title: Diagnostic triage and the role of natriuretic peptide testing and echocardiography for suspected heart failure: an appropriateness ratings evaluation by UK GPs.
abstract: BACKGROUND
  Some UK GPs are acquiring access to natriuretic peptide (NP) testing or echocardiography as diagnostic tests for heart failure. This study developed appropriateness ratings for the diagnostic application of these tests in routine general practice.
  
  
  OBJECTIVE
  To develop appropriateness ratings for the diagnostic application of NP testing or echocardiography for heart failure in general practice.
  
  
  METHODS
  An appropriateness ratings evaluation in UK general practice.
  
  
  METHODS
  Four presenting symptoms (cough, bilateral ankle swelling, dyspnoea, fatigue), three levels of risk of cardiovascular disease (low, intermediate, high), and dichotomous categorisations of cardiovascular/chest examination and electrocardiogram result, were used to create 540 appropriateness scenarios for patients in whom NP testing or echocardiography might be considered. These were rated by a 10-person expert panel, consisting of GPs and GPs with specialist interests in cardiology, in a two-round RAND Appropriateness Method.
  
  
  RESULTS
  Onward referral for NP testing or echocardiography was rated as an appropriate next step in 217 (40.2%) of the 540 scenarios; in 194 (35.9%) it was rated inappropriate. The ratings also show where NP testing or echocardiography were ranked as equivalent next steps and when one test was seen as the more appropriate than the other.
  
  
  CONCLUSIONS
  NP testing should be the routine test for suspected heart failure where referral for diagnostic testing is considered appropriate. An abnormal electrocardiogram status makes referral to echocardiography an accompanying, or more appropriate, next step alongside NP testing, especially in the presence of dyspnoea. Abnormal NP testing should subsequently be followed up with referral for echocardiography.
authors: National Primary Care Research and Development Centre, University of Manchester, Manchester, UK.
authors: Stephen M
authors: SM
authors: Campbell
authors: Ahmet
authors: A
authors: Fuat
authors: Nick
authors: N
authors: Summerton
authors: Neil
authors: N
authors: Lancaster
authors: Fd Richard
authors: FR
authors: Hobbs
mesh_terms: D001291:Attitude of Health Personnel; D015415:Biomarkers / Q000378:metabolism; D032921:Consensus; D003371:Cough / Q000209:etiology; D003951:Diagnostic Errors; D004417:Dyspnea / Q000209:etiology; D004452:Echocardiography; D004489:Edema, Cardiac / Q000209:etiology; D005194:Family Practice; D005221:Fatigue / Q000209:etiology; D006333:Heart Failure / Q000175:diagnosis*; D006801:Humans; D020097:Natriuretic Peptide, Brain / Q000378:metabolism*; D010446:Peptide Fragments / Q000378:metabolism*; D011364:Professional Practice; D012307:Risk Factors; D014218:Triage / Q000379:methods*
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain