Rathod Krishnaraj Sinhji, Ward Helen, Farooqi Fahad
Barking Havering Redbridge NHS Trust.
BMJ Qual Improv Rep. 2014 Oct 21;3(1). doi: 10.1136/bmjquality.u203864.w1691. eCollection 2014.
Typical stable angina is a clinical diagnosis based on history. The challenge for GPs in primary care is to identify those patients who are presenting with either possible or typical angina symptoms and refer onwards for specialist assessment in the local Rapid Access Chest Pain Clinic (RACPC). Our initial information gathering study suggested that referring GPs may be cautiously overdiagnosing angina in primary care, potentially resulting in avoidable or unnecessary referrals to RACPC. We sought a practical and cost effective solution to reducing avoidable referrals by assisting GPs with chest pain discrimination. We tested a change of referral form incorporating chest pain symptom scoring to see whether GP referral quality could be improved and then assessed its impact post implementation. GPs that used the chest pain symptom scoring questionnaire were more than twice as likely to correctly discriminate non-cardiac chest pain. Our post implementation study of the new referral form showed that the proportion of referrals to RACPC with diagnosis of non-cardiac chest pain reduced by almost 19%, and there was a statistically significant 30% fall in the total number of referrals to RACPC. This was likely to be driven by the deterrent effect of the novel referral form on avoidable referrals. Fewer avoidable referrals results in shorter wait times for specialist review, reduces the risk of waiting time breach, and improves RACPC efficiency. In summary, chest pain symptom scoring resulted in improved GP discrimination of chest pain, improved referral quality, fewer overall referrals to RACPC and shorter patient wait times. These benefits were achieved without using additional financial resources and without the time or capital expense of training GPs. These findings could assist GPs and Clinical Commisioning Groups to achieve cost savings by reducing avoidable secondary care referrals.
典型稳定型心绞痛是基于病史的临床诊断。基层医疗中全科医生面临的挑战是识别那些出现可能或典型心绞痛症状的患者，并将其转诊至当地的快速通道胸痛诊所（RACPC）进行专科评估。我们最初的信息收集研究表明，转诊的全科医生在基层医疗中可能会谨慎地过度诊断心绞痛，这可能导致对RACPC的转诊是可避免的或不必要的。我们寻求一种实用且具有成本效益的解决方案，通过协助全科医生进行胸痛鉴别来减少可避免的转诊。我们测试了一种纳入胸痛症状评分的转诊表格的变化，以查看是否能提高全科医生的转诊质量，然后评估其实施后的影响。使用胸痛症状评分问卷的全科医生正确鉴别非心源性胸痛的可能性是原来的两倍多。我们对新转诊表格的实施后研究表明，转诊至RACPC且诊断为非心源性胸痛的比例降低了近19%，转诊至RACPC的总数在统计学上显著下降了30%。这可能是由这种新颖的转诊表格对可避免转诊的威慑作用驱动的。可避免的转诊减少导致专科评估的等待时间缩短，降低了等待时间违规的风险，并提高了RACPC的效率。总之，胸痛症状评分提高了全科医生对胸痛的鉴别能力，改善了转诊质量，减少了转诊至RACPC的总数，并缩短了患者的等待时间。这些益处是在不使用额外财务资源且无需花费时间或资金对全科医生进行培训的情况下实现的。这些发现可以帮助全科医生和临床委托小组通过减少可避免的二级医疗转诊来实现成本节约。
