Queues for cure?

Indications, Utility and Appropriateness of Echocardiography in Outpatient Cardiology

OBJECTIVE

Respect of "appropriateness" is considered an essential requirement, both on the clinical and the economic profile, and also as it helps to shorten the waiting list. However, only a few studies have dealt with the control of appropriateness in clinical practice, and most of them have focused only on hospital admissions and invasive procedures.

MATERIALS AND METHODS

INDICARD-out is a prospective, multicenter study carried out by A.R.C.A. (Associazioni Regionali Cardiologi Ambulatoriali) cardiologists from 13 Italian Regions, providing information on indications, utility and appropriateness of echocardiography in outpatient cardiology.

RESULTS

A total of 2110 prescriptions for echocardiogram were evaluated. Hypertension (23%) and the screening of asymptomatic subjects (17%) by far were the most frequent indications to echocardiography. Overall, 54% of the tests resulted appropriate, 30% were of uncertain appropriateness and 16% were inappropriate. Besides, 31% of the echocardiograms were not useful, and 28% were non pertinent for patient management. The vast majority of prescriptions (72%) came from non-cardiologist physicians (54% from general practitioners). The echocardiograms prescribed by cardiologists were significantly more appropriate, more useful and more pertinent than the tests prescribed by non-cardiologists.

CONCLUSIONS

The appropriateness, utility and pertinence of the echocardiography are still suboptimal in practice cardiology, especially when indicated by non-cardiologists. The cardiologist, from mere executor of tests prescribed and managed by other physicians, should gain the role of the clinician who takes care of all the cardiologic needs of the patient community.

Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial

INTRODUCTION

To evaluate the efficacy of a self-management support program including a 6 week self-management course, individualised phone support and goal setting in osteoarthritis patients on a waiting list for arthroplasty surgery.

METHOD

Randomised controlled trial of 152 public hospital outpatients awaiting hip or knee replacement surgery who were not classified as requiring urgent surgery. Participants were randomised to a self-management program or to usual care. The primary outcome was change in the Health Education Intervention Questionnaire (HeiQ) from randomisation to 6 month follow-up. Quality of life and depressive symptoms were also measured. Changes in pain and function were assessed using the Western Ontario and McMaster Universities (WOMAC) Arthritis Index.

RESULTS

At 6 month follow-up, health-directed behaviour was significantly greater in the intervention [mean 4.29, 95% confidence interval (CI) 3.99-4.58] than the control (mean 3.81, 95% CI 3.52-4.09; P=0.017). There was also a significant effect on skill and technique acquisition for the intervention (mean 4.37, 95% CI 4.19-4.55) in comparison to control (mean 4.11, 95% CI 3.93-4.29; P=0.036). There was no significant effect of the intervention on the remaining HeiQ subscales, WOMAC pain or disability, quality of life or depressive symptoms.

DISCUSSION

The arthritis self-management program improved health-directed behaviours, skill acquisition and stiffness in patients on a joint replacement waiting list, although the observed effects were of modest size (Cohen's d between 0.36 and 0.42). There was no significant effect on pain, function or quality of life in the short term. Self-management programs can assist in maintaining health behaviours (particularly walking) in this patient group. Further research is needed to assess their impact on quality of life and over longer periods.

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study

OBJECTIVE

To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study.

DESIGN

Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients.

SETTING

Royal Hospitals Trust, London, UK.

PARTICIPANTS

3631 consecutive patients undergoing coronary angiography (no exclusion criteria).

MAIN OUTCOME MEASURES

Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up.

RESULTS

The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively).

CONCLUSION

The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography.

Waiting list management in general practice: a review of orthopaedic patients

OBJECTIVE

To review all patients on a current general practice orthopaedic waiting list for outpatient appointments with regard to accuracy of the list, clinical priority, and need for further radiological investigation before hospital attendance.

DESIGN

Record review by one general practitioner and a radiologist, and discussion with patients of management alternatives.

SETTING

Six partner city centre urban fund-holding general practice, list size 8651 (29% low deprivation payment status).

SUBJECTS

116 adults on an orthopaedic waiting list.

MAIN OUTCOME MEASURES

List accuracy (patient details and status on waiting list); clinical priority (severity of condition); further investigations (results of tests after radiological review).

RESULTS

32 patients (28%) were removed from the waiting list because of inaccuracies. 14 patients were considered to be high priority and referred to other hospitals by utilising waiting list initiative funds. Of these patients, five agreed to referral to another hospital (treatment completed on average within three months of rereferral), six did not wish to be rereferred, and two did not attend to discuss the offer and remained on the original waiting list. One prioritised patient had further radiological investigations, was reassured, and was taken off the waiting list. 10 patients had further investigations. These resulted in six patients being referred to other hospitals, three being taken off the waiting list, and one seeking private care.

CONCLUSIONS

Systematic review of patients on an orthopaedic waiting list of one general practice, though time consuming, led to the identification of inaccuracies in the list and changes in management. Costs need further evaluation, but if the findings occur widely substantial benefits could be achieved for patients.

Waiting list dynamics and the impact of earmarked funding

OBJECTIVE

To determine how changes in the number of admissions from waiting lists and changes in the number of additions to the lists are related to list size and waiting times, in the context of local waiting list initiatives.

DESIGN

Review of national and Körner statistics.

SETTING

England (1987-94) and districts of the former Oxford region (1987-91).

MAIN OUTCOME MEASURES

Correlation of quarterly changes in the number of admissions from waiting lists in England with changes in total list size, numbers of patients waiting one to two, or over two years, and number of additions to the lists; examination of changes in waiting list statistics for individual district specialties in one region in relation to funding for waiting list initiatives.

RESULTS

Nationally, changes in the number of admissions to hospital from lists closely correlated with changes in the number of additions to lists (r = 0.84; P < 0.01). After adjusting for changes in the number of additions to lists, changes in the number of admissions correlated inversely with changes in list size (r = -0.62; P < 0.001). Decreases in the number of patients waiting from one to two years were significantly associated with increases in the number of admissions (r = -0.52; P < 0.01); locally, only six of 44 waiting list initiatives were followed by an increase in admissions and a fall in list size, although a further 11 were followed by a fall in list size without a corresponding increase in admissions.

CONCLUSIONS

An increase in admissions improved waiting times but did not reduce list size because additions to the list tended to increase at the same time. The appropriateness of waiting list initiatives as a method of funding elective surgery should be reviewed.