The edition · Family Medicine
A chest pain rule that missed one acute coronary syndrome in 740 consultations
A Dutch trial of point-of-care troponin with the Marburg score, a model for male urinary symptoms that works without urodynamics, what continuity is worth in money, and why a normal result does not reassure by itself.
The edition in brief
POB-HELP was a cluster-randomised diagnostic trial in Dutch general practice testing a rule that combines the Marburg Heart Score with a point-of-care high-sensitivity troponin I. Across 740 patients assessed with the rule, one acute coronary syndrome was missed: sensitivity 98.3% (95% CI 90.8-100) and negative predictive value 99.7% (98.0-100). For myocardial infarction specifically, sensitivity and negative predictive value were both 100%. Specificity was 49.1% and positive predictive value 14.1%, and referral rates did not differ from usual care (54.6% vs 47.1%, p=0.39) - so the rule was safe but did not reduce referrals. Among 601 men with lower urinary tract symptoms across 67 UK practices, a model combining symptom score, bladder diary, examination, prostate specific antigen, uroflowmetry and post-void residual predicted bladder outlet obstruction against urodynamic reference with a validation c-index of 0.82. Detrusor underactivity and overactivity were predicted much less well, at 0.63 and 0.62. An Alberta analysis of roughly 70,000 matched patients with chronic disease estimated that raising clinic continuity to a Usual Provider of Care index of 80-100% across 195,000 patients could be associated with acute care savings over three years, with the largest per-patient gains in the most complex patients. This is a cross-sectional association, not a trial. In an online experiment, 349 people with moderate somatic symptoms judged an identical normal test result as less worrying when the doctor delivering it showed warmth and competence, and were less inclined to seek another opinion.
Male urinary symptoms: a model that reaches the obstruction diagnosis without urodynamics
Use simple non-invasive measures to support an obstruction diagnosis in men with urinary symptoms, but do not rely on them to distinguish detrusor underactivity from overactivity.
How the result is delivered changes what the patient hears
Deliver a normal result with explicit warmth and a stated conclusion; the result alone does not do the reassuring.
Clinic continuity, costed
Prioritise booking complex chronic disease patients back to the same clinic; the association with lower acute care costs was strongest in exactly that group.
When services are reorganised, families absorb what the system drops
Identify and address the family member coordinating a complex patient's care, and check any new access system against your most complex patients rather than your average ones.
Give the patient the words for what should bring them back
Safety-net with a specific sign, a specific time and a specific place, and write all three down.
Point-of-care troponin with the Marburg score missed one acute coronary syndrome in 740
Where a point-of-care high-sensitivity troponin is available, use it within the Marburg Heart Score rather than alone, and expect it to rule out rather than reduce referrals.
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