QJM Advance Access originally published online on February 14, 2006
QJM 2006 99(3):135-141; doi:10.1093/qjmed/hcl013
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Rapid-access chest pain clinics and the traditional cardiology out-patient clinic
From the 1Newham University Hospital, London, 2Barts and The London Queen Mary's School of Medicine and Dentistry, London and 3Department of Epidemiology and Public Health, UCL Medical School, London, UK
Address correspondence to Dr N. Sekhri, Newham University Hospital, Glen Road, Plaistow London E13 8SL. email: neha.sekhri{at}newhamhealth.nhs.uk
Received 22 September 2005 and in revised form 24 November 2005
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Summary |
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Background: The National Service Framework for coronary heart disease recommends rapid-access chest pain clinics (RACPCs) for cardiological assessment of new-onset chest pain within 2 weeks of referral.
Aim: To measure the extent to which an RACPC successfully substituted for an out-patient cardiology clinic (OPCC) at a general hospital, in assessing new-onset chest pain referrals.
Methods: Prospective measurement of attendance and waiting times for consecutive patients at the RACPC and OPCC, and multivariate analysis of factors associated with referral for angiography.
Results: From September 2002 to August 2004, 1382 patients with chest pain attended the RACPC, and 228 patients, the OPCC. All RACPC patients were seen within 24 h of referral, except those referred on Friday afternoons, or the day before national holidays. The mean ± SD waiting time for OPCC appointments was 97 ± 43 days. Of 208 OPCC patients, 30 (14%) fulfilled the RACPC referral criterion of recent onset chest pain (<4 weeks duration) vs. 926/1382 (67%) RACPC patients. Thus the RACPC substituted for the OPCC in 926/956 (97%) new chest pain referrals. Patients from the OPCC were 3.82 (95%CI 1.85–7.90) more likely to be referred for a coronary angiogram. compared to those attending the RACPC.
Discussion: The RACPC has provided efficient and effective substitution for the OPCC in the assessment of new chest pain referrals according to pre-defined referral criteria. Broadening the referral criterion of the RACPC to patients with chest pain of >4 weeks duration would result in more referrals.
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Introduction |
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The National Service Framework (NSF) for coronary heart disease (CHD) recommends rapid-access chest pain clinics (RACPCs) for cardiological assessment of new-onset chest pain within 2 weeks of referral by the family physician.1 Such early assessment cannot usually be achieved in the conventional out-patient cardiology clinic (OPCC), which also has referrals for a wide range of other cardiac conditions (valvular disease, cardiomyopathy, established CHD, heart failure, arrhythmia, etc). The resulting long waiting times for specialist assessment of new-onset chest pain put these patients at risk of acute coronary events that might be prevented with timely cardiological management, including referral for cardiac catheterization.
Implicit in the recommendation for RACPCs was that they should substitute for existing services and reduce referrals to OPCCs of patients who fulfil criteria for rapid assessment of new-onset chest pain. The NSF for CHD encourages local hospitals and primary care trusts (PCTs) to agree on detailed local protocols for assessing such patients, but it is not known whether effective substitution has been achieved. There has been only one small prospective study from Scotland, investigating their effect on chest pain referrals to OPCCs over a 4-week period,2 in which 50% patients who fulfilled local guidelines for the RACPC continued to be referred to the OPCC, despite waiting times of 22 ± 5.5 days and about 3 months, respectively. The investigators expressed concern that the RACPC was potentially diverting resources and contributing to further delay in conventional out-patient assessment.
Retrospective data to allow comparison of the number of OPCC chest pain referrals before and after introduction of the RACPC were not available. With the widespread establishment of RACPCs and the documented risks of delayed assessment of chest pain, it would not be feasible to conduct a randomized controlled trial, to test the effectiveness of this service. We therefore undertook a prospective comparison of chest pain attendances to the RACPC and the OPCC at Newham General Hospital over a 2-year period. Our specific aims were: (i) to quantify the number of patients with incident chest pain attending the OPCC and the RACPC; (ii) to compare the distribution of patients with cardiac and non-cardiac chest pain in both settings; (iii) to measure waiting times for assessment of chest pain in OPCC; (iv) to compare the demographic characteristics of patients with chest pain in OPCC with patients attending RACPC; and (v) to compare rates of referral and determinants of referral for cardiac catheterization in RACPC vs. OPCC.
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Methods |
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A prospective study at Newham General Hospital comparing patients attending the weekly OPCC and the daily RACPC. Both clinics are staffed by the same clinicians.
Rapid-access chest pain clinic (RACPC)
Referrals for the RACPC were made on specially designed referral forms and faxed to a dedicated line within the cardiology department. Clinics were held Monday to Friday from 12:00 to 14:00, and all patients were seen within 24 h of referral, or the next working day in the case of weekends and public holidays. No appointments were made, and patients were seen in order of attendance. Patient data were entered into a database, with dropdown menus to simplify data completion. Clinics were led by a consultant cardiologist and his team of doctors. The setting of the clinic within the cardiology department facilitated easy access to diagnostic tests, including 12-lead ECG, exercise stress test, transthoracic echocardiograms and chest X-ray.
Referral criteria
Local family physicians were the only source of referral to the RACPC, and referral guidelines to the clinic were agreed following discussions between their representatives and the department of cardiology. The indication for referral was recent onset of chest pain in the previous 2–4 weeks, except: (i) patients previously seen for assessment of chest pain, either in the A&E or out-patients department or as in-patients (refer to the out-patient cardiology clinic in the normal way); (ii) patients suspected of having an acute myocardial infarction or unstable angina (refer to the A&E department); (iii) except in exceptional circumstances, do not refer women aged <40 years or men aged <30 years (the probability of coronary disease in these groups is very low).
Out-patient cardiology clinic (OPCC)
The OPCC was held once a week from 09:00 to 12:00, and appointments were made by the central appointments office which received referral letters from primary care The referrals were vetted by a cardiologist and categorized as urgent (within 4 weeks), soon (1–3 months) or routine (next available slot). Almost all requests for chest pain assessment were booked as urgent.
Patients
During a 2-year period (1 September 2002 to 31 August 2004) data on consecutive patients attending the RACPC (n = 1549) and OPCC (n = 276) with new-onset chest pain were recorded. In both groups, we included only the first visit during the study period and excluded patients without chest pain, patients diagnosed with acute coronary syndromes, patients who reported previously diagnosed coronary heart disease or revascularization procedure, patients for whom a diagnosis was not identified as angina or non-cardiac chest pain, and patients with missing data. The remaining 1382 (RACPC) and 228 (OPCC) patients comprised the study groups (Figure 1).
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Data collection
For both groups, data were entered on identical databases, details of which have been reported previously.3 Clinical data included: age, sex, ethnicity, duration of symptoms, character of chest pain, smoking status, history of hypertension, diabetes, pulse rate, systolic blood pressure, drugs and follow-up plan on discharge. Twelve-lead resting electrocardiograms (ECGs) were recorded as normal or abnormal, depending on the absence or presence of any abnormalities of rhythm, conduction, regional ST-segment or T-wave change, left ventricular hypertrophy or Q waves. Exercise treadmill tests were performed at the discretion of clinicians in 54% of RACPC patients and 50% of OPCC patients. Diagnosis of the cause of chest pain (angina or non-cardiac chest pain) was recorded by the clinician at the end of the consultation.
Statistical analysis
Patients in the RACPC and the OPCC were compared using 
2 and t tests for proportions and distributions, respectively. Logistic regression was used to estimate the odds of being referred for an angiogram in univariate and fully-adjusted models, based on covariates associated (p < 0.05) with the outcome of interest. These included diagnosis of angina, age, gender, ethnicity, hypertension, diabetes, current smoking, typicality and duration of symptoms, resting electrocardiograms, exercise treadmill test results and the clinic setting.
Calculation of symptom duration for patients in the OPCC
We defined substitution as the proportion of patients eligible for the rapid-access chest pain clinic who instead attended the out-patient cardiology clinic. Inherent in the out-patient setting are the administrative delays that contribute to the longer waiting times. To adjust for this, the waiting time for the OPCC was calculated as the difference in days between the date on the referral letter to the date of the clinic appointment for each patient attending the OPCC. The waiting time recorded for OPCC patients was subtracted from the duration of symptoms recorded at the time of the out-patient clinic visit, to determine whether the RACPC criterion for recent onset of symptoms (2–4 weeks) was fulfilled at the time of referral by the family physician. The field entries for duration of symptoms were quantified as follows: <2 weeks = 14 days, 2–4 weeks = 28 days, 1–3 months = 90 days, 3–6 months = 180 days, 6–12 months or more = 360 days.
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Results |
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Patient characteristics (Table 1)
OPCC patients tended to be younger, were more commonly South Asian, and all but 2% had had symptoms for >4 weeks at the time they were seen. 26% of OPCC patients were diagnosed with angina, vs. 23% of RACPC patients. Among those diagnosed with angina, aspirin (81% vs. 68%) and beta-blocker (58% vs. 52%) prescription rates were higher in RACPC patients, but the statin (32% vs. 53%) prescription rate was higher in the OPCC. Direct referral for coronary angiography was lower from the RACPC vs. the OPCC (19% vs. 33%), but 50% of the angina patients seen in the RACPC received a further follow-up appointment.
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Waiting times
All RACPC patients were seen within 24 h of referral, except those referred on Friday afternoons, or the day before national holidays who were seen the next working day. The mean ± SD waiting time for OPCC appointments (data available in 208 patients) was 97 ± 43 days.
Substitution
Over the study period, 228 patients, representing 14% of all referrals with previously undiagnosed stable chest pain, attended the OPCC. Of the 208 for whom waiting-time data were available, 33 (16%) had had symptoms for <4 weeks at the time of referral; all but three of whom fulfilled age and gender criteria for the RACPC. Thus 14% (30/217) of OPCC patients fulfilled RACPC criteria, compared with 67% (926/1382) of patients seen in the RACPC. The RACPC, therefore, substituted for the OPCC in 97% (926/956) of new chest pain referrals during the study period.
Predictors of referral for coronary angiography (Table 2)
Among patients diagnosed with angina, rates of referral for coronary angiography were higher in the OPCC than the RACPC (33% vs. 19%). Despite multiple adjustment, the odds of referral for coronary angiography were 3.82 (95% CI 1.85–7.90) for the OPCC relative to the RACPC. Examination of the local catheter registry showed that additional referrals for angiography were made after the index OPCC and RACPC consultations, such that by 17 October 2005, 48% of the OPCC patients and 35% of the RACPC patients had been referred for coronary angiography.
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Discussion |
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We have prospectively compared chest pain referrals to the OPCC and the RACPC at Newham General Hospital, over a 2-year period. The major findings were: (i) waiting times for the RACPC were substantially shorter than waiting times for the OPCC, and (ii) among patients fulfilling eligibility criteria, the RACPC substituted for the OPCC in all but 3% cases.
It is a major requirement of RACPCs that patients with undiagnosed chest pain receive cardiological assessment within 2 weeks of referral, a target rarely achieved in conventional OPCCs. In this study, waiting times were below this target in the RACPC, while those in the OPCC were approximately 3 months, even though patients with chest pain were typically pre-classified as urgent in expectation of a 4-week waiting time. The extent to which these findings can be extrapolated to RACPCs elsewhere will depend on the way services are configured. If there are daily clinics and an open-access policy for accepting referrals, with no waiting lists or other administrative delays, we believe cardiological assessment within 24 h can be achieved in the large majority of patients.
In most centres, RACPCs have been set up in addition to existing OPCCs. The provision of a new service will inevitably attract additional patients, as confirmed by Sutcliffe for RACPCs.4 Additional chest pain referrals for cardiological assessment are desirable, if more at-risk cases are to be treated. The proportions of those diagnosed with angina in the RACPC and OPCC were similar, suggesting that the RACPC is genuinely catering to an unmet need, rather than just seeing large numbers of low-risk patients. But if the effect of RACPCs is to address previously unmet need, this will not in itself reduce out-patient attendance or waiting times for patients with new onset of chest pain, unless all these patients are re-directed to the RACPC, allowing effective substitution for the existing out-patient cardiology service.
Our RACPC, which currently sees about 800 patients per year, has effectively substituted for the OPCC in the assessment of new-onset chest pain, with 97% of all eligible patients now attending the RACPC. However, substitution of the OPCC chest pain service has not been complete. While provision of daily RACPCs successfully attracts more patients with recent-onset chest pain for cardiological assessment, there remains a minority of patients appropriate for the RACPC who are referred to the OPCC, delaying their specialist assessment and treatment. If the RACPC referral criterion for chest pain of <4 weeks duration is ignored, as occurred with 33 patients in our study, then substitution by the RACPC becomes less complete. Opening up the RACPC to all patients, regardless of chest pain duration, would permit more referrals but require more resources.
The RACPC with its structured approach offered more evidence-based therapy, as seen by the higher rates of prescription of aspirin and beta-blockers, although this did not apply to statin therapy. Patients referred to the RACPC often do not have their lipid levels performed prior to clinical assessment, which may partly explain the low statin prescription rate on discharge. But nearly 70% of the RACPC angina patients underwent further cardiology follow-up and although it is likely that most came to receive statins, it is a limitation of our study that we do not know what proportion remained untreated. The finding of a higher referral rate for angiography from the OPCC is hard to explain, since both clinics were staffed by the same doctors, and the patients to both clinics came from the same catchment area. It may reflect longer waiting times and more established clinical symptoms among OPCC patients compared with RACPC patients. This explanation is supported by the Euro Heart Survey of stable angina,5 which reported higher rates of referral for angiography among patients with longer symptom duration. This is unlikely to provide a complete explanation, however, since the local catheter registry showed that the difference persisted in the longer term. Also hard to explain is the small excess of South Asian patients continuing to be referred to the OPCC, although this may reflect the referral practice of certain family physicians. An important way of improving the efficiency of the RACPC service must be to improve the quality of referrals to best use available resources. This highlights the need for regular audits and contact with the primary care providers, to ensure optimum care is provided to the patients.
We believe this is the first study to show the impact of RACPCs on reducing the number of referrals of patients with new-onset chest pain to routine OPCCs. Its strength lies in its prospective design and capturing of parallel clinical data on consecutive patients in two different settings. The same clinicians were involved in patient assessment, both in the out-patient cardiology clinic and the rapid access chest pain clinic, exposing both sets of patients to same level of observer bias. The limitation of this study is that all the data are from a single centre, and the findings may not be generalizable. The study was not designed to capture clinician and patient responses and preferences, which would address some of the qualitative aspects of the impact of this service.
In conclusion, an RACPC can largely take over the task of assessing new onset chest pain, with almost complete substitution of the existing OPCC chest pain service for patients fulfilling referral criteria.
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Acknowledgments |
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We would like to thank Dr K Ranjadayalan and his team for all their support in completing this study, and the NHS Service Delivery and Organization for funding.
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References |
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1. Department of Health. National Service Framework for Coronary Heart Disease: modern standards and service models. 2000;London Department of Health.
2. McGavigan AD, Begley PE, Moncrieff J, Hogg KJ, Dunn FG. Rapid Access Chest Pain Clinics-Can they be Justified? Scot Med J 2003; 48:13–16.
3. Ray S, Archbold RA, Preston S, Ranjadayalan K, Suliman A, Timmis AD. Computer-generated correspondence for patients attending an open-access chest pain clinic. J Roy Coll Physicians Lond 1998; 32:420–1.[Medline]
4. Sutcliffe SJ, de Belder A, Kumar PR, Fox KA, Wood DA, Gandhi MM, et al. A comparison of 5 Rapid Access Chest Pain Clinics. Heart 2002; 87:(Suppl. 11), 12.
5. Daly CA, Clemens F, Sendon JL, Tavazzi L, Boersma E, Danchin N, et al. The clinical characteristics and investigations planned in patients with stable angina presenting to cardiologists in Europe: from the Euro Heart Survey of Stable Angina. Eur Heart J 2005; 26:996–1010.
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