Rapid access clinics for patients with chest pain: will they work in Australia?

Rapid access cardiology services may safely divert people with non‐cardiac chest pain from being admitted to hospital

Chest pain is an exceedingly common cause of presentations to emergency departments, and a large and increasing number of people with suspected cardiac chest pain are being admitted to Australian hospitals (Box). Between 1993–94 and 2007–08, the age‐standardised rate of hospitalisation with acute myocardial infarction increased by 80% and that of unstable angina by 33%, but hospitalisations for chest pain increased by more than 200%.1 Only about one in ten people who present to Australian hospitals with suspected cardiac chest pain receive a final diagnosis of acute coronary syndrome, and no more than 2% of patients with low to intermediate risk of cardiovascular disease are diagnosed with an acute coronary syndrome.2 This raises the question of whether such patients need to be admitted to hospital at all.

The concept of rapid access chest pain clinics (RACPCs) was first described in the United Kingdom during the 1970s. Most hospitals in the UK now have RACPCs, as recommended by the National Service Framework for coronary heart disease,3 and most publications about RACPCs are from the UK.4 The RACPC concept centres on patients being investigated within two weeks of referral from primary care, and a diagnosis being delivered in a cardiologist‐led outpatient service. The reported satisfaction of referrers and patients with RACPCs is high, and the few studies that have explored their cost benefits have also yielded positive findings, with most savings resulting from the lower number of people admitted to hospital.5

A key reason for hospitalising patients with chest pain is the perceived greater safety of monitoring them in hospital. Most short term analyses have found that event‐free survival is very high for patients diagnosed in RACPCs with non‐cardiac chest pain.6,7 In a study that followed 8762 consecutive patients who had attended the RACPCs of six English hospitals, 194 of 6396 patients diagnosed with non‐cardiac chest pain (3%) had major adverse cardiac events during the follow‐up period (median, 2.6 years), suggesting that cardiovascular disease in these patients had been missed at the initial visit. The authors concluded that better diagnostic tests and follow‐up more specific than primary care were needed.8

Is the UK experience directly relevant to Australia? A key difference is that most RACPCs in the UK only accept people with stable chest pain referred from primary care. They do not accept patients with suspected acute coronary syndrome and do not usually review or manage patients with chest pain discharged from an emergency department. The other notable divergence is the difference in the structure of our health systems: some Australian patients do not have regular primary care doctors, and ensuring follow‐up may be more important here than in the UK.

Data on the RACPC model of care are considerably more limited in Australia than in the UK. In two recent reports, most referrals were from emergency departments; each study found that the final diagnosis was cardiac chest pain in fewer than 10% of patients and that rates of re‐presentation to emergency departments and hospitalisation were low.9,10 One of the studies reported high satisfaction among referrers and patients, and found that 11.3% of emergency department referrers would have admitted the patient if the RACPC had not been available.10 Both studies noted the high level of cardiovascular risk factors in their patient populations, indicating a major opportunity for undertaking cardiovascular disease preventive education.

In this issue of the MJA, the report by Black and colleagues11 provides more support for the utility of the RACPC as a safe and efficient model of care in the Australian context. The authors found that rates of emergency department re‐presentation and major adverse cardiac events were lower for 1479 patients seen in an RACPC in Hobart than for an historical control group of 435 patients assessed in general cardiology clinics at the same hospital. The RACPC and historical control groups were reasonably well matched, but follow‐up was limited to 12 months and the numbers of cardiac events were low in both groups, limiting the ability to compare the two approaches.

The RACPC seems a reasonable approach to managing patients in Australia with chest pain who are at low to intermediate risk of cardiovascular disease. Nevertheless, several questions still need to be examined. How should patients be integrated into ongoing care and management after their RACPC visit? What are the risks and likelihood of missing cardiovascular disease in RACPC patients? What would be the cost of establishing and operating RACPCs in Australia? Would they be accepted by cardiologists and the wider community? Would the Australian model come to resemble the UK model, in which most referrals to RACPCs are directly from primary care?

Box – Age‐standardised hospitalisation rates for people with a principal diagnosis of chest pain, Australia, 1993–94 to 2009–10

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Source: Australian Institute of Health and Welfare (AIHW),1 based on data from the National Hospital Morbidity Database; reproduced with permission of the AIHW. The break at 1998–99 corresponds to the move from ICD‐9‐C to ICD‐10‐AM coding (1998–99 hospitalisations were coded with both classifications). ◆