentially”.
“Cardiologists have a hard enough time staying across the latest evidence in their field, so I don’t think it’s possible for GPs to keep up.”
MonashHeart opened Australia’s first rapid assessment chest pain clinic 18 months ago to tackle the issue of involving cardiologists earlier and providing cheaper access for patients to specialist care.
“Waiting times for private cardiologists can be quite lengthy and waiting 3 months to see a specialist is not appropriate”, Dr Antonis said.
“We pride ourselves on being able to see patients with chest pain for observation within 1 to 2 weeks of their discharge. The idea is to send patients on the appropriate treatment pathway as quickly and as easily as possible. We think it’s a model that should be employed widely.”
– Cate Swannell
1. Circulation 2013; 127: 1386-1394
Posted 8 April 2013
Hmm… I wonder if an unreasonable assumption about causation is being made here (that it was the actions of the cardiologist in the follow up within 30 days that made a difference). As an observational study, there seems to be one major confounding factor that was not (and could not) be adjusted for – simply, that the patients who were able to navigate the health system to see a cardiologist within that time frame might also have greater motivation and be more empowered about their own health. That is, an alternate explanation might simply be that patients who are motivated do better with cardiovascular outcomes.
This is yet another example of our society becoming more risk-averse and driving expectations higher and higher. The discussion neglects the fact that patients with chest pain are worked-up in EDs with more precision than ever before (ECGs and Troponins), so that the risk of adverse events in the 30 days post-presentation is indeed very low. This study follows up a group that was dischareged from the ED as low-risk or adverse events, and had no adverse events in the next thirty days, but had risk factors like diabetes. The findings are worth reading: “After adjustment, cardiologist follow-up was associated with significantly lower adjusted hazard ratio of death or MI compared with PCP (hazard ratio, 0.85; 95% confidence interval, 0.78–0.92) and no physician (hazard ratio, 0.79; 95% confidence interval, 0.71–0.88) follow-up.” ALthough the rate of MI or death was statistically significant, the ORs were 0.85 for cardiology f/up and 0.79 for NO follow-up – with overlapping confidence intervals. IN other words, for patients screened in an ED as low-risk, the difference in outcomes between Cardiology follow-up and no follow-up, despite inceased investigation and therapy, was very small.