rapid cardiology
TRANSCRIPT
Rapid Cardiologyand the one stop cardiology services at
Charing Cross Hospital
Kevin Fox
Hammersmith Hospitals NHS Trust and Imperial College, London
Dept of Cardiology, Charing Cross Hospital Imperial College, London
A Rapid Access Clinic Model
GP wants help with a patientRefers to RAC
Patient seen same / next working day (no appointment needed)
Patient is assessed Hx, EX, ECG+/- Holter / Echo / ETT
Diagnosis establishedTreatment commencedOr patient is reassured
Total time 48 hrs!
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The Charing Cross Hospital Rapid Cardiology Service
Rapid Access Chest Pain Clinic Rapid Access Arrhythmia Clinic Rapid Access Heart Failure Clinic
First presentations of suspected angina, tachy or bradyarrhythmia, or heart failure
Clinic runs each weekday morning, no appointments necessary – just a referral note from GP, A and E…
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The Rapid Cardiology Service
Approx 30-40 patients / week Electronic record and computer generated letters
Staffing: Nurse Practitioner- enhanced role particularly with
RACPC patientsHistory/physical measurements/exercise testing
Clinical Fellow - medical supervision of the day’s clinics with responsibility for diagnosis and management
Clinical measurement (and admin) support
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The combined Rapid Cardiology Clinics (population served 150 000 - 200 000)
Rapid Access Clinics at Charing Cross Hospital
Chest pain Heart Failure Arrhythmia
No. seen / week 20 3 15
No. seen /100,000
population/weekday
2 0.3 1.6
No significant pathology (%) 71 64 63
Significant cardiac disease % 29 36 37
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Source of referrals to a RAAC
referral source
other
GP
A&E
referral source
124 10.1
983 80.4
116 9.5
1223 100.0
A&E
GP
other
Total
Frequency Percent
Dept of Cardiology, Charing Cross Hospital Imperial College, London
One stop services for recurrent disease and other problems
Recurrent disease may be serious.
However: It’s difficult to add years
e.g. post CABG angina Rapid access clinic style
evaluation not appropriate
BUT can still use a one stop assessment
co-ordinated tests + consultation Make the single visit effective Assess all the problems
don’t leave a BP of 142 / 86
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Further one-stop services- The encapsulated problem
The murmur at insurance medical
Possible white coat hypertension
Direct performance of the relevant test with report to GP
e.g. Mon pm SpR echo session
Specialist directed, rather than open access, investigation
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Tuesday afternoons at Charing Cross 1999 - 2003
WAS: 34 patients seen between 2pm and 6.30pm
NOW: 12 - 20 patients seen between 2pm and 5pm
What about outcomes?
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Rapid Cardiology Follow up Study
One Year follow up study
Hypothesis: Rapid Cardiology clinics promptly diagnose and
effectively manage patients with first presentation of coronary heart disease, significant arrhythmia and heart failure.
(And this is cost effective)
Study supported by the CHD Collaborative
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Methods
940 consenting patients seen between November 2002 and October 2003
Follow up questionnaire study sent at 1 year
Further follow up of patients through hospital datasets, GP questionnaires, ONS flagging
Dept of Cardiology, Charing Cross Hospital Imperial College, London
All patients - initial versus final diagnosis
final diagnosis
other - non-cardiac:
other cardiac - HT/C
Not
Possible
Definite
initial diagnosis
208 17.0
156 12.8
787 64.3
49 4.0
23 1.9
1223 100.0
Definite
Possible
Not
other cardiac -HT/CAD/HF/VHD/Sbrady/ACS
other - non-cardiac:Anaemia/hypo/hyperT4/CVA/TIA/fits/sync
Total
Frequency Percent
initial diagnosis
other - non-cardiac:
other cardiac - HT/C
Not
Possible
Definite
final diagnosis
102 16.4
11 1.8
465 74.6
30 4.8
15 2.4
623 100.0
Definite
Possible
Not
other cardiac -HT/CAD/HF/VHD/Sbrady/ACS
other - non-cardiac:Anaemia/hypo/hyperT4/CVA/TIA/fits/sync
Total
Frequency Percent
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Rapid Access Cardiology ClinicsInitial diagnosis and diagnosis at 1 yr
Card 1 yr Poss Card 1yr
Not card 1 yr
Not card 1yrTotal
Card ini 150 2 53 205
Poss Card ini 25 18 61 104
Not card ini 12 2 617 631
Total 187 22 731 940
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Key Points – PPV of diagnosis
Positive predictive value of a non cardiac diagnosis is 98%
Positive predictive value of a cardiac diagnosis is 76%
4% ‘Cross-over’ patients (i.e. those referred to the ‘wrong clinic’)
Dept of Cardiology, Charing Cross Hospital Imperial College, London
1 year mortality data
There were 26 (10 cardiac) deaths amongst the cohort of 940 patients
Initial diagnosis ‘cardiac’ Cardiac mortality for those diagnosed initially with
cardiac disease was 7/205 (3.4%)
Initial diagnosis ‘possible or not cardiac’ Cardiac mortality for those with non-cardiac/possible
diagnosis 3/735 (0.4%).
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Cardiac Outpatients visits – ‘Definite’ versus ‘Not cardiac’
cardiac outpatient for cardiac problem
no
yes
cardiac outpatient for cardiac problem
26 17.3
124 82.7
150 100.0
yes
no
Total
Frequency Percent
cardiac outpatient for cardiac problem
20 64.5
11 35.5
31 100.0
yes
no
Total
Frequency Percent
cardiac outpatient for cardiac problem
no
yes
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Visits to GP
Definite Not cardiac
Number of visits to GP for same symptoms
Number of visits to GP for same symptoms
171154320
Fre
quency
30
20
10
0
Number of visits to GP for same symptoms
Number of visits to GP for same symptoms
241211106543210
Fre
quency
120
100
80
60
40
20
0
Number of visits to GP for other symptoms
Number of visits to GP for other symptoms
241816151210876543210
Fre
quen
cy
30
20
10
0
Number of visits to GP for other symptoms
No visits to GP for other symptoms
25121186543210
Fre
qu
en
cy
7
6
5
4
3
2
1
0
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Patient experience of CX RA Cardiac clinics
87%
2%
8%3%
positiveexperience (%)
negative exp (%)
Neutral exp (+and -) (%)
Indeterminate (%)
Patient satisfaction questionnaire
Dept of Cardiology, Charing Cross Hospital Imperial College, London
What’s the secret of our success?
THERE IS NO SECRET!
Trust the epidemiology Today’s work today Be flexible Say YES not NO Sort the problem out NOW Say THANK YOU and feedback the positives
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Rapid Cardiology Questions
Does it need a ‘doctor’?
Does it need to be in secondary care?
Is it cost effective?
How should the service be introduced?
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Rapid assessment : pros and cons
Highly effective diagnostic strategy
Facilitates prompt initiation of appropriate therapy
Provides a specialist assessment for all patients presenting with cardiac disease in the community
Swift reassurance of those without pathology
Expanding evidence of effectiveness
Very popular with patients / GPs
Initial investment in reengineering manpower and resources
RCT data on efficacy not available
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Referrals following opening of the CX RAAC
Number of cases seen per month
0
20
40
60
NovDec Jan Feb Mar AprMay Jun Jul AugSep Oct NovDec Jan Feb Mar AprMay Jun Jul AugSep Oct NovDec Jan Feb
1999199920002000200020002000200020002000200020002000200020012001200120012001200120012001200120012001200120022002
Fre
qu
ency
0
40
80
120
160
0 1 2 3 4 5 6 7
Number of patients seen per day
Fre
qu
ency
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Resources - is it feasible?
Population 200 000 Total 8 / weekday
(but v. variable)
Provisional staffing levels Clinician Nurse Practitioner (ETT +/- Echo) Technician (ECG, ETT, Echo, Holter) Administrative support
Significant proportion of total OPD workload dealt with (and the great majority of new OPDs)
Rapid Access Clinics at Charing Cross Hospital
Chest pain Heart Failure Arrhythmia
No. seen / week 20 3 17
No. seen /100,000
population/weekday
2 0.3 1.7
No significant pathology (%) 71 64 57
Significant cardiac disease % 29 46 43
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Diagnosis of patients seen in the RAAC
AF/Flutter 93 (27%)
Junctional reentrant tachy 20
(6%)
Heart block 12 (3%)
P. atrial tachy 11 (3%)
NSVT 3 (1%)
No significant arrhythmia
detected 211 (60%)
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Diagnostic pattern seen in the Bromley RAHFC (393 cases over 15 months)
Definite HF (n=73)20%
Possible HF (n=95)25%
Not HF (n=205)
55%
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Age distributionRAAC RACPC RAHFC
decade age
decade age
908070605040302010
Freque
ncy
120
100
80
60
40
20
0
decade age
decade age
9080706050403020
Freque
ncy
160
140
120
100
80
60
40
20
0
decade age
decade age
9080706050403010Fre
quen
cy
50
40
30
20
10
0
decade age50.90Mean
decade age50.77Mean
decade age68.54Mean
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Outline structure of cardiology services at CXH:
Population: High CAD riskHealthy
Newly Symptomatic Prevalent disease Screening
+
Prevention
services
GP
CCU+
Secondary care
in-patient services
999 / A+E
Rapid assessment forchest pain / heart failure /
arrhythmia / Other
Specialist clinics: CAD / HF / Rhythm /
Valve / ACHD
Tertiary care (surgery, revascularisation, pacing, electrophysiology, transplantation)
The community heart failure team
1oPCI
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Final Diagnosis in patients initially diagnosed 'non cardiac'
final diagnosis
3 .7
396 98.0
3 .7
2 .5
404 100.0
Definite
Not
other cardiac -HT/CAD/HF/VHD/Sbrady/ACS
other - non-cardiac:Anaemia/hypo/hyperT4/CVA/TIA/fits/sync
Total
Frequency Percent
final diagnosis
other - non-cardiac:
other cardiac - HT/C
Not
Definite
Dept of Cardiology, Charing Cross Hospital Imperial College, London
All responders - symptom severity
symptom severity
none
8-10
4-7
1-3
symptom severity
38 18.3 18.3
35 16.8 35.1
26 12.5 47.6
109 52.4 100.0
208 100.0
1-3
4-7
8-10
none
Total
Frequency PercentCumulative
Percent