Abstract
BackgroundGPs are frequently confronted with patients with acute onset chest pain. Although usually benign, approximately 5% is due to acute coronary syndrome (ACS). Unfortunately, ACS is not always recognised, leading to a missed diagnosis in 2–5% of presentations.AimThe authors set out to study the level of risk GPs are willing to accept with regards to missing an ACS diagnosis, and the receptiveness of implementing new clinical decision aids.Design & settingThis study involved an online survey among GPs in the Netherlands.MethodA concept survey was constructed, which was tested among a panel of 24 GPs. The survey was then modified to achieve content validity. This survey was electronically distributed among 1000 GPs.ResultsA total of 313 (31.3%) GPs completed the survey. Of those surveyed, the median age was 50 years (interquartile range 41–57), 53.0% were female, and 6.4% were specialist GPs ('kaderarts') in cardiology or acute care. GPs estimated the missed ACS rate to be <5.0% in clinical practice, most often estimating a chance of 1.0–2.5% (35.2%) or 0.5–1.0% (29.7%). For atypical case presentations, 70% of GPs would accept a 0.1–1.0% missed diagnosis rate, while keeping the referral threshold to a maximum of 50 unnecessary referrals for each ACS case (75% of responders). GPs would welcome additional decision aids, with 79.2% favouring a clinical decision aid, 77.1% favouring troponin point-of-care (POC) testing, and 85.5% favoring a combination of a clinical decision aid and a troponin POC test.ConclusionGPs perceive that they miss more ACS cases than they feel comfortable with, which is reflected in a defensive referral strategy. The vast majority of GPs would welcome the use of clinical decision aids and/or cardiac biomarker POC testing for ruling out ACS, if accompanied by more certainty than based on clinical judgment alone.
Highlights
Chest pain is a common symptom in general practice, accounting for 0.7–2.7% of all consultations.[1,2,3,4] the underlying cause is usually benign, potentially life-threatening conditions, such as acute coronary syndrome (ACS), may be present in 1.5–10% of all chest pain cases.[1,2,4] The challenge for GPs is to make an accurate diagnostic assessment while being aware of variations in clinical presentation, having access to limited resources, having time restraints, and operating in a changing society with increased concern of medicolegal consequences
GPs perceive that they miss more ACS cases than they feel comfortable with, which is reflected in a defensive referral strategy
The vast majority of GPs would welcome the use of clinical decision aids and/or cardiac biomarker POC testing for ruling out ACS, if accompanied by more certainty than based on clinical judgment alone
Summary
Chest pain is a common symptom in general practice, accounting for 0.7–2.7% of all consultations.[1,2,3,4] the underlying cause is usually benign, potentially life-threatening conditions, such as ACS, may be present in 1.5–10% of all chest pain cases.[1,2,4] The challenge for GPs is to make an accurate diagnostic assessment while being aware of variations in clinical presentation, having access to limited resources, having time restraints, and operating in a changing society with increased concern of medicolegal consequences. Consensus among GPs of an acceptable risk of missing ACS subsequently influences the sensitivity level required for new diagnostic strategies for ruling out ACS. The authors, conducted a survey in which they evaluated the level of uncertainty and risk of missing a diagnosis of ACS that GPs are willing to accept with regards to acute chest pain. The receptiveness of GPs to implementing promising clinical decision aids to help avoid missing ACS in the setting of chest pain was assessed. ACS is not always recognised, leading to a missed diagnosis in 2–5% of presentations
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