The course of nonspecific chest pain in primary care: symptom persistence and health care usage.
BACKGROUND
Nonspecific chest pain is common in primary care, yet knowledge is sparse about its course and outcome and how they relate to optimum health care usage. We investigated the following observations: (1) many patients who present with nonspecific chest pain in primary care show symptom persistence for 6 months, (2) many patients with nonspecific chest pain showed signs of overinvestigation, and (3) many patients with chronic chest pain were referred to mental health specialists.


METHODS
We conducted a prospective, general physician-based cohort study with 6-week and 6-month follow-ups in 74 primary care offices in Hessen, Germany. Of approximately 190 000 consecutive patients who visited their general physicians from October 1, 2005, to July 31, 2006, 807 patients with nonspecific chest pain were identified by an expert committee (delayed-type reference standard). The dropout rate was 2.7%. Main outcome measures were persistent chest pain at a 6-month follow-up visit and health care usage at 6 months.


RESULTS
The rate of persistent chest pain was 55.5%. A total of 10.7% of patients had inappropriate health care usage, defined as 2 or more visits to a cardiologist or 3 or more cardiac diagnostic investigations. Most patients with persistent nonspecific chest pain were referred to a cardiologist, and less than 2% were referred to mental health specialists.


CONCLUSIONS
For most patients with nonspecific chest pain, standard medical care does not offer sufficient help for symptom relief. One-tenth of patients with persistent chest pain underwent additional diagnostic testing of no known clinical benefit. Psychological referrals were rarely given.
Glombiewski
Julia Anna
JA
Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Germany. julia.glombiewski@staff.uni-marburg.de
Rief
Winfried
W
Bösner
Stefan
S
Keller
Heidemarie
H
Martin
Alexandra
A
Donner-Banzhoff
Norbert
N
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D003937:Diagnosis, Differential; D005194:Family Practice / Q000639:trends*; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000706:statistics & numerical data*; D010349:Patient Compliance / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013997:Time Factors