AS part of its review of cardiac imaging services, the Australian Government Department of Health has introduced changes to item numbers in the Medicare Benefits Schedule (MBS) for electrocardiography (ECG), echocardiography, and myocardial perfusion studies, effective from 1 August 2020. I believe they have made a mistake.

There are 29 new items; 18 items have been deleted. The changes will affect patients in regard to access and referral for these services. The changes will affect providers, including consultant physicians, specialists and GPs. The focus for this article is the effects of the changes for GPs.

For clarification, although the Medical Board of Australia describes vocationally registered GPs as specialists, the MBS uses the term “specialist” exclusively to describe non-GP specialists.

The changes, according to the MBS, are intended “to support high-value care and ensure patients have access to the most appropriate tests for their individual symptoms and conditions”, and “to encourage best practice and improve patient outcomes”.

Previous item numbers

Before 1 August, when a GP recorded and reported an ECG trace in their clinic, the patient was eligible for a Medicare benefit for item 11700 ($27.45). If a GP only recorded an ECG trace in their clinic, with no report, the patient was eligible for a Medicare benefit for item 11702 ($13.65). In practice, it would be unusual for a GP not to provide a report on an ECG trace that has been recorded in their clinic. However, a GP could refer the patient’s ECG trace to another medical practitioner for a report, and the patient was eligible for a Medicare benefit for this service under item 11701 ($13.65).

These items – 11700, 11701 and 11702 – were deleted on 1 August 2020.

New item numbers

The new item number for GPs’ ECGs is 11707 (12-lead electrocardiography, tracing only). The Medicare benefit for item 11707 is $16.15. The descriptor indicates that item 11707 is for an ECG to produce a trace only, with the following requirements:

  • the ECG is necessary for clinical decision making;
  • the ECG does not need to be fully interpreted or reported on;
  • the ECG must be reviewed in a clinically appropriate time frame to identify potentially serious or life-threatening abnormalities;
  • the maximum number of times that this item can be used in one day is two.

The first requirement seems superfluous, as in general practice, an ECG will influence clinical decision making in any context. Presumably, this requirement has been stipulated to counter the use of the so-called routine ECG. It is not clear if pre-anaesthetic ECGs will be eligible under this item number. This is particularly relevant for rural GPs.

The second requirement implies that full interpretation and a full report are optional but not necessary. The Medicare benefit is the same, whether the GP provides a full interpretation and full report or not.

The third requirement does not state if the ECG must be reviewed by the GP who arranged the trace, or if the ECG trace must be sent to a consultant physician or specialist for review.

The fourth requirement is not practical in the context of serial ECGs (more than two), which are required in the assessment and management of suspected or confirmed acute coronary syndrome and in the assessment and management of acute arrhythmia. The item 11707 does not apply if the patient is admitted to hospital. This is relevant for rural GPs.

In practice, when a patient has an ECG trace recorded in a GP’s clinic, the GP will review the ECG trace as soon as it has been recorded. This review will identify “potentially serious or life-threatening abnormalities”, such as myocardial infarction, ischaemia and arrhythmia. This review could also be considered to constitute a full interpretation and report.

What is the definition of a full report for an ECG? The explanatory notes in the MBS describe a formal report as follows:

The formal report is separate to any letter and entails interpretation of the trace commenting on the significance of the trace findings and their relationship to clinical decision making for the patient in their clinical context, in addition to any measurements taken or automatically generated.

Most ECG machines and ECG recording devices connected to computers produce a computer algorithm-generated report, with rate, rhythm, axis, PR interval, QRS duration, QTc duration, chest lead voltages, identification of acute ischaemic changes (ST elevation/depression, T inversion, Q waves), and an interpretative summary. In conjunction with the GP’s analysis and interpretation of the trace, and the patient’s clinical context, the computer-generated report provides decision support for a full report.

I contend that, in practice, a GP provides a formal report when the GP reviews the ECG trace with the patient. In a sense, Medicare is getting an ECG report for free.

To meet the criteria for 11707, a GP is expected to review the ECG, so the descriptor is a misnomer, as the service is “trace and review”, not “trace only”. However, if a GP reviews the ECG, the patient is not eligible for a Medicare benefit for the report.

Items 11704, 11705 and 11714

GPs have three options for referral for ECG:

  • a GP can refer the patient to a consultant physician or specialist for an ECG trace and formal report — the patient is eligible for a Medicare benefit for this service under item 11704 ($27.45);
  • a GP can record the patient’s ECG trace at the GP’s clinic (item 11707), and refer the patient’s ECG trace to a consultant physician or specialist for a report — the patient is eligible for a Medicare benefit for this service under item 11705 ($16.15); and
  • a GP can refer the patient to a consultant physician or specialist for the ECG trace and an interpretation or clinical note (not a report) — the patient is eligible for a Medicare benefit for this service under item 11714 ($21.25; by the way, the benefit is listed incorrectly in the Quick Reference Guide as $19.55).

A GP could refer a patient to a dermatologist, an ophthalmologist or any surgical specialist for an ECG trace and interpretation or clinical note. This is an unlikely scenario, but it would be supported by item 11714.

Item 11729 (exercise ECG)

The descriptor for the new item for exercise ECG, 11729, stipulates that in addition to the medical practitioner who is conducting the exercise ECG, there must be “a second person trained in cardiopulmonary resuscitation … at the premise where the testing is performed and is immediately available to respond at the time the exercise test is performed on the patient, if required”. However, the answer to a question about this issue indicates that a “person” is required, not a “medical practitioner”.

Indications for ECG in general practice (“necessary for clinical decision making”)

  • Acute
    • chest pain;
    • dyspnoea;
    • palpitations;
    • irregular pulse;
    • pre-syncope and syncope;
    • stroke/transient ischaemic attack (atrial fibrillation?);
    • delirium;
    • unwell patient with diabetes;
    • coronary heart disease;
    • heart failure
  • Chronic disease management – monitoring
    • coronary heart disease;
    • diabetes;
    • heart failure;
    • hypertension
  • Preventive activities (not recommended in the Red Book (Guidelines for preventive activities in general practice, 9th edition)
    • hypertension;
    • diabetes;
    • smoking;
    • absolute cardiovascular disease risk.

What will these changes to the ECG item numbers mean for general practice?

One can only speculate about the impact of these changes on general practice as a specialty and on GPs.

Many GPs will be offended and annoyed by the implication that they are not competent to read and report an ECG trace, and that they require a specialist or consultant physician for this. GPs are trained to interpret ECGs through medical school and through vocational training in general practice.

The lower Medicare benefit for recording an ECG in general practice may be a disincentive to performing ECGs, potentially resulting in one or more of the following:

  • fewer ECGs being recorded in general practice;
  • access to ECGs being reduced for patients due to
  • practices reducing or ceasing the use of ECG;
  • increased fees and out-of-pocket costs for patients;
  • patients who rely on bulk-billing being unable to afford fees for ECGs that exceed the Medicare benefit (item 11707, $16.15)
  • more patients being referred to pathology services or to cardiologists for ECGs;
  • more patients being transferred to emergency departments by ambulance;
  • more cardiac diagnoses being missed in general practice.

As alternatives to ECGs in general practice, these are suboptimal outcomes for patients, the health budget, safety, and risk management.

What if fewer patients had ECGs recorded and reported in general practice?

If a patient were referred elsewhere for an ECG or an ECG report, there would be a delay in getting the ECG trace and/or the ECG report, so that the consultation with the GP and the ECG report would not be contiguous. This could lead to delays in diagnosis and management.

It would be unsafe to transfer a patient with a possible acute coronary syndrome to a pathology service or to a cardiologist for the purposes of obtaining an ECG. The patient is potentially unstable, and at risk of arrhythmia or cardiac arrest. The waiting room of a pathology service is no substitute for a treatment room in a general practice with a practice nurse and monitoring equipment.

What if GPs continue – and possibly increase – the recording and reporting of ECG traces?

A GP provides a contemporaneous report on the ECG trace in the context of the patient’s clinical presentation. This enables early diagnosis and prompt management, with the potential for better outcomes for the patient and, considering general practice as a whole, the potential for better outcomes for population health.

Examples include:

  • reduced myocardial damage in patients presenting with the ECG features of acute coronary syndrome;
  • reduced risk of stroke, syncope, and cardiomyopathy in patients presenting with ECG-diagnosed atrial fibrillation;
  • recognition of “silent” coronary heart disease or ventricular hypertrophy (eg, in patients with risk factors for cardiovascular disease, in particular, diabetes and hypertension).

A GP can assess the patient, record an ECG trace, report on the ECG trace, and if appropriate, call a cardiologist to discuss the clinical problem. The ECG findings will help to inform the cardiologist’s opinion and advice.

A GP who is not confident with ECG interpretation may record a patient’s ECG trace and then send the ECG trace to a cardiologist for a report. Alternatively, there may be another GP in the practice who can be approached to interpret and report the ECG.

A definitive diagnosis may not be made in general practice, but the ECG can inform a GP’s clinical decision making regarding management, for example, of the following actions:

  • monitor in general practice (or in a rural emergency department); this may include repeat ECGs;
  • send home and review;
  • refer to hospital;
  • call triple-0.

Diagnoses may require serial ECGs and urgent investigations (pathology tests, and imaging); these require the patient to be transferred to hospital.

Charging for recording and reporting an ECG trace in general practice

GPs can offset the low Medicare benefit for item 11707 for recording an ECG by charging appropriately for their service, clinical expertise, and time. For example:

  • charge a higher ECG item fee to the patient — the patient gets the lower rebate compared with the prior rebate for item 11700, so the patient’s out-of-pocket expenses will be higher than in the pre-11707 era;
  • bulk bill the patient for the ECG and for a longer attendance (the attendance includes the time for reporting the ECG and for discussing the report and its significance with the patient);
  • do not charge for the ECG and instead charge for a longer attendance that includes the time to record and report the ECG trace and to review the ECG trace with the patient (private fee, or bulk bill for the longer attendance).

Clearly, the total duration of the consultation needs to meet the time indicator for the descriptor for the appropriate Medicare item for that consultation.

Co-claiming MBS item numbers

One or more of the following items may be co-claimed with item 11707:

  • 10997
    • practice nurse or First Nations’ health practitioner service;
    • benefit $12.40;
    • for a patient who has a General Practice Management Plan and Team Care Arrangements;
    • up to five services per annum.
  • 10987
    • practice nurse or First Nations’ health practitioner service;
    • benefit $24.75;
    • for a First Nations’ patient who has had a health assessment (Medicare item 715);
    • up to 10 services per annum.
  • Bulk billing incentive for patients with a concession card (and children under 16)
    • 10990 (metropolitan), benefit $12.95;
    • 10991 (remote, rural, regional [Modified Monash Model 2–7]), benefit $19.60.

The COVID-19 bulk billing incentive payments can only be co-claimed with in-person and telehealth attendances; they cannot be claimed with ECG service item numbers.

In summary

The potential deleterious effects of the Medicare ECG item number changes include:

  • fewer ECGs recorded and reported in general practice;
  • reduced access to ECGs for patients;
  • delayed and missed diagnoses, leading to:
  • greater numbers of adverse patient outcomes;
  • higher incidence of cardiovascular disease;
  • poorer population health
  • increased costs for patients due to lower rebates and/or higher fees;
  • reduced income for GPs and their practices.

A potential benefit of the Medicare ECG item number changes for Medicare will be a decrease in the benefits paid by Medicare for ECGs in general practice. However, this is myopic. The decrease in costs to Medicare is likely to be more than offset by the increased costs to the health system incurred by delayed and missed diagnoses.

In general practice, GPs should consider:

  • continuing to record ECG traces and to report these traces;
  • increasing the number of ECGs that they record for acute presentations, chronic disease management, and preventive activities with the aim of better outcomes for patients through early diagnosis and intervention;
  • working around the financial constraints imposed by the changes to the MBS ECG item numbers;
  • getting the following for their practice, if they don’t have one:
  • an ECG machine or computer-connected ECG recording device
  • an AED
  • upskilling in ECG diagnosis, and not becoming deskilled in the use and interpretation of ECGs

The changes to the Medicare items for ECGs in general practice not only devalue the Medicare rebate for ECG in general practice; the changes also devalue ECGs and GPs.

Missed and delayed diagnoses are inevitable, leading to adverse patient outcomes, and to downstream medical, social, and economic costs.

ECG is an essential diagnostic tool in general practice; its use in general practice should be enhanced and facilitated.

Medicare has made a mistake in implementing these changes to the MBS cardiac service item numbers.  The Royal Australian College of General Practitioners (RACGP), the Australian College of Rural and Remote Medicine (ACRRM), and the Australian Medical Association (AMA) must advocate on behalf of GPs for these changes to be reversed, and for the item numbers to be enhanced in favour of recording and reporting ECGs in general practice.

Dr Andrew Baird is a GP at the Elwood Family Clinic in Victoria. He is a tutor in professional practice for medical students at the University of Melbourne. 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

 

19 thoughts on “The MBS, the ECG, and the GP

  1. Dr Andrew Bowman says:

    I am a physician in a rural town with no pathology ECG service. Most of the town GPs share rooms & expenses with me so we have by MBS definition “a financial relationship”. Therefore these GPs can no longer refer their ECGs’ for interpretation by me (11705) or for Trace and report (11704). As there is no alternate service in town these ECG’s will need to be sent somewhere else for interpretation with all the associated risks of delay and loss of tracing. In addition there will be no onsite teaching of those GP’s by myself when they bring the tracing to my room. Either that or we will have to do it for free which sadly is not realistic or the patients will have to face increased out of pocket expenses. Yet another example of city Drs making rules without the vaguest knowledge of how things work in the rural community. Shame on you Dr Harper and your cronies

  2. Andrew Baird says:

    3 questions for GPs, please:

    1. What are your opinions on GPs interpreting and reporting ECGs in general practice?
    2. What will be the effects, if any, on patients, on population health, and on the health system, if fewer ECGs get done in general practice due to the changes in the MBS ECG item numbers?
    3. What are your opinions on the MBS ECG item number changes?

  3. Andrew Baird says:

    3 questions for non-GPs, please:

    1. What are your opinions on GPs interpreting and reporting ECGs in general practice?
    2. What will be the effects, if any, on patients, on population health, and on the health system, if fewer ECGs get done in general practice due to the changes in the MBS ECG item numbers?
    3. What are your opinions on the MBS ECG item number changes?

  4. Andrew Baird says:

    Replying to Paul Langton.

    Thank you very much for your comments. Based on the limited evidence, I accept that mandatory requirement for an AED in general practice is a moot point. However, based on the ‘precautionary principle’, I think it’s reasonable to expect that general practices should have an AED.

    High quality CPR should certainly be the expectation in general practice. Accreditation requires all clinical and non-clinical staff to do a BLS course every three years. Perhaps the requirement should be for annual BLS training to enhance a ‘BLS culture’ in practices? Some practices require annual BLS training for their staff.

    I agree absolutely about starting CPR stat while setting up the defibrillator; this is consistent with ‘DRSABCD’.

    I was surprised – and impressed – by the comments about good patient outcomes after prolonged, high quality CPR.

    In the community, high quality CPR will be dependent on bystander CPR. Can we improve the number of people in the community who have the skills for high quality CPR? More BLS training in schools, workplaces, etc?

    Ambulance response times are likely to be longer in rural areas (although in some rural towns, GP clinics and ambulance services are co-located, so response times could be faster). I don’t have data for this.

    And what about GP telehealth? GPs obviously don’t have access to a defibrillator if the patient is at their home or elsewhere. This reinforces the importance of two important factors in a telehealth consultation. Firstly, at the start of the consultation, screening for any potential symptoms that require 000/ED/in-person attendance. Secondly, getting the patient’s exact location (which might not be their home address). This information is necessary for 000 purposes. It’s very unlikely that 000 will need to be called, but if the patient becomes unresponsive during the telehealth consultation, it’s too late to ask where they are …

  5. Paul Langton says:

    Replying to Andrew Baird: Re AED ‘delay’. I agree that an AED is an appropriate aspiration for most GP practices (especially group practices, given the higher pt turnover). But an AED is no replacement for proficient BLS trained staff.
    I strongly doubt most Cardiology consulting rooms would have an AED, unless they are co-located with a stress testing service (in which case having a defibrillator is mandatory); i.e. in situations where a Specialist might consult at a multi-practitioner suite once a fortnight etc.
    High quality CPR is of the essence, with an aim of early defibrillation. Even if a defibrillator is immediately available, and assuming 2 people present, I would always start chest compression whilst the defib was being set up – often takes a minute or two. We do this in the cath lab frequently, but use an non-automated system and can defibrillate within ~30sec.
    I have seen several patients have high quality CPR for ~20 min before successful defib (complex cases) – and they’ve regained consciousness immediately, well enough to want to sit up and ask what all the fuss was about!. Within that context, in major cities ambulance response times are relatively short, as you indicate, but with potential value of the WA & Vic Apps (?other states) that might allow access to a closer AED.
    The trial data are limited by the difficulties in doing such research, hence mostly based on ‘first responder’ studies – which in Au means ambulance services and highly variable quality of bystander CPR before their arrival, with generally poor outcomes. I’d like to think that quality CPR would improve that, even more so with early defibrillation.
    The trials do not really inform us of whether debif with the first few min is critical, or whether good CPR for 10-15 min followed by defib, would have similar outcomes (hence the moot point). Any honest Expert giving evidence to a Coroner would have to agree. It is worth noting that only ~half of out of hospital ‘cardiac arrests’ are associated with a ‘shockable rhythm’, so CPR remains crucial.
    But we all beat ourselves up when a patient has a bad outcome, and ‘what ifs’ are to a degree unavoidable.
    I repeat that I agree that an AED is an appropriate aspiration for most GP practices, and if/when further research shows their value they will no doubt be made mandatory.
    Thanks for a great article on the ECG issue.

  6. David Maconochie says:

    Andrew, this was very well written. Can I suggest that we all write in protest to our MPs? I am writing to mine. Remember when a previous set of committee members with an axe to grind pushed through a 15 minute time descriptor to the standard 23 consult? They had to give way on that one too.

  7. Andrew says:

    Hi Annemie, I agree with you, QTc should be monitored in general practice for patients who are at increased risk of prolonged QTc.

    Automated ECGs give a readout of QTc. However, this is considered to be inaccurate. The advice is to manually measure the QT interval, and to calculate the QTc using a nomogram of QT versus heart rate. I admit that I always use the readout from the automated ECG.

    Prolonged QTc can lead to catastrophic torsade de pointes and other ventricular arrhythmias.

    Female gender, increasing age, and genetic factors are associated with long QT.

    And of course, drugs, and drug interactions can prolong QT, which is why we need to monitor patients with ECG.

    Common drugs in general practice patients that are associated with prolonged QT are: SSRIs, TCAs, 2nd generation antipsychotics, erythromycin, clarithromycin, fluconazole, amiodarone, sotalol, and ondansetron. And of course chloroquine – not a common drug for GP patients, but it’s been a topic of interest in the pandemic.

    Patients taking clozapine should have ECG six-monthly. This is usually managed by the local Clozapine Clinic – but some patients slip through the net.

    Patients who are going to start a drug that potentially prolongs QT should have a pre-Rx baseline ECG. This also applies to potential interactions between 2 QT prolonging drugs. So it’s reasonable to record an ECG before starting erythromycin in a patient who is taking amiodarone. If QTc is normal – proceed with caution. If QTc is teetering on the brink of being prolonged – don’t take the erythromycin.

    There are many lists of QT drugs, eg, https://crediblemeds.org/

  8. Andrew says:

    Thanks very much, Paul, this is excellent advice. I checked the website FAQs:

    Q: What Australian States does the app work in?
    A: The First Responder App is designed for use in Western Australia. App features such as Nearby Defibrillators, Nearby Medical Centres and First Responder Incidents are only supported for Western Australian locations.

    I’m in VIC. GP Clinics can register their AED with Ambulance Victoria at https://registermyaed.ambulance.vic.gov.au/
    (AED owners register their location and opening hours). ‘GoodSAM Responders’ receive an alert when a cardiac arrest is happening nearby – and they are also notified of the nearest AED. ‘GoodSAM Responders’ are trained first aiders.

    All clinical and non-clinical staff in accredited general practices are trained in BLS (including AED) with retraining every 3 years as a minimum. Most general practices have annual retraining for their staff.

    ANZCOR teaches defibrillation ASAP, so it’s interesting to learn that a ‘small’ delay is okay. How long is ‘small’?

    I note that the reference to CPR before defibrillation relates to animal studies.

    In the ROC PRIMED trial: What’s the definition of ‘brief period’? What’s the definition of ‘longer period’?

    I note Dr Langton’s opinion that AEDs in general practice are a moot point. I disagree. I believe that AEDs should be mandatory in general practices to enable ASAP defibrillation when indicated for the unresponsive patient in the general practice, or nearby. AED = potentially lifesaving; No AED = reduced chance of a good outcome.

    In 2019, for Ambulance Victoria, the average Code 1 response time was 11 minutes. (I guess the Fire Brigade could possibly get to the patient quicker). 11 minutes seems to be a long time for pre-defibrillator down time.

    If a patient dies from cardiac arrest in a general practice, the Coroner will be interested to know if the general practice had an AED. And if the general practice didn’t have an AED, the GPs and other staff are going to have to deal with knowing that the patient could – potentially – have survived if there had been an AED. It’s the loss of the chance of a better outcome.

    Do Cardiology clinics have defibrillators? I guess they’re mandatory, and certainly mandatory if exercise stress tests are conducted on-site.

  9. Annemie Beck says:

    Where does monitoring of QTc interval fall in regards to clinical need? In patients struggling with eating disorders monitoring of QTc for changes is clinically relevant and an important consideration of medical instability that would necessitate admission. In addition, a lot of psychiatric (and other) medications can prolong QT interval. Should the GP not monitor these?

  10. Paul Langton says:

    As a Cardiologist, I highly recommend the St John (ambulance service) First Responder App. This automatically send precise GPS co-ordinates to the ambulance serve (speeding up arrival times) and gives AED locations near you, for the fastest access to defibrillation.
    https://stjohnwa.com.au/online-resources/st-john-first-responder-app

  11. Paul Langton says:

    With regards to AEDs in GP practices: Quality CPR is critical, and a (small) delay in first shock compared to early defibrillation is of no consequence. Animal studies show better response in an out of hospital situation with initial CPR (2-3 min) before defibrillation. The ROC PRIMED trial concluded: “Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR”… before defibrillation. So whether GP practices have an AED is a moot point.
    Cummins Ro & Hazinski MF. The Most Important Changes in the International ECC and CPR Guidelines. 2018 available at https://www.ahajournals.org/doi/full/10.1161/circ.102.suppl_1.i-371

  12. Andrew says:

    Hi Pran,

    Thank you for your comments. I believe that you are correct. In all of the scenarios that you describe, the referral for ECG is clinically significant (not ‘screening/routine’). The referring GP would be deemed to have a duty of care to follow up the ECG and to follow through to completion of appropriate action. If there was an adverse outcome, then the GP has failed in their duty of care.

    So, unfortunately, an adverse outcome for the patient, and an adverse outcome for the GP. But not an adverse outcome for Medicare. In fact, Medicare has saved money – by restricting GPs to the 11707 item number.

  13. pran lal says:

    what is the medicolegal position of the GP who decides to send a Patient to a pathology service for an ECG but the person does not attend or attends many hrs or days later and gets lost to follow up by GP. If an Abnormal ECG is not reported immediately or gets lost in the piles of reports that the GP does not see immediately, Or does not attend a recall or makes an appointment and fails to attend. Then develops a stroke because he was not diagnosed in a timely manner to start anticoagulation for AF or he has an acute coronary syndrome and was not referred to hospital in time. OR has severe silent ischaemia but was not referred to hosp for any of the previously stated reasons?? WHO takes the blames- the patient? Medicare ? I will bet that the blame will be pushed onto the GP.

  14. Martin Bailey says:

    that should read- “an area NOT used frequently”

  15. Martin Bailey says:

    Right on Dr Baird . this is penny pinching in an area not used frequently but critical in making or confirming a time sensitive diagnosis. Further the co-claim items available are far too complex, as in several other areas , meaning that it is impossible to remember all these in your head.
    Vale comprehensive general practice!

  16. Anonymous says:

    This is just SO well written! Congratulations Andrew, you have presented your arguments clearly, succinctly and accurately, and I gif one totally support your conclusions and warnings. These changes to ECG “trace and report” item numbers will have potentially disastrous effects on both patients and their GPs, to say NOTHING of the INCREASED COSTS AND DIMINISHED HEALTH OUTCOMES for the population with cardiovascular disease and its co-morbidities.

  17. Andrew Baird says:

    Is ECG a good diagnostic test for use in general practice?

    Yes.

    ECGs have good sensitivity and specificity for the diagnosis of arrhythmia and for the diagnosis of cardiac conduction abnormalities. The most common abnormal rhythm seen in patients in general practice is atrial fibrillation which has implications for rate control, rhythm control, and anticoagulation, etc.

    ECGs have good specificity for the diagnosis of myocardial infarction (MI), but the sensitivity for the diagnosis of MI is only about 60% (so a normal ECG trace is not a good ‘rule out’ for myocardial infarction (MI)).

    ECGs are poor to moderately sensitive and specific for diagnoses of pulmonary embolism, pericarditis, and ventricular hypertrophy.

    ECGs have poor predictive values for the diagnosis of cardiac disease in an asymptomatic low-risk population in general practice – so not a good screening test.

    The positive and negative predictive values (PPV and NPV) of ECG depend on the patient’s presentation and the patient population in general practice. However, it’s unlikely that GPs will calculate PPV and NPV when a patient attends for ECG.

  18. Stuart McMaster says:

    This is an undisguised devaluation of general practice and reflects a disgraceful process in the MBS review.
    As well as any other actions taken by the college I would suggest that the RACGP should seek an explanation from the MBS committee who advised regarding this change
    There would have been cardiologists and GPs on the committee. I would suggest they be personally approached by the RACGP, and the Cardiologists named so that members can choose whether they continue to refer patients to such specialists. I think if we just take this on the chin, continued devaluation of our place in the medical system will continue to occur. Disgusted.

  19. Andrew Baird says:

    General practices are not required to have an ECG machine

    The Royal Australian College of General Practitioners (RACGP) Standards for general practices (5th edition) requires GPs to have “timely access” to an ECG. Practices are not required to have an ECG if they have access to an ECG off-site at a nearby pathology service or hospital.

    General practices are not required to have a defibrillator

    The Standards for general practices (5th edition) encourages practices to have an automated external defibrillator (AED); this is an ‘aspirational indicator’. However, it is not mandatory for a practice to have an AED. It seems remarkable that a person has a better chance of a good outcome if they have a cardiac arrest in a shopping centre rather than in a general practice that does not have an AED.

    I believe that all general practices should have an ECG machine, or a computer-connected ECG recording device. This is the best way of providing ‘timely access’ to ECG in a general practice. The patient’s clinical assessment and the ECG are contiguous. The GP gets immediate information. This is safer, more effective, and more efficient than having to interrupt clinical assessment and management by sending the patient away from the practice to a hospital (possibly by ambulance), specialist or pathology service for the purpose of getting an ECG trace and report.

    I believe that all general practices should have an AED. It should be accessible, and all practice staff should be trained in its use. An AED is truly lifesaving. Use of an ECG machine can improve patient outcomes, but an ECG machine per se is not lifesaving. If a practice has neither ECG nor AED, and cost is an issue, then it seems reasonable that obtaining an AED should take priority over obtaining an ECG machine or computer-connected ECG recording device.

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