Are rapid access cardiology clinics a valued part of a district cardiology service?

Abstract

Background

Improved processes of referral from Primary Care are an important part of a strategy to reduce the population burden of cardiovascular disease. A unique service of rapid access clinics, where primary care practitioners can refer patients to a daily secondary care cardiology service without appointment has been established at Charing Cross Hospital in West London. Previous data have shown the effectiveness of this service in diagnosing and risk stratifying patients with suspected cardiac disease. We evaluated Primary Care and Patient views on this service.

Methods

A patient survey of a cohort of 1223 patients recruited to a follow up study of individuals seen over 1 year in the service and qualitative in-depth interviews of a randomised sample of 10 out of 82 referring Primary Care Practitioners was performed.

Results

Less than 2% of patients had a negative experience of the service. Most patients did not have to revisit the Primary Care Practitioner for the same symptom. Primary Care Practitioners were overwhelmingly positive about the ease of access. They viewed positively the ability to obtain prompt diagnosis or reassurance. The heart failure service was used least but this was the most challenging condition to diagnose. There were concerns about nurse specialist based services and restriction to ‘first presentations’. Communication about the service could be improved.

Conclusions

A ‘no appointment’, one stop, rapid access service for the diagnosis and risk stratification of suspected new cardiac disease is viewed very positively by patients and Primary Care Practitioners.

Introduction

Optimal management of cardiovascular disease in the population requires a coordinated provision of care across health services from primary to secondary and tertiary facilities. Many patients with new symptoms that may be attributable to cardiovascular disease present first to primary care. Prompt and accurate diagnosis is necessary if appropriate treatment and risk stratification is to take place. Rapid access chest pain clinics have become popular in the UK to ensure patients with suspected cardiac chest pain, not requiring immediate hospital assessment receive specialist evaluation within 2 weeks [1]. However the decision on who requires immediate assessment may be difficult and important cardiac disease may present with symptoms other than chest pain. At Charing Cross Hospital in West London we have established a unique rapid access cardiology service. This service consists of three clinics that run each weekday morning to see suspected first presentations of angina (rapid access chest pain clinic: RACPC), brady or tachyarrhythmia (rapid access arrhythmia clinic: RAAC), or heart failure (rapid access heart failure clinic: RAHFC) [2]. No appointments are needed and patients are therefore seen on the same or next working day from referral.

The referral criteria, used on all communications with primary care and in the footer of each clinic letter are:

‘The Rapid Access Chest Pain Clinic, Rapid Access Heart Failure Clinic, Rapid Access Arrhythmia Clinic are open each weekday to see all suspected first presentations of exertional angina, heart failure or cardiac brady or tachy arrhythmias.’

The clinics are run by a nurse specialist (mainly focussed on the RACPC) and a registrar grade cardiologist (RAAC, RAHFC) with cardiac physiologist support and daily consultant supervision. Patients undergo non-invasive investigations (ECG, Echo, Exercise Test, Holter monitoring) on the day of assessment.

The clinical aims are to identify patients with new onset cardiovascular disease, to risk stratify them appropriately, and to initiate evidence based therapies.

Evidence demonstrating effective diagnosis and risk stratification has been previously published based on a prospective cohort of 1223 patients seen over a 12 month period in the service [2]. However to be a valued service the rapid access clinics not only have to be clinically effective, they have to be acceptable to patients. Furthermore services must be acceptable to local Primary Care Practitioners from whom 80% of referrals are received. We therefore studied patients and primary care views on the rapid access cardiology service.