Provision of services for the diagnosis and treatment of heart disease. Fourth report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England

Variation in purchasing for the invasive management of coronary heart disease

This paper reports the results of a postal questionnaire survey of Directors of Public Health in all health authorities in the United Kingdom (as at March 1994). Our aim was to examine variations in the purchasing of coronary artery bypass grafting, percutaneous transluminal coronary angioplasty and coronary angiography. Information on planned service developments in cardiology was also sought. The response rate was 62%. The mean rate of CABG was 374 per million total population (range 162-710); PTCA 183 (range: 18-648); and coronary angiography 1,010 (range 581-2,334). The mean ratio of invasive treatment to angiography was 1:2 Variations in provision were not related to mortality from coronary heart disease or the availability of a local provider. Those districts purchasing higher levels of CABG tended to purchase higher levels of PTCA (Spearman's r = 0.52). Observed variations in purchasing of invasive treatments and investigation for coronary heart disease do not relate to population "need' as defined by mortality rates from CHD. The greatest variations are seen in the purchasing of PTCA, an intervention whose place in the management of CHD is as yet not fully defined. Consensus guidelines on the appropriate use of these interventions and on population needs are required.

General practitioners' requirements from a hospital cardiology department

The requirements of 500 general practitioners from a hospital department of cardiology were sought and assessed from a questionnaire. One hundred and twenty two general practitioners caring for 766,384 patients responded. The most important inpatient service requirement was that cardiologists should be responsible for the management of patients with acute myocardial infarction and other acute cardiac conditions. The expertise and reputation of the consultant cardiologist and the waiting time for an appointment were the two most important outpatient service requirements. The least important aspect was the time patients waited in clinic to see a doctor. Fundholders considered price of outpatient consultations to be unimportant. Waiting times for cardiac catheterisation and non-invasive cardiac investigations together with the quality of the investigation equipment and the technical staff were all considered to be important requirements. Most general practitioners wanted protocols for managing common cardiac conditions. The majority wanted an open access investigation service to reduce outpatient waiting times. Those who did not want an open access service explained that they would not be confident in interpreting the results or deciding subsequent management. An understanding of the requirements of general practitioners is helpful in planning and developing hospital services.

The investigation and management of stable angina. Report of a working party of the Joint Audit Committee of the British Cardiac Society and the Royal College of Physicians of London

This paper is a summary of present practices in the investigation and management of angina. The mechanism, incidence, and prevalence of angina are reviewed, the roles of invasive and non-invasive investigations assessed, and the indications for coronary angioplasty and coronary bypass grafting discussed. Basic audit data sets for primary, secondary, and tertiary care are proposed and potential audit initiatives suggested.