Evaluation of Stress Echocardiography Delivery in the UK

Willis, James (2025) Evaluation of Stress Echocardiography Delivery in the UK. Doctoral thesis (DClinSci), Manchester Metropolitan University.

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Abstract

This thesis provides a detailed examination of stress echocardiography (SE) services within 34 different hospitals, focusing on the SE workforce and highlighting the evolving roles of doctor-led (DL) and cardiac physiologist/scientist and nursing led (CNL) services. Traditionally, SE testing has been predominantly supervised by cardiologists, with nursing and physiologist staff in supporting roles. However, increasing demand and evidenced efficiencies in service delivery have driven the growth of CNL-led services, particularly by cardiac physiologists and scientists. To evaluate the implications of this shift, the study systematically compared DL and CNL SE testing across multiple dimensions, including test modalities, patient risk profiles, workforce contributions, and outcomes. This observational cohort study aimed to focus on four key objectives surrounding the current workforce in SE and how this is adapting to meet growing demand. 1. To describe the demographics, indications and stress echo details for the study cohort. 2. To identify the current workforce involved in delivering stress echocardiography and categorise these based on the staff's individual roles. 3. To investigate if significant differences exist in the patient group and test outcomes seen within a modelled doctor-led or cardiac physiologist/scientist and nurse-led stress echocardiography clinic 4. Also, to identify if there are any significant differences in the reporting volume and style of the different workforce groups. Using an already established collaborative SE research network, data was collected from 34 different Trusts already involved with SE research. These Trusts, based predominately within NHS England, recruited any patient undergoing a SE test over an approximately 3-year period. The collected data examined for each Trust, the volume of SE activity, the size of the recruiting Trust, the modalities used, the risk stratification of patients, the immediate test outcomes and the training and reporting structures employed on a cohort of 8506 patients recruited over three years. Interestingly, the results revealed that 82% of the hospitals within the study group already ran a combined DL and CNL service, resulting in 42.7% (n=3636) of all the SE activity being undertaken on a CNL list. This model was not only limited to larger Trusts. Significant differences existed between the DL and CNL groups, but there were also many similarities. There were similarities in the test indications and in the use of dobutamine as the most common stress agent within the two groups. However, when compared, dobutamine use was significantly higher in the DL group, whilst exercise stress was higher in the CNL group DL SE testing was focused primarily on higher-risk patients with prior cardiac investigations and evidence of cardiac damage. In contrast, CNL-led services demonstrated flexibility, performing SE testing on a broad spectrum of patients, with variable stress mediums. Notably, both groups maintained low complication rates, highlighting the safety of SE testing regardless of the supervising group. The findings also suggest the expanding role of the CNL workforce in SE reporting. Whilst the DL group dominated reporting SE results, the study identified a growing dual and independent reporting trend among CNL practitioners, particularly cardiac physiologists and scientists in the later stages of the study. Current training opportunities remain heavily focused on registrars and fellows within established medical pathways, leaving gaps in training for CNL professionals. This study highlights the importance of addressing these gaps, as this will be critical to ensuring the continued growth and sustainability of SE services across a multidisciplinary workforce. This thesis concludes that the rise of CNL-led clinics reflects an essential adaptation to growing demand, enabling a more robust and flexible diagnostic pathway for patients. Future research should continue to utilise the large-scale, multi-center approach and further explore how the integration of CNL professionals can enhance the efficiency and effectiveness of SE services across diverse healthcare settings. The potential to include more of the devolved nations within future work, can only look to strengthen the national picture, and also seek to identify variations that may exist due to funding models in place.