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European Journal of Heart Failure 2004 6(1):79-83; doi:10.1016/j.ejheart.2003.10.002
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© 2004 European Society of Cardiology

Systematic review of open access echocardiography for primary care

Kamlesh Khunti*

Department of Health Sciences, Division of General Practice and Primary Health Care University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK

* Tel: +44-116-258-4367; fax: +44-116-258-4982. E-mail address: kk22{at}le.ac.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Method
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Over the last few years there has been a revolution in open access echocardiography services due to an increased demand from within secondary care and primary care. There have been some concerns expressed by specialists and open access echocardiography has not been universally welcomed as a means of offering healthcare. Suspected heart failure comprises the majority of primary care referrals for open access echocardiography. There is lack of rigorously controlled studies to support widespread establishment of open access echocardiography services.

Key Words: Open access echocardiography • Heart failure • National Service Framework • Primary care

Received April 1, 2003; Revised June 24, 2003; Accepted October 1, 2003


   1. Introduction
Top
 Abstract
 1. Introduction
2. Method
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Open access echocardiography is defined as echocardiography requested by a general practitioner without prior clinical assessment by a cardiologist [1]. Echocardiography has previously been available to general practitioners only through referral to hospital specialists [2]. Over the last few years there has been an increase in the number of centres providing open access echocardiography services [3]. The recent revolution in open access echocardiography has been due to an increased demand from within secondary care and also from primary care [4]. Due to the limited number of cardiologists in the UK and the high prevalence of cardiac disease, many patients may be managed by general practitioners by open access echocardiography services [1]. A further impetus for open access services has been the publication of the National Service Framework for coronary heart disease [5]. The rationale for open access diagnostic services is that they allow early diagnosis and appropriate treatment [2,4], which in turn may reduce the burden on secondary care services [1,6]. Other reasons for open access include general practitioners enthusiasm for this service, potential for general practitioners to withdraw inappropriate therapy and perhaps a reduction in number of patients being referred to secondary care [7]. However, the cost of setting-up open access services can be considerable [8]. There have therefore been concerns expressed by specialists and open access echocardiography has not been universally welcomed as a means of offering healthcare [8].

Heart failure has provided the major impetus for open access echocardiography services. However, there are other conditions for which echocardiography services have been used including hypertension, murmurs and atrial fibrillation. Until recently there were no suitable guidelines on the most appropriate referrals for open access echocardiography in primary care [1]. The demand is going to increase since the National Service Framework for coronary heart disease has recommended that open-access echocardiography should be made available to all general practitioners [5].

A systematic review of published studies of open access echocardiography services in the UK is reported here.


   2. Method
Top
 Abstract
 1. Introduction
 2. Method
3. Results
 4. Discussion
 5. Conclusions
 References
 
To identify the relevant articles for this systematic review, a search of the Cochrane Trials Register, Medline and Embase, from 1993 to March 2002 was undertaken. The search terms included Mesh terms and keywords: echocardiography, echocardiogram, general practice, family physicians, primary healthcare, and community care. References in the studies identified by the search strategy were checked and the authors contacted and asked about knowledge of any additional studies. All searches were limited to English language articles. Studies were included in this review on the basis of relevance to UK primary care. Data concerning participants’ indications for referrals and results were extracted from published studies. The authors of the published studies were contacted for information on unpublished studies.


   3. Results
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
4. Discussion
 5. Conclusions
 References
 
The search strategy identified five published studies [2,7,9–11] of open access echocardiography in UK primary care (Table 1). All five studies were observational cohort studies. This review does not include published studies of dedicated clinics, for example heart failure clinics [12]. One study reported a practice-based echocardiography service in a single practice of five doctors in Dundee and has not been included in the review [13].


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  		Table 1 Published studies of open access echocardiography in UK primary care. Values are number (%) unless stated otherwise

 
3.1. Uptake of the service
The majority of the general practitioners who use an open access echocardiography service find it useful and there is a high level of general practice and patient satisfaction primarily due to reduced waiting times [7,9]. Despite the high prevalence and incidence of heart failure in primary care [14,15] there have been concerns regarding the low number of patients being referred for open access echocardiography despite wide publicity within their localities [16,17]. There are also wide variations in the number of patients referred for echocardiography by individual general practitioners [10]. There are also wide variations in the types of services offered: some services offer open access to all general practitioners for all indications while others impose restrictions, access is only offered to practices participating in trials [3,16].

3.2. Clinical indications for echocardiography
The commonest clinical indications for open access echocardiography included suspected unexplained breathlessness, heart failure, possible asymptomatic heart failure (with predisposing risk factors), valvular heart disease atrial fibrillation and hypertension.

Sandler and colleagues reported the results of an open access echocardiography service for general practitioners in North Derbyshire [10]. Patients could be referred for unexplained breathlessness, suspected heart failure, atrial fibrillation and heart murmur. During the first 18 months, 486 patients were scanned within a mean time of 49 days (3–97 days). Two-thirds of requests were for unexplained breathlessness or suspected heart failure. The uptake of the service was variable, with individual general practitioners referring between one and 27 patients. Clinical diagnosis of heart failure was more difficult in women than men. Of the patients with suspected heart failure, or unexplained breathlessness, 27% with a normal 12 lead electrocardiogram and 35% with a normal chest radiograph were found to have abnormal left ventricular function. Clinical abnormalities were more likely when echocardiograms were performed for either atrial fibrillation (74% abnormal) or cardiac murmurs (46% abnormal). Two-thirds of patients with suspected heart failure or unexplained breathlessness did not have systolic dysfunction.

Francis and colleagues reported an open access echocardiography service, which was provided to all general practitioners in Edinburgh [2]. The general practitioners were asked to refer patients with an existing diagnosis of heart failure currently being treated with diuretic, symptoms and signs suggestive of heart failure (unexplained breathlessness, fatigue or oedema) or possible asymptomatic left ventricular failure (predisposing risk factors). Overall 259 patients were referred within the first 5 months, of which 12% were considered to be inappropriate referrals. Furthermore, it was not possible to measure chamber dimensions in 42% of patients because of obesity or airways disease. Impaired left ventricular systolic dysfunction was found in 18% and significant valvular disease in 5%. Overall there were clear indications for important changes in treatment in 69% of patients.

Murphy and colleagues reported an open access echocardiography service which was made available to five Darlington practices covering a population of 48 000 patients [11]. Each practice was visited and given a guideline. Indications for referral were patients with a clinical diagnosis of heart failure or if they were currently taking a diuretic without an angiotensin converting enzyme inhibitor. Two hundred and fifty patients were referred within 22 months. An assessment for ejection fraction was possible in 98% of patients. Impaired systolic function was found in 20% and a significant valvular abnormality was found in 8% of patients. They also conducted a case note review 2 months after the echocardiogram. Of the patients with significant left ventricular dysfunction, 78% were eventually started on an angiotensin converting enzyme inhibitor and 70% of patients with significant valve lesion had been referred to hospital.

Sim and Davies reported a service in a hospital in Newport, which was advertised via newsletters and educational meetings. A guideline was distributed to all general practitioners [7]. They reported data on the first 200 patients referred within 13 months: 31 practices referred patients with wide variations in the number of referrals from each practice (1 to 32). Guidelines were followed in 94% of referrals and 90% of patients were seen within 14 days. Left ventricular systolic dysfunction was found in 14% and significant valvular lesions were found in 12% of patients. A questionnaire survey following the service showed that both the general practitioners and patients were very satisfied with the service and most general practitioners found the service useful. The general practitioners indicated that they would have referred 87% of the patients to the hospital if an open access echocardiography service was not available compared to the 11% who were actually referred. Crude cost analysis data showed that the service was cost-effective.

Lindsay and colleagues reported an open access echocardiography service in Glasgow for patients with dyspnoea [9]. A total of 416 patients were referred over a 3-year period. Overall 23% had impaired systolic function and 3% had significant valve lesions. Prior to referral, 60% of patients were receiving either a diuretic or an angiotensin converting enzyme inhibitor or both, as treatment for presumed left ventricular systolic dysfunction. However, the study showed that 73% of these patients were receiving inappropriate therapy. They found that a normal 12 lead electrocardiogram and no previous history or a myocardial infarction was sensitive (98%) and accurate in predicting normal ventricular function.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
5. Conclusions
 References
 
The search strategy identified only five published studies, with 1579 patients, which met the inclusion criteria. All studies were observational studies therefore, despite the increased demand for open access echocardiography [3] there is lack of evidence of effectiveness of such a service in primary care. Most patients with suspected heart failure will be seen and managed by general practitioners [18]. Echocardiography is the current ‘gold standard’ for assessing left ventricular systolic dysfunction. This systematic review confirms that suspected heart failure comprises the majority of primary care referrals for open access echocardiography. Heart failure is a common condition in primary care with high morbidity and mortality. However, effective treatments are now available which can reduce deterioration in symptoms, hospitalisation and death [19,20]. Despite effective treatments, patients with heart failure in primary care are inadequately investigated and do not receive optimum treatment [21–23]. One of the key reasons for this is that diagnosis of heart failure is made on the basis of symptoms and signs. However, accuracy of symptoms and signs is poor and the diagnosis of heart failure needs to be confirmed by further investigations including electrocardiography and echocardiography [24]. One survey showed that general practitioners were aware that echocardiography is a valuable tool, but the importance of early diagnosis and treatment was not fully appreciated [25]. Furthermore, in patients labelled as having heart failure, under-use of echocardiography is associated with poor survival [26]. This may be due to the fact that patients who have an echocardiogram being more likely to be prescribed appropriate medication [27]. Furthermore, recent evidence has shown that general practitioners identify lack of open access echocardiography as a barrier to diagnosing and managing heart failure in primary care [28,29].

A policy of referring all cases of possible heart failure for echocardiography has serious service implications [24], nevertheless, general practitioners are keen to use the service and use the service appropriately [2,30]. One service provided practitioners with a report of the echocardiogram and recommendations on management [2]. There were clear indications for important changes in treatment in nearly 70% of patients. However, whether these recommendations were implemented by the general practitioners is not known. Only 12% of referrals were considered inappropriate [2]. Another study of open access echocardiography found that 73% of patients treated prior to referral were receiving inappropriate therapy, mostly in the form of diuretics [9].

4.1. Guidelines for open access echocardiography
The key to open access investigations is for the implementation of agreed guidelines between specialists and general practitioners [8]. General practitioners will follow referral guidelines in a high proportion of cases [7], but only around half of the open access echocardiography services are providing educational material to guide general practitioners [3].

The British Society of Echocardiography have published recommendations for training and accreditation in echocardiography [31]. These clearly recommend that echocardiography should be performed only by individuals with efficiency level accreditation. There is going to clearly be an increase in the number of patients referred for echocardiography services. However, currently there are too few trained operators to meet this level of demand [32]. Primary care trusts and hospital trusts need to provide an adequate level of funding to supply the necessary equipment and to employ the appropriately trained staff. There should be a minimum amount of information that should be returned to general practitioners. Furthermore, general practitioners require results that are simple to interpret and with the addition of educational material [25,28].

4.2. Cost effectiveness
There have been no formal evaluations of the cost effectiveness of an open access echocardiography service.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
 5. Conclusions
References
 
Direct access echocardiography for general practitioners represents an alternative strategy to referring patients to secondary care. Open access echocardiography implies that the service should be equally available to all general practitioners and for all appropriate indications [4]. Current options for echocardiography services for primary care include a primary care based service or an open access echocardiography service based at a secondary care centre. For open access echocardiography to be effective sufficient numbers of treatable abnormalities need to be detected and these must result in appropriate changes to management of patients [11]. An alternative approach to referring for direct access echocardiography is to have improved access to cardiology services such as rapid access heart failure clinics, so that a rapid specialist clinical assessment and opinion is made available [5,33]. Current evidence suggests that echocardiography services may be appropriate for patients with suspected heart failure. This review indicates a lack of rigorously controlled studies to support widespread establishment of an open access echocardiography service. There is an urgent need for rigorous cost effectiveness evaluation of open access echocardiography services within other models of care including primary care heart failure nurse clinics or consultant led direct access heart failure clinics.


   References
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
 5. Conclusions
 References
 

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