Q J Med 2002; 95: 299-303
© 2002 Association of Physicians
Establishment and feasibility of community-based general-practitioner-led cardiology clinics
From the Department of Cardiology, Guys and St Thomas's Trust, London, UK
Received 14 January 2002 and in revised form 18 February 2002
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Summary |
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Background: Community-based general practitioner (GP) cardiology clinics (locality clinics) offer an alternative to hospital-based cardiology clinics. In the Greenwich area, four GPs were trained for 3 months in cardiology, followed by another 3 months in a hospital out-patient clinic. GPs then established cardiology clinics in their practices and continued to act as hospital clinical assistants on an alternate-week basis.
Aim: To assess referral and investigation patterns for the locality clinics over their first 3 years.
Design: Pilot study, retrospective case-note audit.
Methods: We analysed 125 sets of notes selected at random from the locality and the hospital clinics, and compared them.
Results: There were no differences in demographics or the indication for referral between locality and hospital clinics, and despite the small sample size, no major differences in referral and investigation patterns. In both clinics, 
83% of patients had at least one cardiac investigation, and 63% were discharged after initial consultation. Some 10% of locality patients were referred for follow-up in the hospital clinic. Beta-blockers were prescribed more by hospital doctors (14% vs. 3%), with no significant difference in other cardiac medications. Coronary risk factors were more often recorded in the notes of locality patients.
Discussion: Establishing community-based GP cardiology clinics seems feasible, and these clinics may be the way forward for enhancing cardiac care in the community.
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Introduction |
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Coronary heart disease is a common, frequently fatal and largely preventable condition, which has been highlighted with the publication of the new National Service Framework.1 One of the stated aims within this framework is that patients with new symptoms which their GP thinks might be due to angina are assessed by a specialist within 2 weeks of referral. With current specialist numbers, this would prove difficult. We report here an alternative model of care designed to help improve patient access to specialist opinion and investigation, and to enhance provision of cardiac care in the community setting.
In the light of the successful involvement of general practitioners in the specialized care of certain conditions such as asthma, diabetes, dermatology and antenatal care, we hypothesized that a similar model might be successful in cardiology.
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Methods |
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Service organization and funding
The Greenwich area, which has a resident population of 231 932, is served by 128 general practitioners (GPs). GPs were invited to apply for four posts as GP-cardiologists; applications were encouraged from GPs within multi-partner practices. No previous cardiac training was required, although most of the applicants did have a special interest in cardiology.
Initial funding for the project, to cover the secretary, the posts and locums to cover the absence of the GPs from their normal duties, was obtained for one year from the LIZEI (London Implementation Zone Education Initiative). Subsequent years were funded from the health authority, with the support of the Greenwich Health Care Trust in Southeast London.
The appointed GP-cardiologists underwent a training program in cardiology consisting of lectures and clinical teaching by the consultants and experience with non-invasive investigations over a period of 3 months on a part time basis. This was followed by another 3 months working with the consultant cardiologist twice-weekly in the out-patient clinic.
The GP-cardiologists then established cardiology clinics in their practices, taking referrals from other GPs. These clinics were held every other week, with the GP-cardiologists continuing to act as clinical assistants in the hospital-based consultant clinic on alternate weeks. This provided continuing education and close contact with the consultant. All GP-cardiologists had open access to all hospital non-invasive investigations.
The locality clinics have a central secretary based in Greenwich Hospital. The secretary receives the referrals from the GPs, and organizes the clinics and the appropriate locality appointments according to the patients' address. Notes for the locality clinics are kept in the central office in Greenwich hospital and are separate from the trust hospital notes. The secretary is responsible for organizing the requested tests, obtaining and filing results, typing the correspondence and organizing the follow-up appointments according to the GP-cardiologists' instruction. All correspondence from the locality clinics was also filed in the patient's trust hospital notes.
Evaluation of the service
Three years after starting this service, we examined the use of the locality clinics by eligible GPs. We selected 125 sets of notes of patients seen between October 1997 and October 1998 at random, 61 from the locality clinics and 64 from the hospital clinics. Data were collected from the notes using a predefined questionnaire, and stored on a computer using Excel. Information was collected regarding patients’ demographics and the indication for referral, based on the GP's letter. Palpitations, dysrhythmias and atrial fibrillation were considered as one category, as were dizziness and pre-syncope. The type and number of investigations were recorded. Information on discharges, follow-up and prescriptions was also collected. Coronary risk-factor identification was also recorded. Data are presented as actual numbers and percentages.
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Results |
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Structure and process
Over the 3 years that the service had been available (when the audit was performed), 1200 patients had been seen in the locality clinics. Of the 128 GPs within the zones covered by the locality service, 87 (68%) had referred patients to the locality clinics. Waiting time for initial appointments in the consultant-led hospital-based clinics was 12 weeks; no fall was seen during the duration of the study. In contrast, waiting time for the GP-cardiologists locality clinics was initially 2 weeks but increased to 6–8 weeks by the end of the third year because of the increasing number of referrals.
Demographics, discharge, and follow up
There were no demographic differences in the patients referred to the clinics (Table 1
). Mean age was 61 years (range 17–84) and 60 years (range 26–92) in the locality and hospital clinics, respectively, with similar percentages of men and women. Two-thirds of patients from both groups were discharged after the initial consultation or following one further visit; 10% of patients from locality clinics were referred for further follow-up in the hospital clinics. Of the 125 casenotes reviewed, one hospital and three locality patients failed to attend.
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Indications for referral
Chest pain accounted for half of the referrals to both clinics. There were no statistically significant differences in the indications for referral for patients seen in the locality clinics compared to those referred directly to the hospital consultants in the conventional way (Table 2). There was a trend for more patients with palpitations to be referred to hospital clinics, while more referrals were made to the locality clinics for diagnostic echocardiography, but neither reached statistical significance in the small sample analysed.
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Investigations
No differences were identified in the investigations carried out in both clinics; 83% of patients had at least one cardiac investigation. There was a trend in the hospital clinic to refer more patients for 24-h tapes and angiography (Table 3); almost 5% of the patients seen in the locality clinics subsequently underwent coronary angiography without hospital referral.
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Prescriptions
Patients seen in the hospital clinics were more likely to be prescribed beta-blockers: 14% compared to 3% in locality clinics. There was a trend towards more prescriptions of angiotensin-converting-enzyme inhibitors and statins in the hospital clinics. The prescription rate of calcium channel blockers and nitrates was not different between the two clinics (Table 4).
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Identification of risk factors
GPs tended to record risk factors more frequently in their referrals to the locality clinics compared to hospital clinics (34.4% vs. 12.5%). Similar numbers of patients had one or more risk factor identified on the first consultation in both clinics: 29/61 (47.5%) in locality clinics and 33/64 (51.6%) in hospital clinics. Overall, identification of any risk factor was more likely in the locality clinics than in the hospital-based service (81.9% vs. 64.1%).
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Discussion |
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This is the first description of a community-based out-patient service for cardiology run by specialist GPs. The striking uptake of the service by 68% of the GPs within the localities covered by the locality clinics suggests that, as for other conditions such as diabetes and asthma, GPs are satisfied with the concept of sub-specialization and referral to their colleagues for a further opinion. No formal assessment was made of patient satisfaction, but the informal reports from the GPs as well as the extent to which the service continues to be used, suggests that patients also find the service acceptable. In keeping with this, the Health Authority agreed to continue funding the locality clinics after the initial LIZEI grant had expired. The work of the GP-cardiologists as clinical assistants within the hospital trust has provided ongoing education.
The loss of SHO support in out-patient clinics within the hospital following the Calman reforms has been compensated for by the presence of the GP-cardiologists in their capacity as clinical assistants, and the hospital service now both relies on their support and funds this aspect of the project.
Our audit identified no significant differences between the locality and the hospital cardiology clinics in the kind of problems referred or the outcome. Chest pain comprised the highest percentage of referrals, as one would expect with the high prevalence of ischaemic heart disease. The tendency for more patients with palpitations to be referred to the hospital clinic might be because they are perceived by GPs as more difficult to manage. Alternatively, they may be seen as less urgent and able to wait longer without undue risk. The higher proportion of patients with palpitation accounts for the tendency for more 24-h tapes ordered in the hospital clinic. The higher numbers of referrals for echocardiography to the locality clinics may be an indication that GPs find it easier to request a simple echocardiogram from a GP colleague rather than a hospital consultant. Positive tests in the locality clinics were discussed with a hospital doctor regarding management on most occasions.
To some extent the service has become a victim of its own success, in that waiting times for initial appointment have risen three-fold. Nonetheless, they are still shorter than those are for the hospital clinics, and several patients with urgent problems such as crescendo angina have been successfully diagnosed and ‘fast-tracked’ through to angiography. It is noteworthy that waiting times in the hospital clinics have not fallen, which may indicate the level of unmet need that exists in the region. This has implications for the estimation of future service provision requirement.
Organization of the clinics was relatively straightforward but relied heavily on locally co-operative and motivated GPs and GP-cardiologists, and excellent secretarial support. Difficulties sometimes arose from unexpected quarters; e.g. public transport to the locality clinics, which we believed would be easier for the patients due to their geographical proximity, proved difficult since main bus routes are organized to pass major hospitals but not individual general practices.
Beta-blockers, angiotensin-converting-enzyme inhibitors and statins are known to be under-prescribed by GPs. It is interesting that in our study beta-blockers were more likely to be prescribed by hospital doctors than by specialized GP-cardiologists. Calcium channel blockers are over-prescribed in the community by GPs, but in our study both hospital doctors and GP-cardiologists had a similar prescription rate.
Coronary risk factors were more likely to be recorded in the referrals to locality clinics than to hospital clinics. This may reflect a belief by the referring GP that the hospital doctors will identify risk factors. It may alternatively reflect a greater confidence on the part of the GP who chooses to refer to the locality clinics.
A case has been made for more open access and direct referral to specialists to help deliver a high standard of care to all patients without barriers or delay.2,3 Open-access services, with GPs having direct access to investigations such as echocardiography,4 endoscopy,5 ultrasound6 or one-day chest pain clinics7 without a specialist consultation have been evaluated previously. These have shown that interested GPs use these services appropriately and effectively. Expansion of such open access relies on GPs feeling confident in establishing a diagnosis and ordering appropriate investigations in a given subspecialty. The sub-specialization of GPs, especially within a multi-partner practice, promotes this confidence. The continuing interaction with the hospital consultant also encourages continuing education within the speciality.
We have shown that GP-led community-based cardiology out-patient clinics are feasible and appear valuable, although the sample size is small and further randomized assessment is required. The establishment of such clinics could be a way to enhance cardiac care in the community and help meet the goals of the National Service Framework for Coronary Heart Disease.
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Notes |
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Address correspondence to Dr M. Egred, Cardiac Research Department, Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen AB25 2ZN. e-mail: m.egred{at}abdn.ac.uk
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References |
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1. Coronary Heart Disease National Service Framework. [www.doh.gov.uk/nsf/coronary.htm], March 2000.
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Newby DE, Fox KA, Flint LL, Boon NA. A ‘same day’ direct-access chest pain clinic: improved management and reduced hospitalisation. Q J Med1998; 91:333–7.
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Bowker TJ, Clayton TC, Ingham J, et al. The ASPIRE Study (Action on Secondary Prevention through Intervention to Reduce Events). Heart1996; 75:334–42.
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Wood DA, DeBacker G, Graham I, et al. EUROASPIRE A European Society of Cardiology Survey of Secondary Prevention of Coronary Heart Disease. Eur Heart J1997; 18:1569–82.
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