Attitudes and Referral Patterns of Primary Care Physicians When Evaluating Subjects with Noncardiac Chest Pain?A National Survey

Abstract

Noncardiac chest pain (NCCP) may affect up to 23% of the U.S. population. The clinical approach and referral patterns of primary care physicians (PCPs) when evaluating NCCP subjects are unknown. We aimed to determine the preferences of diagnostic tests, referral patterns, and treatment plans of NCCP patients by PCPs. PCPs were randomly selected from the American Medical Association national membership list. A 24-item questionnaire was mailed, which focused on demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, and treatment plans. Two hundred five (40%) PCPs returned the questionnaire (mean age, 49; 77% males; practice type--community-based, 40.5%; hospital-based, 10.7%; and combined, 47.3%; physician type--internists, 46.3%; family physicians, 44.4%; general practitioners, 4.9%; and others, 2.9%). The mean number of NCCP patients seen in the past 6 months was 108 (6.4% of total patients) and 79.5% were treated primarily by PCPs. The three most common diagnostic tests used were empirical proton pump inhibitor (PPI) trial (45.6%), chest radiograph (39.9%), and upper endoscopy (18.7%). Most PCPs reported that they are either comfortable (44.6%) or very comfortable (21.2%) in diagnosing NCCP. The three most commonly used therapeutic modalities for NCCP were PPIs (37.8%), lifestyle modification (33.7%), and H2 blockers (12.4%). Of those NCCP patients referred to a subspecialist, most ended up in gastroenterology (75.6%), followed by cardiology (7.8%) and pulmonary (1.6%) clinics. We conclude that most PCP's diagnose and treat NCCP patients without referring them to a gastroenterologist. However, diagnostic and treatment strategies may not follow the current understanding and knowledge of the disorder.