College backs GP access to referral-free angiography

Chelsea Heaney

6/06/2024 4:40:49 PM

But while supportive, the RACGP has suggested changing the new item number’s proposed wording.

Man getting a scan.
A new MBS item for GPs could save the system time and money, says the RACGP.

GPs may soon be able to bypass other specialists when requesting computed tomography coronary angiography (CTCA), or angiograms, in a bid to reduce existing access issues.
The proposal comes after the MBS Review Taskforce recommended establishing a new item Medicare item number so that GPs can refer patients who:

  • are not known to have coronary artery disease (CAD)
  • have stable atypical symptoms (suggesting low or intermediate risk of CAD)
  • have a five-year Australian absolute risk of cardiovascular event of greater than or equal to 10%.
RACGP Vice President Associate Professor Michael Clements said the college welcomes the move, but would recommend some changes to the proposal.
‘We support patients having access to CTCA to rule out significant CAD without requiring prior referral to a cardiologist,’ he said.
‘This will decrease delays in patients receiving appropriate care, and costs incurred by the patient including out-of-pocket expenses, opportunity and possible transportation costs.’
Professor Ralph Audehm, who helped develop national guidelines for heart failure, told newsGP the move ‘would really be useful’, especially in rural areas where access to cardiology can be ‘problematic’.
‘Doing a CTCA can quickly sample the issue, but it can also help expedite the referral cardiology and public outpatient,’ he said.
However, even though the taskforce agreed that CTCA is a ‘robust test’, it also outlined potential risks to Medicare expenditure associated with ‘misuse’, including ‘poorly informed providers’ using the test for screening or taking on unnecessary requests from patients.
‘This could result in significant health costs and a flood of patients with low risk or no symptoms, as well as indeterminate findings on CTCA, who are seeking reassurance or advice from specialists or emergency departments,’ the Department of Health and Aged Care said.
But the department states these risks could be mitigated by only allowing GPs to order the test following an absolute risk assessment and it not being repeated for patients with a positive result or within five years of a negative one.
The RACGP provided two key points of feedback:
  • Risk assessments should be conducted using the new Australian CVD risk calculator, which classifies intermediate and high five-year risk estimates at 5% and above
  • The criteria should state that outpatient referral for CTCA is not the test of choice for a person presenting with possible acute coronary syndromes or crescendo angina
Meanwhile, Professor Audehm disagrees with having reliance on risk calculations altogether, pointing out that 30% of all infarcts are in low-risk individuals.
‘Someone who has attended ED for chest pain but is low risk may still need a CTCA when sent home,’ he said.
‘Access to cardiology can be long – so referring for an angiogram is something a GP could do.’
Additionally, for those with chronic obstructive pulmonary disease with frequent aggravations, Professor Audehm said the risk calculator might not distinguish ‘COPD versus cardiac symptoms’.
‘And what of the patient who has “stable” but typical symptoms?’ he queried.
‘Within private healthcare, management is easy but for public outpatients a CTCA would expedite the process and would result in fewer visits and save time and money.’
If the MBS item is added, Dr Audehm said it would help to simplify the process for both patients and providers.
‘With our specialist colleagues, if we often do a lot of pre-work, it means that our specialists are presented with the case and they say, “yep, well, this is what you got”,’ he said.
‘This is what we need to do.’
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newsGP weekly poll Would the reintroduction of MBS items for GPs to trace and report on electrocardiogram (ECGs) be beneficial to patients?

newsGP weekly poll Would the reintroduction of MBS items for GPs to trace and report on electrocardiogram (ECGs) be beneficial to patients?



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Dr Samuel Christopher Ognenis   7/06/2024 1:15:09 PM

A great move. Several patients who would otherwise be on a several month waitlist to see outpatient public cardiology services, could then access the CTCA sooner. They could then be prioritised for review, or even not need to see cardiology.

Dr Patrick Fergal McSharry   7/06/2024 1:52:41 PM

I did not realize I was restricted.( I've come from an environment -while we the PCP's were Gatekeepers - we managed quite high risk/ complex patients and as such had access to these investigations ) I reviewed my referrals for this indication and see that the reason for non-rejection for my patients was they already had seen some hospital specialist or other.
Furthermore, the Insurers C Suite Executives I worked with as Medical Director in Utilization Review and Quality Management were delighted to have as much as possible managed in Primary Care.
There were many incentives ( transitions of care, step down care, incentives to use something like the new Heart Foundation CVS Risk Calculator) with this end of sight.
Yes, we may not be there yet in Australia ( in our level of expertise, hense the Scope of Practice reluctance to increase their payment ( or even allow us to practice at this level) but certainly more Primary Care Physicians ( Office Based Docs such as ourselves)

Dr Patrick Fergal McSharry   7/06/2024 2:00:16 PM

...should start by proving our" cost containment ' value and improving TQM for the whole system ( as it moves towards vertical and horizontal integtration) by showing how we can keep patients out of the Hospital OPD's and wards ) , furthermore we can help the hospital docs, come our to us in Multi- Specialty Clinics in the Community. These type of clinics do exist - ( but they are run centrally ) so they do not embrace to 4- 5 C's of Primary Care ( Barbara as a Pediatrician would not be impressed) :)

A.Prof Christopher David Hogan   7/06/2024 3:41:25 PM

This is a massive advance.
It is a grudging acceptance from the Government that the skills of GPs far exceed scripts, certificates & referrals .
It is a matter of fact that GPs have more skills & experience than the junior staff in Public Hospitals

Dr Shobha Balu   21/06/2024 10:36:02 AM

Well said ! Thank you .