Improving early exclusion of acute coronary syndrome in primary care: the added value of point-of-care troponin as stated by general practitioners

Kip, Michelle M.A.; Noltes, A.M.; Koffijberg, Hendrik; IJzerman, Maarten Joost; Kusters, Ron

doi:10.1017/s1463423617000135

Cited by 6 publications

(5 citation statements)

References 31 publications

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“…overestimated in the current analysis. On the other hand, wide availability of a validated PoCT in the future could lower the threshold for using this test in daily practice, as expected based on previous research (Kip et al, 2017).…”

Section: Strength and Weaknessmentioning

confidence: 55%

“…Therefore, as the use of PoCT will likely be more sophisticated in daily clinical practice, the costs of PoCT have (conservatively) been overestimated in the current analysis. On the other hand, wide availability of a validated PoCT in the future could lower the threshold for using this test in daily practice, as expected based on previous research (Kip et al ., 2017).…”

Section: Discussionmentioning

confidence: 99%

“…The availability of a validated CDR, incorporating a PoCT measuring a biomarker of myocardial damage (eg, high-sensitive troponin (hsTn) or heart-type fatty acid binding protein (H-FABP)) is anticipated, however not yet available (Nilsson et al, 2013;Glatz and Mohren, 2013;Glatz and Renneberg, 2014;Willemsen et al, 2014Willemsen et al, , 2015. The majority of GPs expect future PoCTs to be of added value in ruling out ACS (Kip et al, 2017).…”

mentioning

confidence: 99%

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Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

Willemsen

Kip²,

Koffijberg³

et al. 2017

Prim Health Care Res Dev

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The objective of the paper is to estimate the number of patients presenting with chest pain suspected of acute coronary syndrome (ACS) in primary care and to calculate possible cost effects of a future clinical decision rule (CDR) incorporating a point-of-care test (PoCT) as compared with current practice. The annual incidence of chest pain, referrals and ACS in primary care was estimated based on a literature review and on a Dutch and Belgian registration study. A health economic model was developed to calculate the potential impact of a future CDR on costs and effects (ie, correct referral decisions), in several scenarios with varying correct referral decisions. One-way, two-way, and probabilistic sensitivity analyses were performed to test robustness of the model outcome to changes in input parameters. Annually, over one million patient contacts in primary care in the Netherlands concern chest pain. Currently, referral of eventual ACS negative patients (false positives, FPs) is estimated to cost €1,448 per FP patient, with total annual cost exceeding 165 million Euros in the Netherlands. Based on 'international data', at least a 29% reduction in FPs is required for the addition of a PoCT as part of a CDR to become cost-saving, and an additional €16 per chest pain patient (ie, 16.4 million Euros annually in the Netherlands) is saved for every further 10% relative decrease in FPs. Sensitivity analyses revealed that the model outcome was robust to changes in model inputs, with costs outcomes mainly driven by costs of FPs and costs of PoCT. If PoCT-aided triage of patients with chest pain in primary care could improve exclusion of ACS, this CDR could lead to a considerable reduction in annual healthcare costs as compared with current practice.

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Section: Strength and Weaknessmentioning

confidence: 55%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

Willemsen

Kip²,

Koffijberg³

et al. 2017

Prim Health Care Res Dev

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“…In a Dutch study, experts favored the CRP POCTs over its laboratory equivalent, as the POCTs allow an instantaneous decision regarding the prescription of antibiotic treatment. 80% of the Dutch GPs declare to use CRP POCTs on a regular basis [ 5 , 32 ]. CRP POCTs may reduce antibiotic prescribing at the index visit, but there is a higher rate of return visits [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Utilization of point-of-care tests among general practitioners, a cross-sectional study

et al. 2022

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Background Point-of-care testing (POCT) has numerous potential benefits to improve health care service, especially in resource-limited settings. We aim to identify which POC-tests (POCTs) of laboratory parameters are known, employed, and rated as useful by general practitioners (GPs). Methods A questionnaire with 27 POCTs was posted to a random selection of GPs (n = 451) in Saxony, Germany. Results A total of 208 GPs replied (response rate 46.1%). Out of 27 POCTs, each GP knew an average of 20.3 as laboratory parameters and 9.2 as POCTs. Urine test strips (99.0%), blood glucose test (98.1%), and Troponin I/T (86.4%) were the best-known, followed by INR/Quick (82.5%), Microalbumin (79.1%), and D-dimer (78.6%) POCTs. Yet, solely 0 to 13 POC tests were actually used (mean value 4.6). Urine test strips were employed most frequently (97.6%), followed by blood glucose test (94.7%), Troponin I/T (57.8%), Microalbumin (57.3%), and INR/Quick POCTs (41.7%). Heart fatty binding protein (H-FABP), Syphilis, Coeliac disease, and Malaria appeared as the least frequently used POCTs. The majority of the GPs declared 14 of the 27 POCTs to be useful. Discussion/conclusion The most recurrently employed POCTs are those for diagnosing or monitoring diabetes mellitus, ensued by POCTs addressing acute cardiovascular diseases (Troponin I/T, D-dimer) or monitoring the therapy of infectious diseases or the anticoagulant therapy. POCTs most often rated as useful by GPs are also widely known and frequently used. Nonetheless, the majority of GPs rate only a very limited number of POCTs as useful. Frequent concerns might be low economic benefit, over-reliance, and test accuracy coming along with the complex implementation of the tests requiring technical skills, accurate storage, and the correct interpretation of test results. Trial registration In accordance with the (Model) Professional Code for Physicians in Germany, neither human body materials nor data that can be assigned to a specific human being are used in our study. A declaration of no objection from the Ethics Committee of the Martin-Luther University Halle-Wittenberg (Medical Faculty) confirms no professional or ethical concerns due to completely anonymized data collection and analysis. Our study was therefore not registered in a corresponding registry.

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“…Though most GPs agree that clinical assessment will remain the most important tool in diagnosing chest pain patients, some GPs think that reliable new diagnostic tools (such as PoCTs) could be a useful addition to improve diagnostic accuracy. The general attitude towards such tools seemed more conservative than in recent questionnaire based studies [ 30 , 37 ]. GPs pointed out that such tools should be reliably embedded in clinical care and is regarded as an additional tool rather than an alternative one making clinical judgments unneeded in the future.…”

Section: Discussionmentioning

confidence: 64%

Managing chest pain patients in general practice: an interview-based study

et al. 2018

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BackgroundAssessment of chest pain in general practice is challenging. General practitioners (GPs) often feel uncertainty when dealing with chest pain. The role of new diagnostic tools is yet unclear.Therefore, we aimed to learn: (1) whether or not GPs experience a change in incidence and presentation of chest pain, (2) how GPs deal with uncertainty, and (3) which thoughts, demands and doubts concerning new diagnostic tools occur.MethodsSemi-structured, face to face interview based study, aiming at six main subjects: experienced changes in prevalence of chest pain, the management of chest pain patients, dealing with uncertainty, the GPs’ approach in referring chest pain patients, GPs’ attitude towards ‘unnecessary’ referrals, and the GPs’ suggestions for improving the management of chest pain patients.Results145 GPs in Belgium and the Netherlands were invited to participate, 27 (15 Flemish and 12 Dutch) GPs were interviewed. Data saturation was reached. The number of patients having an acute coronary syndrome among chest pain patients is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. GPs rely on their own judgment above all, and desire new diagnostic tools only when these tools are of proven added value.ConclusionThe incidence of chest pain in general practice is not decreasing according to the GPs. However, the presentation of chest pain is changing. GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe. Uncertainty is regarded as a substantial element of their profession. New diagnostic tools are awaited with cautiousness.Electronic supplementary materialThe online version of this article (10.1186/s12875-018-0771-0) contains supplementary material, which is available to authorized users.

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Improving early exclusion of acute coronary syndrome in primary care: the added value of point-of-care troponin as stated by general practitioners

Cited by 6 publications

References 31 publications

Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

Utilization of point-of-care tests among general practitioners, a cross-sectional study

Managing chest pain patients in general practice: an interview-based study

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