Harskamp Ralf, van Peet Petra, Bont Jettie, Ligthart Suzanne, Lucassen Wim, van Weert Henk
Postdoctoral Researcher and GP Registrar, Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands.
GP and Associate Professor, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
BJGP Open. 2018 Nov 28;2(4):bjgpopen18X101619. doi: 10.3399/bjgpopen18X101619. eCollection 2018 Dec.
GPs are frequently confronted with patients with acute onset chest pain. Although usually benign, approximately 5% is due to acute coronary syndrome (ACS). Unfortunately, ACS is not always recognised, leading to a missed diagnosis in 2-5% of presentations.
The authors set out to study the level of risk GPs are willing to accept with regards to missing an ACS diagnosis, and the receptiveness of implementing new clinical decision aids.
DESIGN & SETTING: This study involved an online survey among GPs in the Netherlands.
A concept survey was constructed, which was tested among a panel of 24 GPs. The survey was then modified to achieve content validity. This survey was electronically distributed among 1000 GPs.
A total of 313 (31.3%) GPs completed the survey. Of those surveyed, the median age was 50 years (interquartile range 41-57), 53.0% were female, and 6.4% were specialist GPs ('kaderarts') in cardiology or acute care. GPs estimated the missed ACS rate to be <5.0% in clinical practice, most often estimating a chance of 1.0-2.5% (35.2%) or 0.5-1.0% (29.7%). For atypical case presentations, 70% of GPs would accept a 0.1-1.0% missed diagnosis rate, while keeping the referral threshold to a maximum of 50 unnecessary referrals for each ACS case (75% of responders). GPs would welcome additional decision aids, with 79.2% favouring a clinical decision aid, 77.1% favouring troponin point-of-care (POC) testing, and 85.5% favoring a combination of a clinical decision aid and a troponin POC test.
GPs perceive that they miss more ACS cases than they feel comfortable with, which is reflected in a defensive referral strategy. The vast majority of GPs would welcome the use of clinical decision aids and/or cardiac biomarker POC testing for ruling out ACS, if accompanied by more certainty than based on clinical judgment alone.
全科医生经常会遇到急性胸痛患者。虽然通常为良性，但约5%是由急性冠状动脉综合征（ACS）引起。不幸的是，ACS并不总是能被识别出来，导致在2%-5%的病例中出现漏诊。
作者着手研究全科医生在漏诊ACS方面愿意接受的风险水平，以及对实施新的临床决策辅助工具的接受程度。
本研究涉及对荷兰全科医生的在线调查。
构建了一项概念性调查，并在由24名全科医生组成的小组中进行测试。随后对调查进行修改以实现内容效度。该调查通过电子方式分发给1000名全科医生。
共有313名（31.3%）全科医生完成了调查。在接受调查的人中，年龄中位数为50岁（四分位间距41-57岁），53.0%为女性，6.4%是心脏病学或急性护理方面的专科全科医生（“骨干医生”）。全科医生估计在临床实践中漏诊ACS的比例<5.0%，最常估计的概率为1.0%-2.5%（35.2%）或0.5%-1.0%（29.7%）。对于非典型病例表现，70%的全科医生会接受0.1%-1.0%的漏诊率，同时将转诊阈值保持在每个ACS病例最多50次不必要转诊（75%的应答者）。全科医生会欢迎额外的决策辅助工具，79.2%的人支持临床决策辅助工具，77.1%的人支持肌钙蛋白即时检测（POC），85.5%的人支持临床决策辅助工具和肌钙蛋白POC检测相结合。
全科医生认为他们漏诊的ACS病例比他们感觉舒适的情况更多，这反映在一种防御性转诊策略中。绝大多数全科医生会欢迎使用临床决策辅助工具和/或心脏生物标志物POC检测来排除ACS，前提是比仅基于临床判断更具确定性。
