We carried out 2563 consultations over the 18 months. We analysed the reasons for consultation as indicated by the GP upon calling the CMC. These were classified as chest pain which may or may not have been of cardiac origin; arrhythmia; hypertension; patient reassurance or unspecified reason (Fig 3). We also reviewed the management decisions of these
2563 consultations, and classified them as: normal ECG with/without minor non-specific changes; mild disorders requiring no further investigation; those requiring referral for further investigation; and patients for whom urgent or immediate hospitalization was indicated. The management distribution analysis (Fig 4) demonstrated that, following the transtelephonic consultation, 81% of patients could be managed by the GP without any further need for referral. Of the 1615 consultations carried out where the GP indicated the reason for consultation as chest pain or atypical pain, 359 patients presented symptoms suggestive of acute ischaemia. Among those patients, significant ST depression was present in 747, significant
ST elevation suggestive of ischaemiaw as present in 107, while 30 patients were diagnosed as definite acute myocardial infarction on ECG grounds (Fig 5).
Of the 461 consultations where the GP indicated past or presenta rrhythmia, 282 had symptoms suggestive of arrhythmia. Of these, 92 had atrial fibrillation or flutter, 21 had supraventricular tachycardia and 5 patients had ventricular bigemini, while 2 presented accelerated junctional rhythm. There were 162 patients in normal sinus rhythm (Fig 6). The system allowed the identification of 479 (19%) patients with urgent cardiac problems, who were offered immediate hospital admission or early outpatient assessment as appropriate. In the remaining 2O84(81%) patients, the need for admission or outpatient investigation was excluded. An analysis of the completed questionnaires provided by the participating GPs revealed that the most common applications for the service were general management of cardiac patients, ECG interpretation and obtaining a cardiologist's opinion, and differentiating cardiac/non-cardiac situations. The maximum benefits were gained by the lteration of management, that is, the opportunity to manage patients in the practice instead of referring them to an accident and emergency department or requiring an outpatient assessment(Table1 ). Although the quality of data available following the
study did not allow for a comparative quantitative referral analysis, the data indicated a change in referral trend reducing the number of non-urgent and unnecessary referrals, while a substantial increase in assessments resulting in diagnosis of severe pathology was noted. A simple comparative cost analysis of teleconsultation compared with referral indicated that substantial savings in hospital resources could be achieved. Hospital consultation time was reduced to the essential communication, which averaged about 3 minutes, or 10% of the ordinary outpatient consultation slot of half an
hour. Further savings were obtained by registrars performing the routine teleconsultations instead of a consultant.