Design
Pilot
A three month pilot phase in two clinics will be used to optimize the intervention and recruitment procedures and finalize baseline assessment instruments. The pilot phase will take place at the Bristol Royal Infirmary (BRI) with the support of the University Hospitals Bristol NHS Foundation Trust and at Newham University Hospital.
Centres
The main phase of the OMA trial will take place at 50 rapid access chest pain clinics (RACPCs) based in acute trusts across England. Clinics will be randomized centrally using minimisaton to balance the two arms by geographical location, size, and nurse involvement in clinical decisions.
Inclusion criteria
- referral by general practitioner with suspected new onset angina on the basis that their chest pain is typical or atypical
- onset within the last 12 months
- aged 40 or above
Exclusion Criteria
- non-cardiac chest pain
- previous admission history with ACS
- Q wave or LBBB on resting ECG
- previous angiography
Intervention
Chest pain clinics will receive an intervention aiming to optimise the evidence based use of angiography (and thereby revascularisation), secondary preventive medication, lifestyle interventions and referral to cardiac rehabilitation. The intervention developed consists of an educational and patient specific decision support programme targeted at doctors and specialist nurses. It will be developed by a clinical team trained in adult learning, motivational methods and an implementation model that focuses on barriers and facilitators to clinician behavior change. Patients will be followed up for three years.
The intervention includes:
- Patient specific decision support embedded in the electronic health record
- Structured training sessions and web-based reinforcement
- Direct communication by letter to the referring GP of each patient and the patient including prescription of secondary prevention medication and anti-anginal drugs, advice on smoking cessation, exercise, details of blood investigation and guidance on management of abnormalities
- A clinical champion in each rapid access chest pain clinic who will receive additional training
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