Workforce models delivering stress echocardiography in the UK - insights from the BSE-NSTEP multi-centre study.
Authors: Willis J , Johnson C , Krasner S , Mccourt A , O'driscoll J , Oxborough D , Paton M , Pearce K , Robinson S , Woodward W , Augustine D X , Leeson P 
Published: January 2025

Abstract

Introduction
The British Society of Echocardiography National Review of Stress Echo Practice (BSE N-STEP) is a large, prospective, multicentre study investigating stress echocardiography (SE) practice within the UK National Health Service. We used this dataset to identify, categorise and compare the characteristics of the workforce groups delivering SE within this real-world study cohort.

Method
Recruitment occurred between September 2020 and June 2023 across 34 NHS trusts. All patients provided informed consent and underwent SE following the local policy of each trust. Baseline characteristics of participants and details of SE procedure were recorded including stress modality and test outcome data. In addition, workforce involved in delivery of each test was self-reported including a description of staff responsible for test delivery, reporting and overall test supervision. Based on this, studies were categorised as either doctor-led (DL) which included both consultants and doctors in training, or cardiac physiologist/nurse-led (CNL). Frequency data was reported for each workforce group with Chi-square analysis used to identify differences between categorical variables.

Results
Data from 8506 patients were included in this analysis. SE supervision was identified as DL in 4839 (56.9%) and CNL in 3636 (42.7%) of which 79% was supervised by a cardiac physiologist. 28 hospitals reported both DL and CNL services. CNL services tended to be within higher volume centres, so that 4 trusts (two regional hospitals and two tertiary) contributed 71% of the total SE activity. Patients in CNL services were of similar age compared to DL service but were more likely to be male (p=0.008) and had a higher risk factor profile including hypertension (54.9% vs 50.1%), hypercholesterolaemia (50.3% vs 39.6%), and diabetes (24.9% vs 18.8%) (p=&lt;0.001). The proportion of patients seen for ischaemic heart disease tests was similar between DL and CNL clinics (89.1% vs 89.7%, p=ns) but CNL services performed more viability (0.8% vs 1.2%, p= 0.04) and pre-op studies (2.6% vs 3.4%, p= 0.03). DL services more commonly performed dobutamine stress studies (63.0% vs 56.3%, p=&lt;0.001) whilst the CNL group performed more exercise SE (42.8% vs 36.4%, p=&lt;0.001). Positivity rates for SE were similar across DL and CNL groups (17.1% vs 17.7%) as were inconclusive/ abandoned tests (3.8% vs 3.6%, p=ns). However, there was a lower rate of reported complications in the CNL services (2.2% vs 5.3% (p= &lt;0.001).
Discussion: Supervision of SE testing has traditionally been led by cardiologists with nursing and physiologist staff acting in supporting roles. This study demonstrates that the UK SE workforce is evolving, with non-medical-led services contributing significantly to the volume of SE activity although clear differences in the test modality remain between DL and CNL services at present.