EDITORIAL
Open access echocardiography: should we proceed?
E.P. de Kluiver, M.J. de Boer
In their article in this issue of the Journal, Baur and co-workers describe a pilot study for open access echocardiography.' In the UK as well as in the Netherlands open access echocardiography has been available for more than a decade. However, whereas for open access stress testing results of randomised controlled trials are widely available, for open access echocardiography these results are scarce. In 1997 Remkes described a successfuil experiment, later followed by publication of a randomised, controlled study in the Netherlands.2'3 Open access echocardiography appears to be of value in daily general practice. It is cost-effective compared with traditional referral, more efficient, better adjusted to the real need of the patient, and can be conducted safely. Furthermore, this facility leads to a reduction in unnecessary referral to the cardiologist and concentration of pathology in the outpatient clinic.3 The experience of Baur et al. with their pilot project is also positive. Echocardiography is a powerfild tool to assess or rule out structural heart disease. There seems to be sufficient evidence for general use of open access echocardiography in daily practice. Nevertheless the availability and its use in the Netherlands is limited. The main reason seems to be the introduction of a new (and controversial) health care reimbursement system (DBC system). This system has no or insufficient financial support for open access diagnostic facilities. This makes it imperative for government and other concerned parties to develop reimbursement strategies that support transmural care managing processes. In this pilot project the indications for open access echocardiography were limited to dyspnoea, cardiac murmur and peripheral oedema ofunexplained origin. However, this facility also proved to be helpful for
other indications such as follow-up or assessment of structural heart disorders and control of antihypertensive therapy by the general practitioner (GP). Open access echocardiography also has additional value when combined with other noninvasive testing. For patients with suspected coronary artery disease and cardiac murmur or other signs and symptoms of co-existing structural defects, echocardiography can precede the exercise testing, thereby ruling out serious structural heart disease. It is important to present the request for echocardiography together with additional medical information like medical history, medication, physical examination data and estimated a priori chance of the presence ofcardiac disease. This information enables the cardiologist to conclude and advise the GP in the context of the patient's medical history. Scrupulous and prudent use of this facility is necessary in situations with limited capacity. The authors describe a 1.5% use ofthe total echocardiography capacity. Others report a steady increase of up to almost 10% of the total capacity. There is always the risk of excessive requests exceeding the maximum capacity (on top ofour daily practice). In ourviewitis therefore imperative that GPs and cardiologists organise feedback meetings to evaluate the requesting behaviour of GPs on a regular basis. These meetings have the additional advantage of continuous education. Considering this, one can conclude that open access echocardiography in the Netherlands is not only feasible, but also contributes to better diagnosis and care for patients with suspected structural cardiac disease, as is nicely demonstrated by the current survey by Baur and co-workers. m References
E.P. de Klulver M.J. de Boor Departrnent of Cardiology, Isala Clinics, Zwolle, the Netherlands Correspondence to: E.P. de Kluiver Department of Cardiology, Isala Clinics, P0 Box 10500, 8000 GM Zwolle, the Netherlands E-mail: [email protected]
qc
Nethcrlands Heart Journal, Volume 14, Number 11, November 2006
1
2 3
Baur LHB, Veenstra L, Lenderink T, et al. Open access echocardiography is feasible in the Netherlands. Neth HeartJ2006; 14:361-5. Remkes PAJ. Non-invasive cardiophysiological testing requested by the general practitioner [thesis]. Rotterdam: Erasmus University Rotterdam, 1997. De Kluiver EP. Effects of direct access to non-invasive cardiophysiological testing requested by the general practitioner [thesis]. Rotterdam: Erasmus University Rotterdam, 2003.
359
Open access echocardiography: should we proceed?
E.P. de Kluiver, M.J. de Boer
In their article in this issue of the Journal, Baur and co-workers describe a pilot study for open access echocardiography.' In the UK as well as in the Netherlands open access echocardiography has been available for more than a decade. However, whereas for open access stress testing results of randomised controlled trials are widely available, for open access echocardiography these results are scarce. In 1997 Remkes described a successfuil experiment, later followed by publication of a randomised, controlled study in the Netherlands.2'3 Open access echocardiography appears to be of value in daily general practice. It is cost-effective compared with traditional referral, more efficient, better adjusted to the real need of the patient, and can be conducted safely. Furthermore, this facility leads to a reduction in unnecessary referral to the cardiologist and concentration of pathology in the outpatient clinic.3 The experience of Baur et al. with their pilot project is also positive. Echocardiography is a powerfild tool to assess or rule out structural heart disease. There seems to be sufficient evidence for general use of open access echocardiography in daily practice. Nevertheless the availability and its use in the Netherlands is limited. The main reason seems to be the introduction of a new (and controversial) health care reimbursement system (DBC system). This system has no or insufficient financial support for open access diagnostic facilities. This makes it imperative for government and other concerned parties to develop reimbursement strategies that support transmural care managing processes. In this pilot project the indications for open access echocardiography were limited to dyspnoea, cardiac murmur and peripheral oedema ofunexplained origin. However, this facility also proved to be helpful for
other indications such as follow-up or assessment of structural heart disorders and control of antihypertensive therapy by the general practitioner (GP). Open access echocardiography also has additional value when combined with other noninvasive testing. For patients with suspected coronary artery disease and cardiac murmur or other signs and symptoms of co-existing structural defects, echocardiography can precede the exercise testing, thereby ruling out serious structural heart disease. It is important to present the request for echocardiography together with additional medical information like medical history, medication, physical examination data and estimated a priori chance of the presence ofcardiac disease. This information enables the cardiologist to conclude and advise the GP in the context of the patient's medical history. Scrupulous and prudent use of this facility is necessary in situations with limited capacity. The authors describe a 1.5% use ofthe total echocardiography capacity. Others report a steady increase of up to almost 10% of the total capacity. There is always the risk of excessive requests exceeding the maximum capacity (on top ofour daily practice). In ourviewitis therefore imperative that GPs and cardiologists organise feedback meetings to evaluate the requesting behaviour of GPs on a regular basis. These meetings have the additional advantage of continuous education. Considering this, one can conclude that open access echocardiography in the Netherlands is not only feasible, but also contributes to better diagnosis and care for patients with suspected structural cardiac disease, as is nicely demonstrated by the current survey by Baur and co-workers. m References
E.P. de Klulver M.J. de Boor Departrnent of Cardiology, Isala Clinics, Zwolle, the Netherlands Correspondence to: E.P. de Kluiver Department of Cardiology, Isala Clinics, P0 Box 10500, 8000 GM Zwolle, the Netherlands E-mail: [email protected]
qc
Nethcrlands Heart Journal, Volume 14, Number 11, November 2006
1
2 3
Baur LHB, Veenstra L, Lenderink T, et al. Open access echocardiography is feasible in the Netherlands. Neth HeartJ2006; 14:361-5. Remkes PAJ. Non-invasive cardiophysiological testing requested by the general practitioner [thesis]. Rotterdam: Erasmus University Rotterdam, 1997. De Kluiver EP. Effects of direct access to non-invasive cardiophysiological testing requested by the general practitioner [thesis]. Rotterdam: Erasmus University Rotterdam, 2003.
359
