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

Open access echocardiography (OAE) is defined as echocardiography that is requested by, reported to, and acted upon by general practitioners (GPs). Echocardiography provides information about cardiac anatomy (e.g. volumes, geometry, mass) and function (e.g. left ventricular function and wall motion, valvular function, right ventricular function, pulmonary artery pressure, pericardium). In the population referred by the GPs, the pretest likelihood of disease is much lower than in the (prescreened) hospital population. Thus OAE is mainly used as a screening tool to exclude clinically relevant abnormalities. The most common indications for OAE are assessment of asymptomatic murmurs, breathlessness and suspected heart failure. OAE is able to exclude significant valvular heart disease, with the exception of dynamic, exercise-related mitral regurgitation. OAE is also valuable in a breathless patient if left ventricular (LV) dysfunction (ejection fraction <40 %) is found, leading to a management change, e.g. starting an ACE inhibitor and β-blocker. However, a normal systolic LV function in a breathless patient does not exclude a cardiac cause of breathlessness, as this may be caused by diastolic LV dysfunction, ischaemia or paroxysmal heart rhythm problems. In such cases, the echocardiographic examination needs to be interpreted in the context of clinical history and examination, ECG, exercise ECG or other tests. Van Gurp et al. describe their experience with OAE, which was set up independently from the regional hospitals [1]. The aim of the study was to demonstrate that OAE reduces the number of referrals to the cardiologist and found a decrease in intended referrals within a mean follow-up of 4 months (92 % vs. 34 %, p<0.001). However, the aim of the study should have been: reducing the number of referrals, without compromising patient care. This means that one should also investigate subsequent patient management (change in medication), delayed referrals and hospitalisations. Ideally, this should have been investigated in a randomised controlled trial. The indication for echocardiography (and potential referral to the cardiologist) in the present study was suspected valve disease in the majority of cases and, less often, suspected heart failure: 81 (55 %) and 55 (35 %), respectively. However, one would expect a much higher number of heart failure indications, as 54 GP practices participated. Each year approximately 7 patients are expected to develop heart failure for the first time in a Dutch average general practice of 2350 patients. Therefore, the OAE indication of suspected heart failure should have been 7 times higher, i.e. circa 375 patients instead of 55 [2]. This underutilisation of OAE in suspected heart failure is also obvious in other studies [3–5].