Attitudes and Referral Patterns of Primary Care Physicians When Evaluating Subjects with Noncardiac Chest Pain?A National Survey

Abstract

Noncardiac chest pain (NCCP) may affect up to 23% of the U.S. population. The clinical approach and referral patterns of primary care physicians (PCPs) when evaluating NCCP subjects are unknown. We aimed to determine the preferences of diagnostic tests, referral patterns, and treatment plans of NCCP patients by PCPs. PCPs were randomly selected from the American Medical Association national membership list. A 24-item questionnaire was mailed, which focused on demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, and treatment plans. Two hundred five (40%) PCPs returned the questionnaire (mean age, 49; 77% males; practice type--community-based, 40.5%; hospital-based, 10.7%; and combined, 47.3%; physician type--internists, 46.3%; family physicians, 44.4%; general practitioners, 4.9%; and others, 2.9%). The mean number of NCCP patients seen in the past 6 months was 108 (6.4% of total patients) and 79.5% were treated primarily by PCPs. The three most common diagnostic tests used were empirical proton pump inhibitor (PPI) trial (45.6%), chest radiograph (39.9%), and upper endoscopy (18.7%). Most PCPs reported that they are either comfortable (44.6%) or very comfortable (21.2%) in diagnosing NCCP. The three most commonly used therapeutic modalities for NCCP were PPIs (37.8%), lifestyle modification (33.7%), and H2 blockers (12.4%). Of those NCCP patients referred to a subspecialist, most ended up in gastroenterology (75.6%), followed by cardiology (7.8%) and pulmonary (1.6%) clinics. We conclude that most PCP's diagnose and treat NCCP patients without referring them to a gastroenterologist. However, diagnostic and treatment strategies may not follow the current understanding and knowledge of the disorder.

Patients Dismissed From the Hospital With a Diagnosis of Noncardiac Chest Pain: Cardiac Outcomes and Health Care Utilization

“…Although repeated ED visits for chest pain are to be expected, the number of repeated cardiology evaluations and the paucity of GI consultations are surprising. Our result is in direct contradistinction to results from a survey by Wong et al 24 of 205 primary care physicians in the United States. These investigators reported that, when referring patients for further management of NCCP, most primary care physicians preferred consultation by a gastroenterologist (75.6%) and less frequently asked for consultation by a cardiologist (7.8%).…”

The view of gastroenterologists on non‐cardiac chest pain in Asia

“…[17][18][19][20] It is also uncertain whether chest X-ray is useful in evaluating the cause of NCCP in the absence of coexisting pulmonary symptoms such as cough, haemoptysis, shortness of breath and other symptoms. 8 Although not being used commonly as first-line test, specialized oesophageal testing such as 24 h pH study, manometry, barium swallow and Bernstein test were being used in quite a number of cases. This may reflect the complex nature of the cases being seen by the gastroenterologist but it may also suggest an excessive use of tests trying to find ⁄ exclude the cause for the chest pain.…”

Dor torácica não-cardiogênica

“…A maioria dos pacientes é diagnosticada e tratada por médicos clínicos, com apenas 17% dos pacientes encaminhados para o gastroenterologista (44) (Figura 1).…”