Chest pain symptom scoring can improve the quality of referrals to Rapid Access Chest Pain Clinic

Typical stable angina is a clinical diagnosis based on history. The challenge for GPs in primary care is to identify those patients who are presenting with either possible or typical angina symptoms and refer onwards for specialist assessment in the local Rapid Access Chest Pain Clinic (RACPC). Our initial information gathering study suggested that referring GPs may be cautiously overdiagnosing angina in primary care, potentially resulting in avoidable or unnecessary referrals to RACPC. We sought a practical and cost effective solution to reducing avoidable referrals by assisting GPs with chest pain discrimination. We tested a change of referral form incorporating chest pain symptom scoring to see whether GP referral quality could be improved and then assessed its impact post implementation. GPs that used the chest pain symptom scoring questionnaire were more than twice as likely to correctly discriminate non-cardiac chest pain. Our post implementation study of the new referral form showed that the proportion of referrals to RACPC with diagnosis of non-cardiac chest pain reduced by almost 19%, and there was a statistically significant 30% fall in the total number of referrals to RACPC. This was likely to be driven by the deterrent effect of the novel referral form on avoidable referrals. Fewer avoidable referrals results in shorter wait times for specialist review, reduces the risk of waiting time breach, and improves RACPC efficiency. In summary, chest pain symptom scoring resulted in improved GP discrimination of chest pain, improved referral quality, fewer overall referrals to RACPC and shorter patient wait times. These benefits were achieved without using additional financial resources and without the time or capital expense of training GPs. These findings could assist GPs and Clinical Commisioning Groups to achieve cost savings by reducing avoidable secondary care referrals.