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Editor,—Over recent years there has been increasing interest both from clinicians and managers in open access cardiology services. The paper by Agrawal and colleagues1 has again highlighted this. The most significant of their conclusions is the 47% reduction in the number of referrals for chest pain evaluation to the cardiology service. It is important, however, not to lose sight of the fact that the aim of an open access service should be to reduce the number of unnecessary referrals while identifying all appropriate patients. A fairer review of the results of this study should therefore include an assessment of whether the general practitioner's decision, in the light of the test result, was correct.
Of the 70 post-test referrals, 10 had a negative test result. In their case the exercise test did not affect the eventual decision. It is possible therefore that their referral was delayed and that they may have undergone an unnecessary investigation.
The exercise test result reduced the number of referrals to the cardiology service by 116; 45 of these had positive tests, of which six were strongly positive. Those not referred despite a strongly positive test cannot be viewed as a success for the service. The new National Service Framework is likely to require that every patient with angina should see a consultant cardiologist. This would therefore entail a clinic appointment for all those with a positive exercise test (45 patients).
Furthermore, 30 of the patients not referred had an inconclusive test, a result which cannot be used to affect the referral decision. It is arguable that these patients should have been seen in addition.
In the light of the above, the reduction in referrals would be from 186 to 145, a reduction but by no means as significant.
It can be concluded therefore that although open access exercise electrocardiography can indeed reduce the number of referrals to a unit, there needs to be some input from the consultant cardiologist running the service to ensure that patients are not lost from the system to their detriment.