Does involvement of the supervising general practitioner impact urgency allocation and diagnosis of acute coronary artery syndrome in patients with chest discomfort who contact out-of-hours primary care?

Abstract

Abstract Background: Primary care triage nurses use a semi-automatic decision support tool called the ‘Netherlands Triage Standard’ for telephone triage during out of office hours. In some cases, the triage nurse consults the supervising general practitioner (GP) to decide on the urgency allocation. The aim of this study is to evaluate the relation between consulting the supervising GP and (i) the urgency allocation and (ii) the diagnosis of ACS and other life-threatening events (LTEs) in patients calling the OHC-PC with chest discomfort. Methods: Patient call characteristics and follow-up data were retrieved from recorded phone calls, and GPs’ electronic medical files, respectively. Patients in whom the supervising GP was involved were compared with patients in whom not. Logistic regression was used to analyse data and calculate odds ratios (ORs) for the relation between involvement of the supervising GP and urgency allocation and the diagnosis of ACS/other LTE or ACS alone. Results: 2,195 patients were included in this study. In 1,148 (52.2%) the supervising GP was consulted, and there were no clear differences in symptoms with patients in whom the GP was not consulted, however they were on average three years younger and had more comorbidities. This resulted if compared to patients in whom the supervising GP was not involved in a higher urgency allocation (OR 1.26 (95% CI 1.06-1.50)), but a lower -non-significant- occurrence of ACS or other LTE (OR 0.79 (95% CI 0.63-1.01)) or ACS alone (OR 0.79 (95% CI 0.61-1.03)). This relation was significant after correction for age and sex (adjusted OR 0.75 (95% CI 0.59-0.96), and 0.75 (95% CI 0.57-0.98), respectively). These results were mainly driven by females; OR of ACS/other LTE in ‘consulted’ group 0.68 (95% CI 0.47- 0.98)), males OR 0.86 (95% CI 0.63-1.19). In the 215 (9.8%) patients who eventually showed to have an ACS and in whom the supervising GP was involved, less often a high urgency was allocated (OR 0.32 (95% CI 0.17-0.61)); females OR 0.24 (95% CI 0.08-0.69), males OR 0.39 (95% CI 0.17-0.87). In both the ‘consulted’ group with ACS as in the ‘not consulted’ ACS group, the NTS-generated low urgency cases were overruled to a high urgency just as often (23.9% vs 22.7%). The NTS-generated urgency was downgraded to low urgent in 2 cases (2.8%) in the ‘consulted’ group and in no case (0.0%) in the ‘not consulted’ group. Conclusion: In half of the patients, the supervising GP was involved, and they had similar symptoms as patients in those in whom no consultation took place. These patients were diagnosed less with an ACS but received more often a high urgency allocation. However, this discrepancy was completely driven by patients who had no ACS, more so in females. This suggests that patients in whom the GP was consulted were more difficult to triage resulting in relative over-triage of those without ACS or other LTE.