The Dutch experience of open access echocardiography

Abstract

Keywords: open access echocardiography, rapid access echocardiography, echocardiography, heart failure, valvular heart disease, hypertension D ue to the ageing population, the general practitioner will see more patients with symptoms of dyspnoea. 1,2 For the general practitioner, with his limited diagnostic facilities, it is frequently very difficult to distinguish between dyspnoea due to cardiac and non-cardiac causes. 3 Dyspnoea can be due to systolic or diastolic dysfunction, but can also be caused by pericardial disease, hypertension and non-cardiac abnormalities.Often, a normal electrocardiogram or a low brain natriuretic peptide (BNP) level can exclude left ventricular dysfunction. Unfortunately, the positive predictive value of both methods is not very high. 4,5 Electrocardiograms have a positive predictive value of 35% and a negative predictive value of 98% to detect or exclude heart failure. Measurement of plasma BNP gave a positive predictive value of 5 to 38% depending on the cut-off point and a negative predictive value of 92 to 100% in the Framingham Heart Study. 5 If there is still doubt about the aetiology of dyspnoea, echocardiography can help to differentiate between a cardiac cause and a non-cardiac cause. Besides this, it can also provide information about structural abnormalities that cause dyspnoea in certain patients. In an older population, not only the number of patients with heart failure increases, but also the incidence of hypertension and murmurs of unknown aetiology will rise. A correct diagnosis is not easy despite an extensive physical examination and auscultation. 6,7 Therefore, in the very south-east of the Netherlands (the Parkstad area) general practitioners were given the opportunity to ask for an echocardiogram without referring the patient to the department of cardiology. This was for

Who goes where? A prospective study of referral patterns within a newly established primary care team

“…They concluded that access to existing services must be increased, and significant resources must be put into the development of dedicated primary care services [10]. A study in the Netherlands shows that the advantage of open access echocardiography is that the general practitioner is able to make a better diagnosis and unnecessary referrals of patients with suspected cardiac disease can be avoided [11]. In this study, the GP had already decided in 17% of the outpatient referrals which therapy or diagnostic test they felt was most appropriate.…”

Open access echocardiography: from high budget to low budget referral, but what about quality of patient care and delayed referral to the cardiologist?

“…circa 375 patients instead of 55 [2]. This underutilisation of OAE in suspected heart failure is also obvious in other studies [3–5]. …”

Novel Strategies for the Detection of Systolic and Diastolic Heart Failure

“…Diastolic heart failure is very common, especially in elderly women [ 27 ]. Patients with diastolic heart failure often have left venricular hypertrophy and relatively well preserved systolic function.…”

“…The most easy may to have a correct diagnosis is by echocardiography. The last decade several projects in and outside the UK have been developed to make echocardiography directly available to general practitioners [ 27 , 49 - 52 ]. Open access echocardiography is defined as echocardiography requested by a general practitioner without prior clinical assessment by a cardiologist [ 53 ].…”