In our health system, out-patient cardiology is the natural reference point of primary care physicians for all the cardiology problems affecting their patients. There is a great variety of organisational models for this service throughout Spain. In some places, the same cardiologists attend both out-patients and those admitted to hospital, while in others both the personnel and resources are different.
A fluid relationship
The Sección de Cardiología Extrahospitalaria is an official scientific section of the Sociedad Española de Cardiología (Spanish Society of Cardiology) and is mainly comprised of cardiologists in private practice and those working for the public health service in out-patient clinics, but without responsibility during hospital admissions. In theory, these cardiologists constitute an intermediate between primary care and specialized in-patient care, and thus the relationship with both levels has to be fluid.
Problems affecting the quality of care
In carrying out their work these cardiologists face problems that differ from those of hospital cardiologists. Although not clearly defined or measured, these problems are commonly regarded as affecting the quality of care delivered to patients. The Section decided to address this issue by comparing the opinion of its cardiologists with some simple measurements taken during regular appointments with their patients.
141 cardiologists identified and prioritised the main problems affecting the care given to their patients. Concurrently, information from 1477 cardiologic appointments offered by these same doctors was also analysed; items considered included the reason for and source of referral to the cardiologist, changes in diagnosis or treatment attributable to this appointment, and subsequent referral on of the patient.
The main problems identified by the cardiologists relate to the quality of care delivered, including excessive delay in complementary tests and reduced time per appointment due to work overload (too many appointments). The lack of connection with primary care physicians is also felt to be a big problem, which, in the opinion of two out of every three cardiologists, results in over 20% of all patients sent from primary care being given incorrect pharmacological treatment. In addition, an excessive number of patients are referred to cardiologists who are already overloaded and have long waiting lists.
When individual appointments are analysed, the picture is somewhat different. The average duration of an appointment is 15 minutes, only 3 minutes short of the 18 minutes which the attending physicians for these very same appointments estimated as being, on average, ideal. 87% of all patients are considered to be appropriately referred to the cardiologist; 5% should have remained in primary care and a further 5% should have been referred earlier.
39% of all appointments had been made by the cardiologists themselves, rather than by primary care physicians or other cardiologists. 36% were symptom-free check-ups. Only one out of every seven patients (14%) was given a new diagnosis in this appointment and a little over one out of every four (28%) had his/her treatment changed.
48% of all patients are referred on to their primary care physician, but a new appointment with the cardiologist is also made. Only 14% of all patients are “definitively” sent to other health care professionals (10% to primary care and 4% to other specialists). The cardiologists themselves are thus the main source of their own waiting lists, and not other professionals.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
Cardiologists themselves hold the key
In conclusion, there some discrepancies between the problems perceived by cardiologists and the information provided by direct observation of the situation. To a great extent, cardiologists themselves hold the key to the problems identified as affecting the quality of care offered to their patients.
In order to improve the situation, there is no a single measure or set of simple measures that apply to all settings. The solutions have, probably, to be designed locally but they share a common ground: the communication between cardiologists working out of hospital and their peers at the hospital has to improve, as well as the communication between the former and primary care physicians. Until this is reached, cardiologists working out of hospital could probably review their protocols and offer specialized follow-up only to those patients that will benefit from it. Many others can be effectively followed in other settings, as primary care. This may need some additional training for physicians working there, tasks where extra-hospital cardiologists may play an important role. It will also be a step forward in improving communication with primary care physicians.