A patient with chest pain faces a fragmented journey across GP surgeries, chest pain clinics, and hospitals, and researchers will now track 3.76 million adults over a decade to map every missed opportunity for diagnosis and treatment. This matters because unacceptable variations in care for coronary disease are widespread across the NHS, yet no large-scale study has linked primary care, specialist clinics, and hospital records to explain why some patients fare worse than others. The programme will identify where the system fails—from delayed diagnosis to suboptimal risk prediction—and test whether a computerised decision-support tool in 50 chest pain clinics (9,740 patients) can reduce deaths and repeat heart attacks over three years. If successful, the intervention could be rolled out nationally, giving clinicians real-time guidance tailored to each patient’s risk. The research also evaluates whether blood biomarkers and genetic variants improve risk prediction beyond standard checks, potentially sparing low-risk patients from unnecessary invasive procedures. By combining quantitative surveys and ethnographic studies across 230 hospitals, the team will pinpoint organisational factors that drive outcome differences, offering actionable targets for NHS quality improvement.
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BACKGROUND Unacceptable variations in care for patients with coronary disease are ubiquitous, but we do not have prospective large scale outcomes research linking general practice, specialist clinic, and in-patient hospital care. In order to evaluate explanations for these variations and test new interventions which are actionable in the NHS, we propose unique new observational research and a major randomised trial. AIM To evaluate important new opportunities for improving quality of care and outcomes for patients with chronic stable angina and acute coronary syndromes (ACS), integrated across the patient journey, and at different levels of care (summarised in Figure 1) OBJECTIVES (i) To determine the cumulative impact of missed opportunities for improving patient outcome, from the beginning to the end of the patient journey, across five of the most common symptomatic coronary presentations, assessing inequalities in care and outcome. (ii) To determine at the level of the individual hospital the extent to which the organisation and processes of care have an impact on the patient journey. (iii) To establish the effectiveness and cost-effectiveness of a multi-faceted intervention targeting initial specialist management at hospital chest pain clinics of patients early in the symptomatic phase of the patient journey. (iv) To determine whether novel biomarkers are a cost-effective addition to existing clinical information in predicting the progression of chronic stable angina to acute fatal and non-fatal events.RESEARCH PLANSWe define patient outcomes as death and major (including repeat) cardiovascular events, throughout the programme.(i) We will identify patients presenting with coronary disease between 2002-11, and reconstruct the longitudinal patient journey by establishing a linkage between primary care record datasets (GPRD, Q Research ~3.76 million adults), the Myocardial Infarction National Audit Project (MINAP), hospitalisation and death. We will examine missed opportunities for diagnosis, treatment and risk prediction, at multiple time points, and assess their relative impact on outcome.(ii) We will determine how each of the 230 hospitals nationally differ in terms of patient outcomes after ACS, and identify explanations for variation which are amenable to action within the NHS, using quantitative surveys and an ethnographic study of hospital care.(iii) We will randomise 50 hospital chest pain clinics (9,740 patients) to a multi-faceted intervention based on patient specific computerised decision support, education and support vs usual care, and follow patients for 3 years for the primary outcome of fatal and non-fatal cardiovascular events.(iv) Exploiting the trial population in (iii) as a risk prediction cohort, we will measure novel biomarkers (e.g. BNP) and common genetic variants, and assess any incremental prognostic information beyond conventional clinical information. Cost-effectiveness will be assessed in a decision analysis of invasive management. RESEARCH TEAM EXPERTISE IMPACTING ON SERVICE PROVISION National leadership roles, influencing NHS innovation: NICE guidelines (Chair post MI Feder, Chair chest pain Timmis), HTA methodology (Sculpher, Abrams), NHS (Medical Director Keogh), DH Policy (National Director of Heart Disease and Stroke, Boyle), MINAP Academic Group (Chair Timmis), Q-Research (Director Hippisley-Cox), European Society of Cardiology (Chair Section on Epidemiology, Hemingway). During the current RAE period applicants have published > 25 applied research papers influencing service change in high impact general medical journals (NEJM/JAMA/Lancet/BMJ/ArchIntMed) and > 30 papers in top cardiovascular journals and secured >£10m in grant funding for applied research. RESEARCH ENVIRONMENT UCLH is the co-ordinating centre for MINAP, and has a strong track record in longitudinal cardiovascular health, healthcare and inequalities research. The clinical environment of chest pain clinics presents twin
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