128 MORE DISCHARGES, LESS FOLLOW-UP AND SIMILAR RATES OF CORONARY ANGIOGRAPHY: INITIAL ‘REAL-WORLD’ EXPERIENCE OF NICE GUIDANCE ON ASSESSMENT OF CHEST PAIN OF RECENT ONSET IN THE RAPID ACCESS CHEST PAIN CLINIC
Bibliographic record
Abstract
<h3>Introduction</h3> In March 2010 NICE clinical guideline number 95 described a new protocol-driven pathway for the investigation of chest pain of recent onset. This emphasised the importance of establishing pre-test probability of coronary artery disease and encouraged the use of non-invasive coronary and myocardial perfusion imaging. We sought to determine the impact of these changes on resource utilisation in particular coronary angiography and need for out-patient review. <h3>Methods</h3> Clinical disposition for patients attending the nurse-led Rapid access chest pain clinic (RACPC) at Royal Derby hospital between January and August 2011 was analysed using a dedicated database. During this period an established exercise tolerance test-driven protocol was in place. The proposed NICE RACPC protocol was applied retrospectively to this cohort to produce a projected model of outcomes. The new RACPC protocol was implemented in July 2012 and disposition was recorded prospectively for 9real-world9 patients attending between July and November 2012. Proportions were compared with Pearson9s χ<sup>2</sup> test and p value of <0.05 was taken to be significant. <h3>Results</h3> Results are summarised in figure 1. A total of 916 patients were analysed: 360 patients attended RACPC between July and November 2012 and 556 during 2011. Of these 517 (56.4%) were male. 364 (39.7%) were deemed inappropriate referrals by NICE criteria and were discharged to the GP. Typical angina was diagnosed in 191 (20.8%) and non-angina symptoms in 333 (36.4%). 562 (61.4%) underwent a treadmill exercise tolerance test, of which 136 (14.9%) were reported as positive for ischaemia. Implementation of the new protocol-driven RACPC pathway during 2012 resulted in a significant reduction in cardiology clinic follow-up compared with 2011 (2% vs 23%, p<0.0001). Rates of discharge to the GP upon initial consultation were higher (67.5% vs 60%, p=0.02) with fewer direct admissions from RACPC (3% vs 6%, p=0.008), whereas the rate of coronary angiography (10.3% vs 8%, p=0.57) was similar. The rate of myocardial perfusion scanning remained similar (9.2% vs 6%, p=0.13) while uptake of CT coronary angiography currently was lower than predicted by NICE at 2.5%. Observed rates of angiography and MPS during 2012 were similar to those predicted by the NICE retrospective model. <h3>Conclusions</h3> In this ‘real-world9 study, implementation of the 2010 NICE guidance on the initial evaluation of chest pain of recent onset with a protocol-driven RACPC pathway resulted in a greater proportion of initial discharge to primary care with less frequent outpatient review and similar rates of referral for coronary angiography. Utilisation of non-invasive coronary imaging in the initial assessment of chest pain is likely to expand and longitudinal outcome studies are required to confirm the safety of revised RACPC protocols.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".