Sustainability

This article describes how using the C.Net5000 ambulatory ECG monitor in general practice creates a significant improvement in health service efficiency. The improvements are sustainable in both the short term and the longer term, as is evidenced by the hundreds of existing users over the last eight years.

Annual indicative budgetary benefits are based on 30 patient referrals from a typical primary care practice to secondary care, valued at £378 per referral, with the service redesign leading to an annual saving of £5,067.

A resting ECG is inappropriate for detecting intermittent arrhythmia, a 24-hour ambulatory ECG being the preferred alternative. However this usually means a referral to a cardiology outpatient department, which can result in some patients waiting periods of up to 26 to 40 weeks for ambulatory monitoring.

Results from a published study [1] show that of the patients referred to a cardiologist, up to 60% do not have any serious cardiac arrhythmia, so the referral may not have been necessary, while 6 to 8% are at risk of life-threatening arrhythmia.

Making ambulatory cardiac monitoring devices available directly to primary care practices allows GPs to monitor and analyse arrhythmias as soon as the patient presents.

In line with the National Service Framework guidance for cardiac arrhythmia [2], patients are managed more effectively by monitoring their cardiac rhythm for 24 hours following a first visit to the GP, and reviewing the arrhythmia report:

  • If symptoms were recorded but no arrhythmia detected, referral is unnecessary, on the grounds of no arrhythmia detected during symptomatic events.
  • If symptoms were not recorded, repeat the assessment and consider referral to a cardiologist.
  • If the report shows cardiac arrhythmias, send the report to the cardiologist for confirmation of urgent or non-urgent referral.

In addition to receiving more timely diagnosis and treatment, patients following this redesigned service in general practice experience a positive impact on their wellbeing together with reduced anxiety levels and psychological issues associated with cardiac problems.

Existing Patient Pathway

pathway-current

New Patient Pathway

pathway-new

Figure 1. Simplified patient pathway using ambulatory ECG monitoring in general practice

The criteria for success is seen as a reduction in the number of referrals to cardiology outpatient departments in the short term and a reduction in the number of accident and emergency admissions from stroke in the longer term. These can be determined by annual measurements of:

  • The number of patients assessed.
  • The number of referrals to cardiology outpatient departments.
  • The number of patients requiring urgent referral.
  • The number of emergency admissions due to cardiac arrhythmia.

As an example, consider a primary care practice that currently refers 30 patients each year to a cardiology outpatient department for investigation of possible intermittent cardiac arrhythmia. The data below shows estimated benefit per patient of at least £168.90 when this service redesign is implemented.

Using the figures from the above two tables, the cost saving resulting from service redesign is shown in Tables 3 and 4.

References

[1] P. Standing, M. Dent, A. Craig, B. Glenville, Changes in referral patterns to cardiac outpatient clinics with ambulatory ECG monitoring in general practice, British Journal of Cardiology, 2001, Vol. 8 No. 6, pp. 394–398.

[2] The National Service Framework for Coronary Heart Disease: Chapter 8, Arrhythmias and Sudden Cardiac Death, 2007. View

[3] Unit Costs of Health and Social Care, Personal Social Services Research Unit (PSSRU), University of Kent, 2007. View