A value-based model using upskilled GPs to deliver community cardiology clinics is associated with improved outcomes and reduced downstream interventions compared with outpatient hospital services

Background

Inexorable growth in outpatient cardiology referrals has prompted development of alternative care-delivery models, but comparative outcome data are lacking. One approach involves GPs with additional specialty training delivering community-based cardiology services within a clinical governance and professional support framework integrated with secondary care.

Purpose

To compare long-term clinical outcomes of patients assessed in a community-based GP-Cardiology (GPC) service versus a hospital-based cardiology (HC) service.

Methods

Observational cohort study of 1,788 patients (1,048 GPC; 740 HC) attending outpatient cardiology over a 7-month period. Patients were selected using a common triage protocol as part of a UK-based service development project. Median follow-up was 6.8 years.

Primary outcome: time to first major adverse cardiovascular event (MACE), defined as cardiovascular death, non-fatal MI, or non-fatal stroke. Secondary outcomes: MACE components, all-cause mortality, unplanned hospitalisation, and emergency department or ambulatory assessment unit (ED/AAU) attendance.

Time-to-event outcomes were analysed using Kaplan–Meier methods and Cox proportional hazards models, unadjusted and adjusted for age and sex.

Results

Baseline characteristics and referral indications were broadly similar between groups. However, the GPC group was significantly older than the HC group; adjusted analyses were therefore performed.

In the unadjusted analysis, MACE was lower in the GPC group (5.9% vs 8.4%; HR 0.69 [95% CI 0.49–0.98]; p=0.039), with no significant differences in other outcomes.

In the adjusted analysis, the GPC group demonstrated a significant reduction in MACE (HR 0.59 [95% CI 0.41–0.84]; p=0.003), with consistent reductions across secondary outcomes including cardiovascular death, non-fatal MI, all-cause mortality, and unplanned hospitalisation. Non-fatal stroke and ED/AAU attendance did not differ significantly between groups (Table 1).

Non-invasive investigation rates were comparable between groups. Downstream complex cardiac interventions were less frequent in the GPC group (11.7% vs 22.2%; P<0.001), particularly those not routinely subject to MDT approval (Table 2).

Conclusion

The integrated GPC service was associated with significantly lower rates of MACE, all-cause mortality, and unplanned hospitalisation compared to the HC service, possibly due to better compliance with guideline-directed medical therapy. Moreover, downstream complex cardiac interventions were substantially lower in the GPC group, likely reflecting appropriate risk stratification and selective escalation. There was no difference in the use of non-invasive investigations. These findings support the safety, clinical- and cost-effectiveness of this value-based healthcare approach to community GP-Cardiology services.