Excess of mortality in patients with chest pain peaks in the first 3 days period after the incident and normalizes after 1 month

Background. Patients presenting with chest pain have a 5% chance of experiencing a coronary event. These patients are at risk of mortality and should be recognized and referred to secondary care

GPs' reasons for referral of patients with chest pain: a qualitative study

<p>Abstract</p> <p>Background</p> <p>Prompt diagnosis of an acute coronary syndrome is very important and urgent referral to a hospital is imperative because fast treatment can be life-saving and increase the patient's life expectancy and quality of life. The aim of our study was to identify GPs' reasons for referring or not referring patients presenting with chest pain.</p> <p>Methods</p> <p>In a semi-structured interview, 21 GPs were asked to describe why they do or do not refer a patient presenting with chest pain. Interviews were taped, transcribed and qualitatively analysed.</p> <p>Results</p> <p>Histories of 21 patients were studied. Six were not referred, seven were referred to a cardiologist and eight to the emergency department. GPs' reasons for referral were background knowledge about the patient, patient's age and cost-benefit estimation, the perception of a negative attitude from the medical rescue team, recent patient contact with a cardiologist without detection of a coronary disease and the actual presentation of signs and symptoms, gut feeling, clinical examination and ECG results.</p> <p>Conclusion</p> <p>This study suggests that GPs believe they do not exclusively use the 'classical' signs and symptoms in their decision-making process for patients presenting with chest pain. Background knowledge about the patient, GPs' personal ideas and gut feeling are also important.</p

Signs and symptoms in children with a serious infection: a qualitative study

BACKGROUND: Early diagnosis of serious infections in children is difficult in general practice, as incidence is low, patients present themselves at an early stage of the disease and diagnostic tools are limited to signs and symptoms from observation, clinical history and physical examination. Little is known which signs and symptoms are important in general practice. With this qualitative study, we aimed to identify possible new important diagnostic variables. METHODS: Semi-structured interviews with parents and physicians of children with a serious infection. We investigated all signs and symptoms that were related to or preceded the diagnosis. The analysis was done according to the grounded theory approach. Participants were recruited in general practice and at the hospital. RESULTS: 18 children who were hospitalised because of a serious infection were included. On average, parents and paediatricians were interviewed 3 days after admittance of the child to hospital, general practitioners between 5 and 8 days after the initial contact. The most prominent diagnostic signs in seriously ill children were changed behaviour, crying characteristics and the parents' opinion. Children either behaved drowsy or irritable and cried differently, either moaning or an inconsolable, loud crying. The parents found this illness different from previous illnesses, because of the seriousness or duration of the symptoms, or the occurrence of a critical incident. Classical signs, like high fever, petechiae or abnormalities at auscultation were helpful for the diagnosis when they were present, but not helpful when they were absent. CONCLUSION: behavioural signs and symptoms were very prominent in children with a serious infection. They will be further assessed for diagnostic accuracy in a subsequent, quantitative diagnostic study

The proof of (un)certainty: diagnostic research on 'chest pain' in a GP setting

Over the last 20 years, a substantial change in the epidemiology of acute myocardial syndrome (ACS) has occurred. Non-ST-segment elevation myocardial infarction (NSTEMI) now constitutes the majority of AMIs and the 30-days fatality rate of hospitalized AMI patients has improved markedly with a decrease of 56%.(1) One of the reasons for the decrease is the decline in AMI severity, probably due to the contribution of prevention therapy and the use of aspirin and beta-blockers before admission.(2) Another reason is the improvement of the management of patients with ACS, including pharmacological treatment (beta-blockers, statins, angiotensin-converting enzymes) with or without percutaneous coronary intervention (PCI). In STEMI patients in hospital, mortality decreased from 8.4% to 4.6% and in NSTEMI patients from 2.9% to 2.2 % (not significant) between 1999 and 2005.(3)To maximize patient outcome it is important that GPs refer ACS patients urgently to start treatment as soon as possible.(4,5,6)In contrast to the 30-days mortality, the one-year mortality did not change, although the mortality related to cardiovascular diseases decreased from 62% to 50% in the period 87-91 versus 2002-2006.(1)In the study of Chan et al., where every patient underwent cardiac catheterization, one-year mortality was 9.5% for STEMI patients and 14.3% for NSTEMI.(2) The higher mortality rate for NSTEMI than STEMI was also found in other studies.(1,3,7) Reasons for the higher mortality were co-morbidity and probably insufficient prescription of guideline-recommended medications on discharge.(7) It may be an important role for the GP during follow-up of those patients to make sure that they are treated in anappropriate manner.Acute myocardial infarction and acute coronary syndrome are studied very intensively; a search in Pubmed of Myocardial Ischemia today (03.04.2010) produces 311,505 references, and in combination with Diagnosis there are still 190,096 references. But of those 190,096 references, only 1,369 remain in combination with Primary Health Care or Physicians, Family . Less than 0.7 % of all AMI or ACS diagnostic studies were done in primary health care or in a general practice setting. In order to support the continuous improvement of general practice, we tried to increase the knowledge about GPs treatment decisionsin relation to patients presenting with chest pain. We investigated this domain with a variety of designs: a diagnostic systematic review, a qualitative study to detect some of the criteria a GP uses when dealing with chest pain patients, an observational study to confirm some of the results of this qualitative study, and finally a simulation model to study the influence of changing the treatment threshold on the number of treated patients. In this chapter, we will discuss the main results of these studies, as well as their limitations and the proposal of a research agenda for issues that were not covered. 1. Dealing with chest pain within general practiceAccuracy of typical signs and symptomsWe conducted a diagnostic meta-analysis to determinate the accuracy of ten important signs and symptoms in referred and non-referred patients. Based on our inclusion criteria, we selected 28 studies. We were as strict as possible with respect to the completeness and rigour of the follow-up in the selected studies. 16 out of the 28 selected studies included non-selected patients. In this group absence ofchest wall tenderness on palpation had a pooled sensitivity of 92% (95% CI: 86 to 96) for acute myocardial infarction and 94% (95% CI: 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% CI: 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive LR, namely 2.92 (95% CI: 1.97 to 4.23) for acute myocardial infarction. The other pooled positive LRs fluctuated between 1.05 and 1.49. Negative LRs varied between 0.98 and 0.23. Absence of chest wall tenderness on palpation had a negative LR of 0.23 (95% CI: 0.18 to 0.29).Based on this meta-analysis, we were not able to define an important role for most individual signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low prevalence settings. After the publication of this meta-analysis one additional study was published and we are aware of two more which have not yet been published.(8) All three studies largely confirm our results. Only two studies were performed in a general practice setting, so we decided to look for primary care studies, defined as settings in which patients were seen who were not referred by other medical practitioners. Most of the pooled results were heterogeneous, due to different settings, inclusion criteria and reference standards. The non-homogeneous pooled results in particular must be interpreted very carefully. Some studies suggested a difference in the diagnostic accuracy of signs and symptoms according to age(9,10) or gender(11), but the number of available studies was insufficient to perform subgroup analysis.Although the combination of signs and symptoms, their context, the severity and the progression from the start influenced the interpretation, it was impossible to study this because there were (almost) no included studies which studied the diagnostic accuracy of combinations of signs and symptoms. Only three of the selected studies combined different signs and symptoms, i.e. Short(12) (previous or not-previous history of acute coronary syndrome and studied signs and symptoms), Lee(13) (sharp or stabbing pain and pain pleuretic, positional or reproduced by palpation and no prior acute coronary syndrome) and Hartgarten(14) (radiating pain and sweating; difficult breathing and nausea/vomiting). In Lee s study, the combination of three variables sharp or stabbing pain, no history of angina or myocardial infarction, and pain that was reproduced by chest-wall palpation or that had a pleuretic or positional component identified the lowest-risk group. Of 48 such cases, not one patient had a diagnosis of myocardial infarction, unstable angina, or stable angina. Other variables, including age, sex and risk factors for coronary artery disease, did not contribute further to the identification of a low-risk group. Research agenda Studies on chest pain with or without additional signs and symptoms in a primary care setting are necessary to improve diagnosis in a setting with only 5% of all chest pain patients having a serious cardiac disorder.(15) Individual patient data (IPD) of different studies can be combined to obtain better results. Such a study is currently being prepared within an international collaboration.Referring or not referring patients In qualitative studies, the goal is not to recruit a representative sample of participants to quantify opinions, but rather to elicit all possible opinions and views on a specific subject. In a semi-structured interview, 21 GPs were asked to describe why they did or did not refer a patient presenting with chest pain. Interviews were taped, transcribed and qualitatively analysed. Histories of 21 patients were studied. Six were not referred, seven were referred to a cardiologist and eight to the emergency department. In our data, saturation was reached, which probably suggests that the most important criteria were identified. All the interviews were conducted with highly motivated GPs and they responded honestly and voluntarily to the interviewer. The latter was illustrated by the ten GPs explaining cases where they possibly made an error. The interviews were taken within a couple of days after the GP had seen the patient with chest pain, to prevent the GPs reinterpreting their diagnostic reasoning in the light of information from a cardiologist or based on the evolution of the patient s condition. This study suggests that the background knowledge on the patient, the patient s current clinical presentation and the GP s personal opinions are used by GPs when deciding on whether or not to refer a patient with chest pain to secondary care. It is striking that background knowledge on the patient coronary risk factors, differences in behaviour, playing down the seriousness was considered to be an important factor in the decision-making process. For those factors, knowing the patient is essential. The current clinical presentation with the results of the physical examination in particular is used to rule in diseases other than acute coronary syndrome which need no referral. An ECG was used to confirm the presence of an acute coronary syndrome and refer the patient. A normal ECG was a reason for not referring, but only in combination with long duration of the pain and in absence of risk factors. Additionally, the GP s gut feeling is sometimes more important than the presence of individual signs and symptoms. The GP s personal ideas the patient s age, perception of a negative attitude from the medical rescue team, recent patient contact with a cardiologist, past errors were additional factors in the decision-making process. Sometimes, uncertainty about the diagnosis caused an unnecessary referral. Referring older people had a higher threshold than referring younger people. The recruitment of GPs who were willing to participate in the interviews was a difficult process. The prospect of being judged and facing possible criticism may have been a reason for non-collaboration. Loss of time without financial compensation could be another reason. More reminders may have been helpful. Although e-mail is an easy way to recruit GPs, the response proved to be limited. Compared to the general population of GPs in Flanders, the participating GPs were similar in age and practice organization single-handed or group practice but not in gender: female GPs are underrepresented in our sample. Our data did not reveal any difference in reasoning between the three females or the three trainees, and the male group of experienced participants. Of course, gender bias is always possible. In addition, we have to take into consideration the difference between reported behaviour and actual performance.(16,17)Research agendaThe new reasons for referral mentioned in our study, namely differences in patient behaviour, gut feeling, the perception of a negative attitude from the medical rescue team, should now be further evaluated for their effect in a subsequent quantitative study, in a synthesis of qualitative studies or both. 2. Patients with chest pain within general practice: an observational studyCertainty of initial diagnosis and referral rate1996 patients were included (male 52%). A majority of patients consulting with chest pain are not referred by their GP. However, 40% of the patients were suspected of having a serious disease and had to be referred.Men were referred more often (OR=1.44; 95% CI: 1.13 to 1.82). Age showed no relationship to referral (OR=1.06; 95% CI: 0.83 to 1.35) but predicts urgent referral (OR=1.46; 95% CI: 1.02 to 2.08). Not maleness or age alone, but probably the increased risk of serious heart disease in men versus women and in older versus younger age groups are the reasons for this higher urgently referral rate. Also, the higher number of initial diagnoses of somatoform disorder , which seldom results in referral, may be a reason for the low number of urgent referrals in women.Patients suspected of having serious heart disease are referred in 85% of cases. Odds ratios for referral were high with 11.58 (95% CI: 5.72 to 23.44) when the GP was certain of his diagnosis and 2.96 (95% CI: 1.59 to 5.51) if not, versus patients not suspected of having serious heart disease. If the GP was uncertain, in all disease categories 54% (95% CI: 48 to 59) of the patients were referred non-urgently. The high rate of referrals in case of uncertainty in all initial diagnostic categories could beexplained by the fear of missing a serious diagnosis. Fifty-seven patients in whom the GP was certain of his initial diagnosis of serious heart disease were not referred. We found this strange as we would have expected almost all of these patients to be referred for further work-up. To explore this phenomenon, we conducted a phone survey of the GPs including 23 randomly selected patients. It revealed 12 patients with known heart disease and numerous past referrals for which the situation did not really represent an aggravation. For six patients, the hypothesis of serious heart disease could be ruled out after careful physical examination and history taking. One patient refused referral and no information was retained about four patients. Apart from the latter four, none of these situations really required a referral. Such findings are specific for general practice and important when discussing referral rates.Research agendaAn observational study on the reasons for the certainty or uncertainty of the working diagnosis would be very interesting. Certainty of a working diagnosis and certainly uncertainty are influenced by gut feeling. A follow-up study to find out the final diagnosis would give us more information on the value of gut feeling. Mortality and referral rate1558 patients were included. We standardised our group according to age and gender of the Belgian population of 1999. Three-day standardized mortality ratio was 151.0 (95% CI: 82.3 to 250.3) for urgently referred patients, 45.5 (95% CI: 12.4 to116.0) for non-urgently and 13.6 (95% CI: 1.7 to 49.4) for non-referred patients. The one-month standardized ratios were respectively 27.6 (95% CI: 18.0 to 40.4), 6.7 (95% CI: 2.5 to 14.6) and 4.7 (95%CI: 1.9 to 9.7). The standardized ratios of two to twelve months were normal for the urgent referral group (1.3; 95% CI: 0.7 to 2.2) and for the non-urgent referral group (1.0; 95% CI: 0.5 to 1.9) and even less in the non-referred group (0.4; 95% CI: 0.2 to 0.9).Mortality in the first three days and first month after consulting for chest pain is very high. There is a marked trend in mortality according to the referral type urgently referred, non-urgently referred and not referred suggesting effective risk stratification by the general practitioner. After one month, mortality normalises for all groups,suggesting that the surviving patients are well-treated and the condition causing the chest pain no longer influences survival compared to the general population. Because of the relatively small number of events, the 95% CI, especially for the mortality within three days, is very wide. So these results should be interpreted with caution. In the six cases where a patient was not referred urgently and died within three days, the patients refused urgent referral, presented with no or unclear signs and symptoms or experienced a quickly changing medical situation. It is possible that GPs are reluctant to urgently refer patients with low disease probability. We received follow-up information on 86% of the patients. However, information could not be retrieved from 7.8% of patients because the GPs could not identify their patients, based on the identification code they supplied to the research group. Most missing patients were non-referred patients, who were the youngest and healthiest, probably rarely consulting the GP. This is also the reason why the mortality ratios may have been slightly overestimated, because more information about the non-referred patients (with the lowest mortality) is missing than from the other groups. Assuming that there were no deceased patients in the missing group, the one-month mortality rate would change from 0.8 to 0.6% for the non-referred patients group, from 1.4 to 1.2% for the non-urgent referred group and from 10.7 to 8.6% for the urgently referred group. On the other hand, assuming that all patients from the missing data group died, the one-month mortality rate would change to 25.9%, 17.9% and 27.2% respectively. We do not have a final diagnosis for the non-referred patients, in whom acute coronary may be a minor event and may even go undetected.23 But, since this study was designed to evaluate mortality, it does not affect our conclusions. Research agendaOur present study has yielded some hypotheses that could be further investigated in future studies. The marked trend in mortality between urgently referred, non-urgently referred and non-referred patients suggests that GPs adequately stratify the risk for immediate mortality. However, it is not always clear which threshold they use to refer a patient with chest pain, and what influences this threshold.Moreover, the question as to their preference for urgent or non-urgent referral is as yet unresolved. Secondly, although the mortality in non-urgently referred and non-referred patients was lower than that in the urgently referred category, these patients do experience an increased risk for immediate mortality compared to the general population. A new study with registration of all final diagnoses would allow further research on risk factors for immediate mortality and could be incorporated in referral decisions in the future.Transport and referral rate 1996 patients were included. For non-urgently referred patients, 92.7% (95% CI: 89.1to 95.2) were transported by family and neighbours, 4.8% (95% CI: 2.8 to 7.9) by ambulance and 2.5% (95% CI: 1.2 to 5.1) by GPs themselves. For urgently referred patients, ambulances transported 56.9% (95% CI:51.1 to 62.7), family and neighbours 36.9% (95% CI: 31.4 to 42.7) and the GP 6.1% (95% CI: 3.7 to 9.5). There was a significant difference in mortality rate according to the type of transport: of the 73 patients who were transported by ERT, 8(11.0%) died within a period of three days; of the 100 transported by ambulance, 6 (6.0%) died; of the 26 transported by the GP, 1 (3.8%), died; and of the 401 transported by neighbours or family, 4 (1%) died. Almost half of the urgently referred patients with chest pain are transported in unsafe conditions. A possible bias is the large number of missings in the non-urgently referred patients. There are several explanations for this: these patients did not go to the specialist, they did not return to the GP, or the GP neglected this part of the registration. Including the 18 patients with ACS without known transport type could change the suboptimal transport from 53% to 51% (if all 18 were transported by ambulance) or to 61.1% (if no one was transported by ambulance). Research agenda In our qualitative study we found that the perception of a negative attitude from the medical rescue team was a factor for not urgent referring. More investigation of this may be very interesting. Survey among GPs after they have called an ambulance is a possibility. Interviews with physicians of the medical rescue teams may be useful too. 3. Treatment thresholdsThe distribution of disease probabilities after multiple testing and the effect of modifying (i.e. lowering) the treatment threshold on the proportions of treated patientsLowering the threshold from 95% to 50% and 5% in simulations with a prevalence of 50%, 10% and 1% after tests with high accuracy has nearly no influence on the number of patients treated because the diseased and non-diseased patients groups are nearly perfectly separated. In real situations, using tests with lower accuracy, lowering the threshold will increase the number of treated patients substantially. More diseased patients are treated than non-diseased down to a threshold of 5% and prevalence of 10%. Under these values it is the opposite, but nearly all diseased patients are treated. Physicians fear applying low thresholds, they correctly estimate based on utility theory, because they intuitively see post test probability distributions as Gaussian (Van den Ende J, Bruyninckx R. By lowering the threshold, we'll treat them all. International workshop on clinical reasoning. King's College, London. 2010). This study might help convincing clinicians that for a wide range of prevalences and test accuracies, bringing the threshold down is entirely justified. Three studies on tuberculosis in developing countries proved that by lowering the treatment threshold the number of treated patients did not increase linearly and that many more diseased patients were treated.(18,19,20)A simulation is not the real life situation. First, we supposed all tests to perform independently of each other. In real life, some tests will interact with each other to a certain extent. Second, for convenience, we did not apply different accuracies to consecutive tests. Otherwise, we would have a multitude of final post-test probabilities, with insufficient numbers per category for representation as a distribution. Third, we did order all ten tests for all patients, which is not realistic. If the disease probability plummets under a certain threshold, no more tests are ordered, and vice versa for a high post testprobability.(21)It was not our intention to determine the threshold according to the principles of Pauker and Kassirer, based on the result of the benefit and risk/cost for the diseased patients and the disutility for the non-diseased patients, but to study the influence of different hypothetical thresholds on the number of treated and untreated patients.(21,22)Research agendaThe effect of using different treatment thresholds on the number of diseased and non-diseased patients treated should be applied to other existing datasets with other diseases than tuberculosis, different prevalences and different settings, including primary, secondary and tertiary care. Final conclusionIt was not possible to define an important role for individual signs and symptoms in the di

The diagnostic value of macroscopic haematuria for the diagnosis of urological cancer in general practice

BACKGROUND: The diagnostic value and the impact of some signs and symptoms in most diseases in primary care have only been studied incompletely. AIM: To assess the diagnostic value of macroscopic haematuria for the idagnosis of urological cancer (bladder, kidney) in a general practice setting, as well the influence of age, sex, and some additional signs and symptoms. DESIGN OF STUDY: Diagnostic study. SETTING: The study was performed in a sentinel station network of general practices in Belgium, covering almost 1% of the population. SUBJECTS: All patients attending their general practitioner and complaining of haematuria during 1993 and 1994 were included for the prospective part of the study. Every patient diagnosed with a urological cancer in this period was registered for the retrospective part. METHOD: Mean outcome measures of sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio were used to assess diagnostic value. RESULTS: Within the registration year 1993-1994, patient-doctor encounters, related to 83,890 patient-years, were registered. The positive predictive value (PPV) for urological cancer was 10.3% (95% CI = 7.6% to 13.7%). Sensitivity was 59.5% (95% CI = 50.4% to 60.1%). The PPV of patients aged over 60 years was 22.1% (95% CI = 15.8% to 30.1%) for men and 8.3% (95% CI = 3.4% to 17.9%) for women. In the age group 40 to 59 years, the PPV was 3.6% (95% CI = 0.6% to 13.4%) for men and 6.4% (95% CI = 1.7% to 18.6%) for women. In the prospective part of the study, no urological cancer was found in the age group under 40 years. CONCLUSION: Men older than 60 years of age with macroscopic haematuria have a high positive predictive value for urological cancer. In these patients, a thorough investigation is indicated. In patients over 40 years of age of either sex, referral or watchful waiting can be justified.status: publishe

Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care

Background: Serious infections in children (sepsis, meningitis, pneumonia, pyelonnephritis, osteomyelitis, and cellulitis) are associates with considerable mortality and morbidity. In children with an acute illness, the primary care physician uses signs and symptoms to assess the probability of a serious infection and decide on further management. AIM: To analyse the diagnostic accuracy of signs and symptoms, and to create a multivariable triage instrument.Design of the study: A prospective diagnostic accuracy study. Setting: Primary care in Belgium.Methos: Children aged 0-16 years with an acute illness for a maximum of 5 days were included consecutively. Signs and symptoms were recorded and compared to the final outcome of these children (a serious infection for which hospitalization was necessary). Accuracy was analyzed bivariably. Multivariable triage instruments were constructed using classification and regression tree (CART) analysis. Results: A total of 3981 children were included in the study, of which 31 were admitted to hospital with a serious infection (0.78%). Accuracy of signs ans symptoms was fairly low. Classical textbook signs (menigeal irritation impaired peripheral circulation) had high specificity. The primary classification tree consisted of five knots and had sensitivity of 96,8% (95% CI=83.3 to 99.9), specificity 88.5% (95%CI= 87.5 to 89.5), positive predictive value 6.2% (95%CI= 4.2 to 8.7), and negative predictive value 100.0% (95%CI= 99.8 to 100.0), by which a serious infection can be excluded in children testing negative on the tree. The sign paramount in all tres was the physician's statement 'something is wrong'. Conclusion: Some individual signs have high specificity. A serious infection can be excluded based on a limited number of signs and symptoms.status: publishe

Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care

BACKGROUND: Serious infections in children (sepsis, meningitis, pneumonia, pyelonephritis, osteomyelitis, and cellulitis) are associated with considerable mortality and morbidity. In children with an acute illness, the primary care physician uses signs and symptoms to assess the probability of a serious infection and decide on further management. AIM: To analyse the diagnostic accuracy of signs and symptoms, and to create a multivariable triage instrument. DESIGN OF STUDY: A prospective diagnostic accuracy study. SETTING: Primary care in Belgium. METHOD: Children aged 0-16 years with an acute illness for a maximum of 5 days were included consecutively. Signs and symptoms were recorded and compared to the final outcome of these children (a serious infection for which hospitalisation was necessary). Accuracy was analysed bivariably. Multivariable triage instruments were constructed using classification and regression tree (CART) analysis. RESULTS: A total of 3981 children were included in the study, of which 31 were admitted to hospital with a serious infection (0.78%). Accuracy of signs and symptoms was fairly low. Classical textbook signs (meningeal irritation impaired peripheral circulation) had high specificity. The primary classification tree consisted of five knots and had sensitivity of 96.8% (95% confidence interval [CI] = 83.3 to 99.9), specificity 88.5% (95% CI = 87.5 to 89.5), positive predictive value 6.2% (95% CI = 4.2 to 8.7), and negative predictive value 100.0% (95% CI = 99.8 to 100.0), by which a serious infection can be excluded in children testing negative on the tree. The sign paramount in all trees was the physician's statement 'something is wrong'. CONCLUSION: Some individual signs have high specificity. A serious infection can be excluded based on a limited number of signs and symptoms

Why does the general practitioner refer patients with chest pain not-urgently to the specialist or urgently to the emergency department? Influence of the certainty of the initial diagnosis

BACKGROUND: Chest pain is an initial symptom for several minor diseases but acute myocardial infarction (AMI) should not be missed. AIM: To assess the influence of initial diagnosis and degree of certainty of this initial diagnosis on the referral decision and the referral method (urgent-non-urgent) in patients contacting their GP with chest pain. STUDY DESIGN: Observational study. SETTING: The study was performed in a sentinel network of general practices in Belgium, covering almost 1.6% of the population. SUBJECTS: All patients attending their GP and complaining of chest pain during 2003. METHOD: The relationships were reported as proportions and in odds ratios (OR) with their 95% confidence intervals. RESULTS: 1996 patients were included (men 52%). Men were referred more often (OR = 1.44; 95% CI: 1.13-1.82). Age shows no relation to referral (OR = 1.06; 95% CI: 0.83-1.35) but predicts urgent referral (OR = 1.46; 95% CI: 1.02-2.08). Odds ratios in case of serious heart disease were high with 11.58 (95% CI: 5.72-23.44) when the GP was certain of his diagnosis and 2.96 (95% CI: 1.59-5.51) if not. If the GP was uncertain, in all disease categories 54% (95% CI: 48-59) of the patients were referred non-urgently. CONCLUSION: Referral rates for patients with chest pain were influenced by the initial diagnosis and the degree of certainty of this initial diagnosis.status: publishe

Half of the patients with chest pain that are urgently referred are transported in unsafe conditions

Background: patients with an acute coronary syndrome should be referred to hospital urgently to start reperfusion therapy as soon as possible. Owing to the risks of ventricular fibrillation and pulseless ventricular tachycardia, urgent transport should be organized under safe conditions, that is, with a defibrillator at hand. Aim: To evaluate the type of transport of patients with chest pain referred by their general practitioner (GP). Desing of study: Observational study. Setting: a sentinel network of general practices in Beligum, covering almost 1.6% of the total population. Patients: One thousand nien hundred and ninety-six patients with chest pain attending their GP in 2003. Method: Descriptive analyses reporting proportions along with their 95% coincidence interval (CI). Results: Male patients were referred to hospital more often than female patients: 44,9% (95% CI: 41.6-47.8) versus 36.5% (95% CI 33.4-39.6). For patients who were referred routinely, 92.7% (95% CI: 89.1-95.2) were transported by family and neighbours, 4.8% (95% CI: 2.8-7.9) by ambulance and 2.5% (95% CI: 1.2-5.1) by GPs. For patients who were referred urgently, ambulances transported 56.9% (95% CI: 51.1-62.7), family and neighbours 36.9% (95% CI: 31.4-42.7) and the GP 6.1% (95% CI: 3.7-9.5). Conclusion: Almost half of the patients with chest pain who require urgent referral are transported in unsafe conditions.status: publishe