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At the heart of general practice since 1960

How to cut unnecessary referrals with a GP-based ECG monitoring service

Dr Max Hickman on how an open-access scheme for Holter monitoring is keeping many arrhythmia patients out of secondary care

Dr Max Hickman on how an open-access scheme for Holter monitoring is keeping many arrhythmia patients out of secondary care

Low-risk patients with a history of palpitations but no serious cardiac disease have traditionally clogged up cardiac outpatient departments. Indeed, when our practice started to look at the arrhythmia pathway for our area two years ago, we found that 20 to 30% of referrals to cardiology were for palpitations.

After seeing a cardiologist and having a 24-hour or seven-day ECG, the vast majority of patients turned out to have nothing wrong with them and were discharged.

41218474In June last year we introduced a community-based 24-hour and seven-day ECG monitoring service in eight GP practices across two PBC consortiums. This is successfully allowing serious arrhythmias to be detected early and preventing many unnecessary referrals to secondary care for patients who have palpitations but no underlying serious arrhythmia. We aim to turn around reports within four weeks of the initial referral and have picked up a number of significant pathologies as well as reassuring many patients.

Getting started

The initial stakeholder event to develop a new pathway was sponsored by Pfizer, which provided an independent facilitator with no drug promotion. As the idea developed, we realised it was a suitable scheme to be run under PBC. Annual running costs are funded out of freed-up resources.

The scheme runs across Colchester PBC group and Tendring Clinical Commissioning group – two consortiums that share management staff and together cover the North East Essex PCT area comprising 52 practices with 317,000 patients.

A stakeholder event – involving clinicians from primary and secondary care, PCT and acute trust managers and a patient representative – resulted in a working group being set up to agree which patients could be managed by open-access Holter monitoring. The exclusion criteria established were:

• patients under 18

• those with family history of sudden cardiac death before the age of 40 or cardiomyopathy

• those with exertional cardiac symptoms, and where an ECG shows left bundle branch block or evidence of pre-excitation such as Wolff-Parkinson-White syndrome.

It was also decided it was very important that the protocol for results should be clear cut – we didn't want any grey areas as the practices that are running the service do not necessarily have a GP with cardiology training.

Another development at this stage was that Colchester Hospital University Foundation Trust, which had understandably assumed that this would be a hospital service, opened its own direct-access service.

This means we are in fact in competition with them and local GPs can refer to either. Both services can co-exist as long as there is enough throughput for all the providers.

Equipment, training and costs

We looked at several types of monitoring equipment and decided to use the Reynolds Life Card from a company called Space Labs. This is the same equipment that is used in secondary care locally, giving reassurance that our tests offer the same quality as those carried out in secondary care.

Set-up costs were £24,570 for the purchase of 10 machines, software and memory cards and these were paid for by the PCT out of pump-priming funds. Other costs arose from supporting clinical lead work to develop the pathway and the service but these were minimal as most of the work was done by PBC group members as part of their usual remuneration for PBC work and our PBC executive officer, Tracy Buckingham. We had sponsorship from a few drug companies for catering costs at a launch event that we held at our local postgraduate centre.

The initial training was provided free by the equipment supplier. Rachel Clarke, a nurse practitioner in my practice and PBC group member, has also worked with these machines in a hospital post, and she has been a great help with the training.

No new staff have had to be employed.

Eight practices in the area offer the service and practices were asked to bid to run it. We made sure there was a good geographical spread so every area has a local practice offering the service. Those PBC members involved in developing the care pathway took a back seat in the actual commissioning and the PCT has developed processes to deal with potential conflicts of interest, including PEC sign-off. Each practice has a lead GP who takes responsibility.

The PCT pays £105 per test carried out.

Making a referral

All the GPs in the consortium can refer patients to the service using a referral form, which shows the criteria for referral and exclusion.

The referring GP has a list of providers and chooses which practice to send the patient to. They carry out some basic tests (FBC, LFTs, U&Es, TFTs, blood glucose and 12-lead ECG) and send the results of these with the referral form.

We encourage the referring GP to look at the test results and, if they feel the palpitations are caused by ectopics, to reassure the patient without sending them for monitoring.

The working group agreed that a result was normal if the report came back as not more than 5% ectopics on the recording. This figure was based on the opinion of our cardiologist. Any other result is deemed abnormal.

If the result is normal, the patient is reassured – unless the symptom diary they keep during the test shows no symptoms during the recording, in which case they are reassured with caution, and we write to their referring GP and let them decide whether to do further investigations.

If the result is abnormal we recommend seeking a specialist opinion, except in the case of paroxysmal atrial fibrillation – where we recommend management according to the latest NICE guidelines.

How it works in my practice

My practice is one of the eight providing the tests in the area. We have had 38 referrals to date and 10 of these came from within the practice.

The scheme is currently limited to patients with a history of palpitations not present at the time of consultation, and we make sure those with a high risk are referred directly to secondary care.

At my practice we offer appointments to have the monitor fitted at a time convenient to the patient. We carry out about three to four tests a week in the practice so it fits in around seeing other patients quite easily.

We ask them to fill in a questionnaire, which sometimes shows they should be filtered out under the exclusion criteria. They are then fitted with the monitor by a trained nurse who talks them through the test and gives them a leaflet explaining what they should and shouldn't do. If the frequency of symptoms is daily we do a 24-hour ECG and if it is less we do seven-day monitoring.

When the recording is finished it is transferred from a memory card to a computer program, where it can be checked before it is sent for analysis. Sometimes the abnormality can be seen straight away, in which case the lead GP can communicate immediately with the patient's GP. Results are then sent by secure email for full analysis by a program called Pathfinder, which gives a six- or seven-page report detailing abnormalities, heart rate, number of ectopics and so on.

This is done at one of two sites for a fixed fee per test – either the local hospital or a private company in Plymouth called Express Diagnostics. Personally, I send any external referrals to our local hospital where a cardiologist will look at the report. If it is one of our patients I'm usually happy to have the analysis done at Express Diagnostics, which charges less.

I look at the report, referral letter, patient questionnaire and write back to the referrer with results and recommendations. The referrer also receives a copy of the report and patient questionnaire.

The box below shows two case studies of how the pathway works.

Benefits

In the first four months across the whole area 110 tests were carried out – 38 of them at my practice. Of these, 20 tests were normal with symptoms experienced during the test, 10 were normal but with no symptoms and eight were abnormal – of which three had SVTs, two had more than 5% ectopics, one had AV block, one had paroxysmal atrial fibrillation and one had multiple arrhythmias.

This means about 80% had no abnormalities and many of these would previously have been referred to secondary care.

The PCT has been very supportive of the whole process as it was done as part of the arrhythmia care pathway and involved all the stakeholders from the beginning.

It brings care closer to home and provides a quicker service. Previously patients were having to wait months to be seen. But now we are generally able to get the result back with the referring GP within four weeks of referral.

The PCT pays £105 per test. A referral to secondary care would probably cost about £220 for a first outpatient appointment and follow-up. This could mean the service saves at least £30,000 over a year.

In general practice we can be very flexible about when we see patients and we provide a responsive service . Patients receive a service close to home, they don't have to travel to hospital, the test is done quickly and results obtained quickly, and patients are kept informed of the process.

Many patients are kept out of secondary care, which means costs are lower, and they may be diagnosed more quickly – which can have an effect on their morbidity if abnormalities are present.

Most importantly, the service is of equal quality to that offered by secondary care. It uses the same equipment and analysis.

There are some drawbacks, however. There could be capacity issues – our main job is looking after our practice's patients – and the setting up is onerous, especially when it is being done for the first time. We underwent a huge amount of negotiation with the PCT, acute trust and Space Labs, and spent a lot of time sorting out teething problems and logistical issues with the technology.

Expanding

I see this scheme as the start of the development of cardiology services in the community and I would like to expand it to cover other indications for 24-hour ECG.

We are hoping to extend the service to monitor patients with atrial fibrillation. Many GPs would like us to cover those with syncope and pre-syncope, although the acute trust is reluctant for us to offer this in primary care because it considers syncope patients to be higher risk. We intend to develop this by training up some of the clinical leads in practices as formal cardiology GPSIs, who will be able to appropriately investigate these patients using Holter monitoring.

Dr Max Hickman is chair of Colchester PBC group and a GP in Colchester

The PCT pays £105 per test but if it was done in secondary care it would probably cost around £220.

Dr Max Hickman and nurse practitioner Rachel Clarke with one of the ECG monitors Dr Max Hickman and nurse practitioner Rachel Clarke with one of the ECG monitors How the pathway works

67-year old male
• Intermittent palpitations (less than daily)
• Seven-day ECG organised
• Palpitations on evening of seventh day
• Prolonged SVT seen on Lifescreen
• Preliminary report sent to GP
• Recording sent for Pathfinder analysis
• Full report sent to GP within three weeks


74-year-old female
• Intermittent fast palpitations
• Past history of IHD
• Seven-day ECG organised
• Recording shows paroxysmal AF
• Result communicated to referring GP while awaiting full Pathfinder analysis

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