Service should be reserved for equivocal cases

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7000.327 (Published 29 July 1995) Cite this as: BMJ 1995;311:327
  1. David I Slovick
  1. Consultant physician in medicine for the elderly Southend Healthcare Trust, Rochford, Essex SS4 2RB

    EDITOR—C M Francis and colleagues claim that their open access echocardiography service was “well used” and led to advice being given to change management for nearly 70% of patients.1 I fear that they have been unsuccessful if they were trying to increase the currently low rates of prescription of angiotensin converting enzyme inhibitors in heart failure: the number of patients referred for echocardiography was small compared with the numbers of patients with known and unknown left ventricular dysfunction in the study population. The study population can be assumed to be roughly 1.1 million (assuming average practice lists for the 550 general practitioners canvassed). Among these patients up to 2% may already have left ventricular dysfunction2 (that is, over 22000) and an annual incidence of left ventricular dysfunction of 0.1 to -0.2% (that is, 1100-2200 patients) coud be expected. So the referral of 259 patients for echocardiography over five months is a drop in the ocean, even if it is argued that echocardiography is unnecessary to diagnose left ventricular dysfunction in all cases.

    The key difficulty in increasing the use of angiotensin converting enzyme inhibitors may be the reluctance of general practitioners to alter the treatment of patients who do not pose a clinical problem. It is time consuming to explain the reason for echocardiography in hospital to asymptomatic patients and even more time consuming to convert to treatment with an angiotensin converting enzyme inhibitor, with all the blood tests required before and after.

    For this reason, in the Southend area we are focusing on the interface between general practitioners and hospitals in a pilot study for a larger audit project. Patients are being identified in a paper exercise at the general practice, and only those with equivocal disease are referred for echocardiography. The question remains whether general practitioners will act on the information given on their patient's cardiac status and alter their drug treatment, but help with sessional provision of additional medical and nursing staff may be required to achieve the desired result.


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