1
|
Mark DG, Huang J, Ballard DW, Vinson DR, Rana JS, Sax DR, Rauchwerger AS, Reed ME. Emergency Department Referral of Patients With Chest Pain for Noninvasive Cardiac Testing and 2-Year Clinical Outcomes. Circ Cardiovasc Qual Outcomes 2024; 17:e010457. [PMID: 38779848 DOI: 10.1161/circoutcomes.123.010457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing. METHODS A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events. RESULTS Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48-68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02-1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99-1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%). CONCLUSIONS Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population.
Collapse
Affiliation(s)
- Dustin G Mark
- Departments of Emergency Medicine (D.G.M., D.R.S.), Kaiser Permanente Medical Center, Oakland, CA
- Critical Care Medicine (D.G.M.), Kaiser Permanente Medical Center, Oakland, CA
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Dustin W Ballard
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
- Department of Emergency Medicine, Kaiser Permanente Medical Center, San Rafael, CA (D.W.B.)
| | - David R Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
- Department of Emergency Medicine, Kaiser Permanente Medical Center, Roseville, CA (D.R.V.)
| | - Jamal S Rana
- Cardiology (J.S.R.), Kaiser Permanente Medical Center, Oakland, CA
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Dana R Sax
- Departments of Emergency Medicine (D.G.M., D.R.S.), Kaiser Permanente Medical Center, Oakland, CA
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| |
Collapse
|
2
|
Doan VD, Zheng C, Onwuzurike J, Chen A, Wu YL, Lee MS. Prognostic Value of Stress Myocardial Perfusion Imaging Across the Spectrum of Cardiovascular Risk. Can J Cardiol 2024:S0828-282X(24)00355-6. [PMID: 38734205 DOI: 10.1016/j.cjca.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/27/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is widely used to identify ischemia. There is limited research to evaluate if there is a risk threshold below which SPECT-MPI may not add significant prognostic value. METHODS Between January 1, 2012, and December 31, 2018, individuals who underwent SPECT-MPI were stratified into 4 risk groups. The primary outcome was acute myocardial infarction (MI) or death. Multivariable Cox proportional hazards regression analysis was used to calculated hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS Among 48,845 patients (52.3% male, median age 67 years), 8.5% were low risk, 4.8% borderline risk, 18.1% intermediate risk, and 68.6% high risk based on the American College of Cardiology pooled cohort equation. Ischemia was more commonly detected in the high-risk cohort (19.4% in high-risk vs 6.5% in low-risk). SPECT-MPI testing was associated with a significantly increased use of preventive medications such as statin therapy, regardless of stress test results. At a median follow-up of 4.2 years, there was no significant association between ischemia and death or MI in the low-risk cohort (adjusted HR, 1.91; 95% CI, 0.94-3.92) or the borderline-risk cohort (adjusted HR, 1.58; 95% CI, 0.79-3.15). Ischemia was associated with a higher risk of death or MI in the intermediate-risk (adjusted HR, 1.57; 95% CI, 1.24-1.99) and high-risk groups (adjusted HR, 1.54; 95% CI, 1.44-1.64). CONCLUSIONS SPECT-MPI was less useful for risk stratification among low-risk patients because of their low event rates regardless of test results.
Collapse
Affiliation(s)
- Vinh D Doan
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - James Onwuzurike
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA.
| |
Collapse
|
3
|
Ellenbogen MI, Wiegand AA, Austin JM, Schoenborn NL, Kodavarti N, Segal JB. Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis. J Gen Intern Med 2023; 38:2519-2526. [PMID: 36781578 PMCID: PMC10465435 DOI: 10.1007/s11606-023-08060-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Healthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA. OBJECTIVE To learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse. PARTICIPANTS Leaders at select healthcare systems in the USA. INTERVENTIONS None APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework. KEY RESULTS We interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse. CONCLUSIONS Our qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.
Collapse
Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA.
| | - Aaron A Wiegand
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Matthew Austin
- Department of Anesthesia and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA
| | - Nihal Kodavarti
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
4
|
Smetana GW, Benson MD, Juraschek SP, Burns RB. Would You Recommend a Statin to This Patient for Primary Prevention of Cardiovascular Disease? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2022; 175:862-872. [PMID: 35696686 PMCID: PMC10096340 DOI: 10.7326/m22-0908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the United States. Hypercholesterolemia is a principal modifiable risk factor for the primary prevention of CVD. In addition to lifestyle modification, statins are an important tool to reduce risk for CVD in selected patients. A useful strategy to identify candidates for statins is to estimate the 10-year risk for CVD through the use of a validated risk calculator. Commonly used calculators include the Framingham risk score and the pooled cohort equation. Multiple randomized controlled trials have shown that statins reduce the risk for CVD in patients without known CVD. Two recent guidelines have proposed an approach to the use of statins in primary prevention of CVD. The American College of Cardiology/American Heart Association and the U.S. Department of Veterans Affairs guidelines form the basis for this discussion. The guidelines differ on the use of advanced testing to modify the 10-year CVD risk estimate and on the need for low-density lipoprotein cholesterol targets to establish the efficacy of statins. Advanced testing with coronary artery calcium measurement may be helpful for patients who are potentially eligible for statin therapy but who are uncertain if they wish to take a statin. In this paper, 2 experts, a preventive cardiologist and a general internist, discuss their approach to the use of statins for primary prevention of CVD and how they would apply the guidelines to an individual patient.
Collapse
Affiliation(s)
- Gerald W Smetana
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (G.W.S., M.D.B., S.P.J., R.B.B.)
| | - Mark D Benson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (G.W.S., M.D.B., S.P.J., R.B.B.)
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (G.W.S., M.D.B., S.P.J., R.B.B.)
| | - Risa B Burns
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (G.W.S., M.D.B., S.P.J., R.B.B.)
| |
Collapse
|
5
|
Kini V, Parks M, Liu W, Waldo SW, Ho PM, Bradley SM, Hess PL. Patient Symptoms and Stress Testing After Elective Percutaneous Coronary Intervention in the Veterans Affairs Health Care System. JAMA Netw Open 2022; 5:e2217704. [PMID: 35727581 PMCID: PMC9214585 DOI: 10.1001/jamanetworkopen.2022.17704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Up to 60% of patients in the US receive a stress test within 2 years of percutaneous coronary intervention (PCI), prompting concerns about the possible overuse of stress testing. OBJECTIVE To examine the proportion of patients who underwent stress testing within 2 years of elective PCI, proportion of patients who had symptoms that were consistent with coronary artery disease (CAD), timing of stress testing, and site-level variation in stress testing among symptomatic and asymptomatic patients. DESIGN, SETTING, AND PARTICIPANTS This cohort study used administrative claims data and clinical records from the US Department of Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking program. Patients who underwent stress testing within 2 years of elective PCI for stable CAD between November 1, 2013, and October 31, 2015, at 64 VA facilities were included in the analysis. Patients who received stress testing for staging purposes, cardiac rehabilitation evaluation, or preoperative testing before high-risk surgery were excluded. Data were analyzed from June to December 2020. MAIN OUTCOMES AND MEASURES The main outcome was the proportion of patients who underwent stress testing and had symptoms that were consistent with obstructive CAD, using definitions from the 2013 clinical practice guideline (Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease). Secondary outcomes were the timing of stress testing (assessed using a cumulative incidence curve) and site-level variation in stress testing (assessed using multilevel logistic regression models). RESULTS A total of 3705 consecutive patients (mean [SD] age 66.3 [7.6] years; 3656 men [98.7%]; 437 Black individuals [11.8%], 3175 White individuals [85.7%], and 93 individuals [2.5%] of other races and ethnicities [Asian, Hispanic or Latinx, or unknown]) had elective PCI. Of these patients, 916 (24.7%) received a stress test within 2 years, among whom 730 (79.7%) had symptoms that were consistent with obstructive CAD at the time of stress testing. Visual inspection of a cumulative incidence curve for stress testing showed no rapid increases in stress testing at 6 months or 1 year after PCI, which might coincide with routine clinical visits. The proportion of symptomatic patients who underwent stress testing at each VA site ranged from 67.7% to 100%, with no significant site-level variation in stress testing. CONCLUSIONS AND RELEVANCE Results of this study suggest that most veterans who underwent stress testing within 2 years after elective PCI had symptoms that were consistent with obstructive CAD. Therefore, measuring low-value stress testing using only administrative claims data may overestimate its prevalence, and concerns about overuse of post-PCI stress testing may be overstated.
Collapse
Affiliation(s)
- Vinay Kini
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Monica Parks
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Wenhui Liu
- Veterans Affairs Eastern Colorado Healthcare System, Aurora
| | - Stephen W. Waldo
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Veterans Affairs Eastern Colorado Healthcare System, Aurora
- Veterans Affairs Clinical Assessment Reporting and Tracking Program, Veterans Health Administration Office of Quality and Patient Safety, Washington, DC
| | - P. Michael Ho
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Veterans Affairs Eastern Colorado Healthcare System, Aurora
| | | | - Paul L. Hess
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Veterans Affairs Eastern Colorado Healthcare System, Aurora
| |
Collapse
|
6
|
Tolsma RT, Fokkert MJ, van Dongen DN, Badings EA, van der Sluis A, Slingerland RJ, van 't Riet E, Ottervanger JP, van 't Hof AWJ. Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:160-169. [PMID: 34849660 PMCID: PMC8826840 DOI: 10.1093/ehjacc/zuab109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/01/2021] [Accepted: 11/04/2021] [Indexed: 12/13/2022]
Abstract
Aims Although pre-hospital risk stratification of patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) by ambulance paramedics is feasible, it has not been investigated in daily practice whether referral decisions based on this risk stratification is safe and does not increase major adverse cardiac events (MACE). In Phase III of the FamouS Triage study, it was investigated whether referral decisions by ambulance paramedics based on a pre-hospital HEART score, is non-inferior to routine management. Methods and results FamouS Triage Phase III is a non-inferiority study, comparing the occurrence of MACE before (Phase II) and after (Phase III) implementation of referral decisions based on a pre-hospital HEART score. In Phase II, all patients were risk-stratified and referred to the hospital; in Phase III, low-risk patients (HEART score ≤ 3) were not referred. Primary endpoint was MACE (acute coronary syndrome, revascularization, or death) within 45 days. A total of 1236 patients were included. Mean age was 63 years, 43% were female, 700 patients were included in the second phase and 536 in the third phase in which 149 low-risk patients (28%) were not transferred to the hospital. Occurrence of 45 days MACE was 16.6% in Phase II and 15.7% in Phase III (P = 0.67). Percentage MACE in low-risk patients was 2.9% in Phase II and 1.3% in Phase III. After adjustments for differences in baseline variables, the hazard ratio of 45 days MACE in Phase III was 0.88 (95% confidence interval 0.63–1.25) as compared to Phase II. Conclusion Pre-hospital risk stratification of patients with suspected NSTE-ACS, avoiding hospitalization of a substantial number of low-risk patients, seems feasible and non-inferior to transferring all patients to the hospital.
Collapse
Affiliation(s)
- Rudolf T Tolsma
- Emergency Medical Service, Ambulance IJsselland, Voltastraat 3A, 8013 PM Zwolle, The Netherlands
| | - Marion J Fokkert
- Department of Clinical Chemistry, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Dominique N van Dongen
- Department of Cardiology, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Erik A Badings
- Department of Cardiology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands
| | - Aize van der Sluis
- Department of Cardiology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands
| | - Robbert J Slingerland
- Department of Clinical Chemistry, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Esther van 't Riet
- Department of Research, UMCU, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, MUMC, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.,Department of Cardiology, Zuyderland MC, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
| |
Collapse
|
7
|
Mark DG, Shan J, Huang J, Ballard DW, Vinson DR, Kene MV, Sax DR, Rauchwerger AS, Reed ME. Higher intensity of 72-h noninvasive cardiac test referral does not improve short-term outcomes among emergency department patients with chest pain. Acad Emerg Med 2022; 29:736-747. [PMID: 35064989 DOI: 10.1111/acem.14448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is unclear whether referral for cardiac noninvasive testing (NIT) following emergency department (ED) chest pain encounters improves short-term outcomes. METHODS This was a retrospective cohort study of patients presenting with chest pain, without ST-elevation myocardial infarction or myocardial injury by serum troponin testing, between 2013 and 2019 to 21 EDs within an integrated health care system. We examined the association between NIT referral (within 72 h of the ED encounter) and a primary outcome of 60-day major adverse cardiac events (MACE). Secondary outcomes were 60-day MACE without coronary revascularization (MACE-CR) and 60-day all-cause mortality. To account for confounding by indication for NIT, we grouped patient encounters into ranked tertiles of NIT referral intensity based on the likelihood of 72-h NIT referral associated with the initially assigned emergency physician, relative to local peers and within discrete time periods. Associations between NIT referral-intensity tertile and outcomes were assessed using risk-adjusted multivariable logistic regression. RESULTS Among 210,948 eligible patient encounters, 72-h NIT referral frequency was 11.9%, 18.3%, and 25.9% in low, intermediate, and high NIT referral-intensity encounters, respectively. Compared with the low referral-intensity tertile, there was a higher risk of 60-day MACE within the high referral-intensity tertile (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.04 to 1.17) due to more coronary revascularizations without corresponding differences in MACE-CR or all-cause mortality. In analyses stratified by patients' estimated risk (HEART score; 50.5% lower risk, 38.7% moderate risk, 10.8% higher risk), the difference in 60-day MACE was primarily attributable to moderate-risk encounters (OR = 1.15, 95% CI = 1.08 to 1.24), with no differences among either lower- (OR = 1.10, 95% CI = 0.92 to 1.31) or higher- (OR = 1.01, 95% CI = 0.90 to 1.14) risk encounters. CONCLUSION Higher referral intensity for 72-h NIT was associated with higher risk of coronary revascularization but no difference in adverse events within 60 days. These findings further call into question the urgency of NIT among ED patients without objective evidence of myocardial injury.
Collapse
Affiliation(s)
- Dustin G. Mark
- Departments of Emergency Medicine and Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland California USA
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland California USA
- School of Medicine University of California San Francisco San Francisco California USA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Dustin W. Ballard
- Division of Research Kaiser Permanente Northern California Oakland California USA
- Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael California USA
| | - David R. Vinson
- Division of Research Kaiser Permanente Northern California Oakland California USA
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville California USA
| | - Mamata V. Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro California USA
| | - Dana R. Sax
- Division of Research Kaiser Permanente Northern California Oakland California USA
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland California USA
| | - Adina S. Rauchwerger
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Mary E. Reed
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | | |
Collapse
|
8
|
Cubedo J, Padró T, Vilahur G, Crea F, Storey RF, Lopez Sendon JL, Kaski JC, Sionis A, Sans-Rosello J, Fernández-Peregrina E, Gallinat A, Badimon L. Glycosylated apolipoprotein J in cardiac ischaemia: molecular processing and circulating levels in patients with acute ischaemic events. Eur Heart J 2021; 43:153-163. [PMID: 34580705 DOI: 10.1093/eurheartj/ehab691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/16/2021] [Accepted: 09/15/2021] [Indexed: 11/12/2022] Open
Abstract
AIM Using proteomics, we previously found that serum levels of glycosylated (Glyc) forms of apolipoprotein J (ApoJ), a cytoprotective and anti-oxidant protein, decrease in the early phase of acute myocardial infarction (AMI). We aimed to investigate: (i) ApoJ-Glyc intracellular distribution and secretion during ischaemia; (ii) the early changes in circulating ApoJ-Glyc during AMI; and (iii) associations between ApoJ-Glyc and residual ischaemic risk post-AMI. METHODS AND RESULTS Glycosylated apolipoprotein J was investigated in: (i) cells from different organ/tissue origin; (ii) a pig model of AMI; (iii) de novo AMI patients (n = 38) at admission within the first 6 h of chest pain onset and without troponin T elevation at presentation (early AMI); (iv) ST-elevation myocardial infarction patients (n = 212) who were followed up for 6 months; and (v) a control group without any overt cardiovascular disease (n = 144). Inducing simulated ischaemia in isolated cardiac cells resulted in an increased intracellular accumulation of non-glycosylated ApoJ forms. A significant decrease in ApoJ-Glyc circulating levels was seen 15 min after ischaemia onset in pigs. Glycosylated apolipoprotein J levels showed a 45% decrease in early AMI patients compared with non-ischaemic patients (P < 0.0001), discriminating the presence of the ischaemic event (area under the curve: 0.934; P < 0.0001). ST-elevation myocardial infarction patients with lower ApoJ-Glyc levels at admission showed a higher rate of recurrent ischaemic events and mortality after 6-month follow-up (P = 0.008). CONCLUSIONS These results indicate that ischaemia induces an intracellular accumulation of non-glycosylated ApoJ and a reduction in ApoJ-Glyc secretion. Glycosylated apolipoprotein J circulating levels are reduced very early after ischaemia onset. Its continuous decrease indicates a worsening in the evolution of the cardiac event, likely identifying patients with sustained ischaemia after AMI.
Collapse
Affiliation(s)
- Judit Cubedo
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Teresa Padró
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Gemma Vilahur
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Filippo Crea
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, Roma 00168, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Via Giuseppe Moscati, 31, Roma 00168, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK
| | | | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Alessandro Sionis
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Cardiology Department, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Jordi Sans-Rosello
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Cardiology Department, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | | | - Alex Gallinat
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Lina Badimon
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Autonomous University of Barcelona, Bellaterra 08193, Spain
| |
Collapse
|
9
|
Ellenbogen MI, Prichett L, Newman-Toker DE, Brotman DJ. Characterizing the relationship between diagnostic intensity and quality of care. Diagnosis (Berl) 2021; 9:123-126. [PMID: 34261203 PMCID: PMC10642069 DOI: 10.1515/dx-2021-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The relationship between diagnostic intensity and quality of care has not been well-characterized at the hospital level. We performed an exploratory analysis to better delineate this relationship using a hospital-level diagnostic overuse index and accepted hospital quality metrics (readmissions and mortality). METHODS We previously developed and published a hospital-level diagnostic overuse index. A hospital's overuse index value (which ranges from 0 to 0.986, with larger numbers indicating more overuse) was our predictor variable of interest. The outcome variables were excess readmission ratios and mortality rates for common medical conditions, which CMS publicly reports. The model controlled for Elixhauser comorbidity score, hospital bed size, hospital teaching status, and random effects that vary by state. RESULTS We did not find a statistically significant relationship between our overuse index and the quality measures we evaluated. CONCLUSIONS The lack of a significant relationship between diagnostic intensity and quality, at least as measured by our overuse index and the tested quality metrics, suggests that well-targeted efforts to reduce diagnostic overuse in hospitals may not adversely impact quality of care.
Collapse
Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Hopkins Business of Health Initiative, Johns Hopkins University, Baltimore, MD, USA
| | - Laura Prichett
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - David E Newman-Toker
- Department of Neurology, Armstrong Institute Center for Diagnostic Excellence, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel J Brotman
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
10
|
Chou SC, Hong AS, Weiner SG, Wharam JF. Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care. Circulation 2021; 144:336-349. [PMID: 34176279 PMCID: PMC8323713 DOI: 10.1161/circulationaha.120.052501] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Supplemental Digital Content is available in the text. Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear.
Collapse
Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - Arthur S Hong
- Departments of Internal Medicine and Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas (A.S.H.)
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School, Boston, MA (J.F.W.).,Harvard Pilgrim Health Care Institute, Boston, MA (J.F.W.)
| |
Collapse
|
11
|
Moumneh T, Sun BC, Baecker A, Park S, Redberg R, Ferencik M, Lee MS, Douillet D, Roy PM, Sharp AL. Identifying Patients with Low Risk of Acute Coronary Syndrome Without Troponin Testing: Validation of the HEAR Score. Am J Med 2021; 134:499-506.e2. [PMID: 33127371 DOI: 10.1016/j.amjmed.2020.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Current guidelines for patients with suspected acute myocardial infarction are mainly based on troponin testing, commonly requiring an emergency department visit. HEAR score (History, Electrocardiogram, Age, and Risk factors) is a risk stratification tool validated in Europe, deduced from the HEART score (History, Electrocardiogram, Age, Risk factors, and Troponin), already implemented in clinical practice. We aimed to validate the HEAR score to rule out an acute myocardial infarction without needing biomarker testing. METHODS Retrospective cohort study at 15 emergency departments between May 2016 and December 2017. All adult encounters evaluated for possible acute myocardial infarction with a physician-documented HEART score for health plan members of Kaiser Permanente Southern California were included. Patients with an ST-segment elevation myocardial infarction, those under hospice care, or with a "do not resuscitate" status were excluded. HEAR scores from 0-8 were calculated for each encounter and used to report 30-day acute myocardial infarction or all-cause mortality for each score. RESULTS There were 22,109 patient encounters included in the study. Overall, 30-day acute myocardial infarction or death occurred in 1.1% of patients. Among the 4106 patients (19%) with a HEAR score <2, 3 died and 2 experienced an acute myocardial infarction within 30 days (0.1%; 95% confidence interval, 0.1-0.3). Sensitivity and specificity were 97.9% and 18.8%, respectively. CONCLUSIONS A low HEAR score may accurately identify patients with a very low risk of 30-day acute myocardial infarction or death, representing a cohort of patients who might appropriately forego biomarker testing. Future research is warranted to assess the impact of implementing the HEAR score into routine clinical practice.
Collapse
Affiliation(s)
- Thomas Moumneh
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015 UMR INSERM 1083, Université d'Angers, Angers, France.
| | - Benjamin C Sun
- Department of Emergency Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Aileen Baecker
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - Stacy Park
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - Rita Redberg
- Division of Cardiology, University of California, San Francisco
| | - Maros Ferencik
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center
| | - Delphine Douillet
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015 UMR INSERM 1083, Université d'Angers, Angers, France
| | - Pierre-Marie Roy
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015 UMR INSERM 1083, Université d'Angers, Angers, France
| | - Adam L Sharp
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena; Department of Health Systems Science, Kaiser Permanente School of Medicine, Pasadena
| |
Collapse
|
12
|
Ellenbogen MI, Prichett L, Johnson PT, Brotman DJ. Development of a Simple Index to Measure Overuse of Diagnostic Testing at the Hospital Level Using Administrative Data. J Hosp Med 2021; 16:77-83. [PMID: 33496661 PMCID: PMC7850599 DOI: 10.12788/jhm.3547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We developed a diagnostic overuse index that identifies hospitals with high levels of diagnostic intensity by comparing negative diagnostic testing rates for common diagnoses. METHODS We prospectively identified candidate overuse metrics, each defined by the percentage of patients with a particular diagnosis who underwent a potentially unnecessary diagnostic test. We used data from seven states participating in the State Inpatient Databases. Candidate metrics were tested for temporal stability and internal consistency. Using mixed-effects ordinal regression and adjusting for regional and hospital characteristics, we compared results of our index with three Dartmouth health service area-level utilization metrics and three Medicare county-level cost metrics. RESULTS The index was comprised of five metrics with good temporal stability and internal consistency. It correlated with five of the six prespecified overuse measures. Among the Dartmouth metrics, our index correlated most closely with physician reimbursement, with an odds ratio of 2.02 (95% CI, 1.11-3.66) of being in a higher tertile of the overuse index when comparing tertiles 3 and 1 of this Dartmouth metric. Among the Medicare county-level metrics, our index correlated most closely with standardized costs of procedures per capita, with an odds ratio of 2.03 (95% CI, 1.21-3.39) of being in a higher overuse index tertile when comparing tertiles 3 and 1 of this metric. CONCLUSIONS We developed a novel overuse index that is preliminary in nature. This index is derived from readily available administrative data and shows some promise for measuring overuse of diagnostic testing at the hospital level.
Collapse
Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Corresponding Author: Michael I. Ellenbogen, MD; ; Telephone: 443-287-4362
| | - Laura Prichett
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Pamela T Johnson
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daniel J Brotman
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| |
Collapse
|
13
|
Kini V, Mosley B, Raghavan S, Khazanie P, Bradley SM, Magid DJ, Ho PM, Masoudi FA. Differences in High- and Low-Value Cardiovascular Testing by Health Insurance Provider. J Am Heart Assoc 2021; 10:e018877. [PMID: 33506684 PMCID: PMC7955432 DOI: 10.1161/jaha.120.018877] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline‐concordant testing between Medicaid versus commercial insurance patients <65 years, and between Medicare Advantage versus Medicare fee‐for‐service patients ≥65 years. Methods and Results Using data from the Colorado All‐Payer Claims Database from 2015 to 2018, we identified patients eligible to receive a high‐value test recommended by guidelines: assessment of left ventricular function among patients hospitalized with acute myocardial infarction or incident heart failure, or a low‐value test that provides minimal patient benefit: stress testing prior to low‐risk surgery or routine stress testing within 2 years of percutaneous coronary intervention or coronary artery bypass graft surgery. Among 145 616 eligible patients, 37% had fee‐for‐service Medicare, 18% Medicare Advantage, 22% Medicaid, and 23% commercial insurance. Using multilevel logistic regression models adjusted for patient characteristics, Medicaid patients were less likely to receive high‐value testing for acute myocardial infarction (odds ratio [OR], 0.84 [0.73–0.98]; P=0.03) and heart failure (OR, 0.59 [0.51–0.70]; P<0.01) compared with commercially insured patients. Medicare Advantage patients were more likely to receive high‐value testing for acute myocardial infarction (OR, 1.35 [1.15–1.59]; P<0.01) and less likely to receive low‐value testing after percutaneous coronary intervention/ coronary artery bypass graft (OR, 0.63 [0.55–0.72]; P<0.01) compared with Medicare fee‐for‐service patients. Conclusions Guideline‐concordant testing was less likely to occur among patients with Medicaid compared with commercial insurance, and more likely to occur among patients with Medicare Advantage compared with fee‐for‐service Medicare. Insurance plan features may provide valuable targets to improve guideline‐concordant testing.
Collapse
Affiliation(s)
- Vinay Kini
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | | | | | - Prateeti Khazanie
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis MN
| | - David J Magid
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | - P Michael Ho
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO.,Veterans Affairs Eastern Colorado Health Care System Aurora CO
| | - Frederick A Masoudi
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| |
Collapse
|
14
|
Natsui S, Sun BC, Shen E, Redberg RF, Ferencik M, Lee MS, Musigdilok V, Wu YL, Zheng C, Kawatkar AA, Sharp AL. Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes. Circ Cardiovasc Qual Outcomes 2021; 14:e006297. [PMID: 33430609 DOI: 10.1161/circoutcomes.119.006297] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events. METHODS We conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction. RESULTS Thirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%). CONCLUSIONS Wide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.
Collapse
Affiliation(s)
- Shaw Natsui
- National Clinician Scholars Program, University of California, Los Angeles (S.N.).,Department of Emergency Medicine. Los Angeles, CA (S.N.)
| | - Benjamin C Sun
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.C.S.)
| | - Ernest Shen
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Rita F Redberg
- Division of Cardiology, University of California, San Francisco (R.F.R.)
| | - Maros Ferencik
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland (M.F.)
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center (M.-S.L.)
| | - Visanee Musigdilok
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Yi-Lin Wu
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Chengyi Zheng
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Aniket A Kawatkar
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Adam L Sharp
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| |
Collapse
|
15
|
Leis B, Bare I, Marshall K, Buschau E, Penner L, Keith C, De Villiers JS, Orvold J. Reducing Unnecessary Noninvasive Testing for Inpatients With Unstable Angina: The RUNIT Protocol. CJC Open 2020; 3:516-523. [PMID: 34027356 PMCID: PMC8129432 DOI: 10.1016/j.cjco.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/05/2020] [Indexed: 11/16/2022] Open
Abstract
Background Routine inpatient transthoracic echocardiography (TTE) for patients with unstable angina is common, but it anecdotally adds little value to clinical care. A practice audit at our academic hospital demonstrated that 61.5% of patients with troponin-negative chest pain (TNCP) had normal left ventriculography (LVG) during coronary angiography and normal TTE on the same admission (duplicate testing). Methods We developed the Reducing Non-Invasive Testing (RUNIT) protocol, a clinical algorithm applied by clinical nurses to patient with TNCP. We performed a prospective assessment of rate of duplicate testing before and after intervention. If patients met certain simple clinical criteria, their TTE was cancelled (RUNIT positive). Patients then proceeded to have either coronary angiography with LVG or noninvasive risk stratification. We aimed to reduce duplicate testing by 25% over a 1-year period. Balancing measures included pathology on ordered TTEs, 30-day readmission, length of stay, and number of LVG. Results Among 254 patients admitted with TNCP over 12 months, we reduced duplicate testing from 61.5% (before intervention) to 34% (P = 0.001). There was no clinical difference in 30-day readmission (0.9% vs 0.7%), and length of stay was significantly shorter in RUNIT positive (3.48 vs 4.16 days, P = 0.02). The majority of duplicate TTEs did not reveal any management-informing pathology. RUNIT-positive patients underwent more LVG than RUNIT-negative patients (78.3% vs 62.8%, P = 0.008). Conclusion We achieved a sustained reduction in reflexive TTE ordering in patients with TNCP, and we discuss the potential of nursing-led interventions to address other areas of low value care in cardiology.
Collapse
Affiliation(s)
- Benjamin Leis
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Idris Bare
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kirsten Marshall
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Elise Buschau
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Penner
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Cassandra Keith
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - J S De Villiers
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Jason Orvold
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| |
Collapse
|
16
|
Chui PW, Esserman D, Bastian LA, Curtis JP, Gandhi PU, Rosman L, Desai N, Hauser RG. Facility Variation in Troponin Ordering Within the Veterans Health Administration. Med Care 2020; 58:1098-1104. [PMID: 33003051 PMCID: PMC7666100 DOI: 10.1097/mlr.0000000000001424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current United States guidelines recommend troponin as the preferred biomarker in assessing for acute coronary syndrome, but recommendations are limited about which patients to test. Variations in troponin ordering may influence downstream health care utilization. METHODS We performed a cross-sectional analysis of 3,308,131 emergency department (ED) visits in all 121 acute care facilities within the Veterans Health Administration from 2015 to 2017. We quantified the degree to which case mix and facility characteristics accounted for variations in facility rates in troponin ordering. We then assessed the association between facility quartiles of risk-adjusted troponin ordering and downstream resource utilization [inpatient admissions, noninvasive testing (stress tests, echocardiograms), and invasive procedures (coronary angiograms, percutaneous coronary interventions, and coronary artery bypass grafting surgeries)]. RESULTS The proportion of ED visits with troponin orders ranged from 2.2% to 64.5%, with a median of 37.1%. Case mix accounted for 9.5% of the variation in troponin orders; case mix and differences in facility characteristics accounted for 34.6%. Facilities in the highest quartile of troponin ordering, as compared with those in the lowest quartile, had significantly higher rates of inpatient admissions, stress tests, echocardiograms, coronary angiograms, and percutaneous coronary intervention. CONCLUSIONS Significant variation in troponin utilization exists across Veterans Health Administration facilities and that variation is not well explained by case mix alone. Facilities with higher rates of troponin ordering were associated with more downstream resource utilization.
Collapse
Affiliation(s)
- Philip W Chui
- Section of Cardiovascular Medicine, Department of Internal Medicine
| | - Denise Esserman
- School of Public Health, Yale University School of Medicine, New Haven, CT
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine
- Center for Outcomes Research and Evaluation, Yale New-Haven Hospital, New Haven, CT
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Department of Internal Medicine
| | - Lindsey Rosman
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nihar Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine
- Center for Outcomes Research and Evaluation, Yale New-Haven Hospital, New Haven, CT
| | - Ronald G Hauser
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
17
|
Kawatkar AA, Sharp AL, Baecker AS, Natsui S, Redberg RF, Lee MS, Ferencik M, Wu YL, Shen E, Zheng C, Musigdilok VV, Gould MK, Goodacre S, Thokala P, Sun BC. Early Noninvasive Cardiac Testing After Emergency Department Evaluation for Suspected Acute Coronary Syndrome. JAMA Intern Med 2020; 180:1621-1629. [PMID: 33031502 PMCID: PMC7536619 DOI: 10.1001/jamainternmed.2020.4325] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Professional guidelines recommend noninvasive cardiac testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI). OBJECTIVE To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive cardiac testing vs no testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge. EXPOSURES Noninvasive cardiac testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome. MAIN OUTCOMES AND MEASURES The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge. RESULTS A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin. CONCLUSIONS AND RELEVANCE Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.
Collapse
Affiliation(s)
- Aniket A Kawatkar
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Adam L Sharp
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Aileen S Baecker
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Shaw Natsui
- National Clinician Scholars Program, Department of Emergency Medicine, University of California, Los Angeles
| | - Rita F Redberg
- Division of Cardiology, Department of Medicine, School of Medicine, University of California, San Francisco.,Editor, JAMA Internal Medicine
| | - Ming-Sum Lee
- Division of Cardiology, Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland
| | - Yi-Lin Wu
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Ernest Shen
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Chengyi Zheng
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Visanee V Musigdilok
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Michael K Gould
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
| | - Steve Goodacre
- School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
| | - Praveen Thokala
- School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
| | - Benjamin C Sun
- Leonard Davis Institute of Health Economics, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
18
|
Stopyra JP, Snavely AC, Lenoir KM, Wells BJ, Herrington DM, Hiestand BC, Miller CD, Mahler SA. HEART Pathway Implementation Safely Reduces Hospitalizations at One Year in Patients With Acute Chest Pain. Ann Emerg Med 2020; 76:555-565. [PMID: 32736933 DOI: 10.1016/j.annemergmed.2020.05.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/14/2020] [Accepted: 05/27/2020] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE We determine whether implementation of the HEART (History, ECG, Age, Risk Factors, Troponin) Pathway is safe and effective in emergency department (ED) patients with possible acute coronary syndrome through 1 year of follow-up. METHODS A preplanned analysis of 1-year follow-up data from a prospective pre-post study of 8,474 adult ED patients with possible acute coronary syndrome from 3 US sites was conducted. Patients included were aged 21 years or older, evaluated for possible acute coronary syndrome, and without ST-segment elevation myocardial infarction. Accrual occurred for 12 months before and after HEART Pathway implementation, from November 2013 to January 2016. The HEART Pathway was integrated into the electronic health record at each site as an interactive clinical decision support tool. After integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or nonlow risk (appropriate for further inhospital evaluation). Safety (all-cause death and myocardial infarction) and effectiveness (hospitalization) at 1 year were determined from health records, insurance claims, and death index data. RESULTS Preimplementation and postimplementation cohorts included 3,713 and 4,761 patients, respectively. The HEART Pathway identified 30.7% of patients as low risk; 97.5% of them were free of death and myocardial infarction within 1 year. Hospitalization at 1 year was reduced by 7.0% in the postimplementation versus preimplementation cohort (62.1% versus 69.1%; adjusted odds ratio 0.70; 95% confidence interval 0.63 to 0.78). Rates of death or myocardial infarction at 1 year were similar (11.6% versus 12.4%; adjusted odds ratio 1.00; 95% confidence interval 0.87 to 1.16). CONCLUSION HEART Pathway implementation was associated with decreased hospitalizations and low adverse event rates among low-risk patients at 1-year follow-up.
Collapse
Affiliation(s)
- Jason P Stopyra
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Anna C Snavely
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kristin M Lenoir
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian J Wells
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - David M Herrington
- Internal Medicine, Division of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Chadwick D Miller
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Simon A Mahler
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC; Implementation Science and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
19
|
van Dongen DN, Tolsma RT, Fokkert MJ, Badings EA, van der Sluis A, Slingerland RJ, van 't Hof AW, van 't Riet E, Ottervanger JP. Referral decisions based on a prehospital HEART score in suspected non-ST-elevation acute coronary syndrome: design of the FamouS Triage 3 study. Future Cardiol 2020; 16:217-226. [PMID: 32551888 DOI: 10.2217/fca-2019-0030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: It is not yet investigated whether referral decisions based on prehospital risk stratification of non-ST-elevation Acute Coronary Syndrome (NSTE-ACS) by the complete History, ECG, Age, Risk factors and initial Troponin (HEART) score are feasible and safe. Hypothesis: Implementation of referral decisions based on the prehospital acquired HEART score in patients with suspected NSTE-ACS is feasible and not inferior to routine management in the occurrence of major adverse cardiac events within 45 days. Study design & methods: FamouS Triage 3 is a feasibility study with a before-after sequential design. The aim is to assess whether prehospital HEART-score management including point-of-care troponin measurement is feasible and noninferior to routine management. Primary end point is the occurrence of major adverse cardiac events within 45 days. Conclusion: If referral decisions based on prehospital acquired risk stratification are feasible and noninferior this can become the new prehospital management in suspected NSTE-ACS.
Collapse
Affiliation(s)
| | - Rudolf T Tolsma
- Regional Ambulance Service IJsselland, Zwolle, The Netherlands
| | - Marion J Fokkert
- Department of Clinical Chemistry, Isala Hospital, Zwolle, The Netherlands
| | - Erik A Badings
- Department of Cardiology, Deventer Hospital, Deventer, The Netherlands
| | | | | | - Arnoud Wj van 't Hof
- Department of Cardiology, MUMC, Maastricht, The Netherlands.,Department of Cardiology, Zuyderland MC, Heerlen, The Netherlands
| | - Esther van 't Riet
- Department of Research & Development, Deventer Hospital, Deventer, The Netherlands
| | | |
Collapse
|
20
|
Temporelli PL. Prevention after acute coronary syndrome the ‘less is more’ philosophy. Eur Heart J Suppl 2020; 22:E153-E156. [PMID: 32523461 PMCID: PMC7270904 DOI: 10.1093/eurheartj/suaa082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abstract
In the cardiology field, in recent years, we have witnessed an exponential increase in the use of both invasive and non-invasive instrument diagnostics. Particularly after an acute coronary syndrome, instrumental examinations, especially non-invasive ones, are often prescribed inappropriately until they almost completely replace the clinical evaluation. Their correct use, on the contrary, would require the choice of a test to be prescribed according to the epidemiological and clinical context of the individual patient. The strategy of early diagnosis, obtainable through instrumental screening and borrowed from oncological pathologies, was transferred ‘tout court’ in the cardiovascular field without any scientific basis, replacing the pharmacological or non-pharmacological intervention, such as the appropriate lifestyle, aimed at reducing cardiovascular risk factors. The guidelines of the main scientific societies define the most appropriate paths in the management of the coronary heart disease patients, both in the immediate post-acute phase and in the chronic phase. Although the guidelines sometimes show an excessive simplification of clinical problems, in an age in which the control of health expenditure has become a priority the correctness of the indications is an indispensable objective, being incontrovertible that a test is indicated only when an instrumental examination is able to modify the diagnostic-therapeutic path and the outcome of the patient.
Collapse
Affiliation(s)
- Pier Luigi Temporelli
- Divisione di Cardiologia, Istituti Clinici Scientifici Maugeri, IRCCS, Via Revislate 13, Veruno 28010, Italy
| |
Collapse
|
21
|
Safaee MM, Dalle Ore CL, Corso KA, Ruppenkamp JW, Lau D, Ames CP. Trends in Posterior Cervical Fusion for Deformity in the United States from 2000 to 2017. NEUROSURGERY OPEN 2020. [DOI: 10.1093/neuopn/okaa001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
BACKGROUND
Posterior cervical decompression and fusion (PCF) is a common treatment for cervical spondylotic myelopathy. Treatment paradigms are shifting from simple decompression and fusion to correcting cervical deformities.
OBJECTIVE
To identify trends in PCF with an emphasis on cervical deformity and surgical complexity.
METHODS
Adults who underwent PCF from 2000 to 2017 were retrospectively identified in the Premier Healthcare Database (PHD) using International Classification of Disease Codes (ICD) 9 and 10. Patients were dichotomized into those with or without deformity diagnosis. PCF complexity was defined by adjunct surgical codes, including anterior cervical fusion, extension to thoracic levels, and osteotomy. Patient characteristics, including demographics, functional comorbidity index (FCI), and hospital characteristics, were extracted and annual procedures were projected to the US population.
RESULTS
A total of 68 415 discharges for PCF were identified. Compound annual growth rate (CAGR) of PCF from 2000 to 2017 for nondeformity cases was 9.7% and 16.5% for deformity. The demographics with the greatest growth were deformity patients aged 65 to 74 yr (15.1%). The CAGR of anterior cervical fusion and extension to thoracic levels was higher for deformity patients compared to nondeformity patients, 13.6% versus 3.9% and 20.4% versus 16.6%, respectively.
CONCLUSION
Rates of PCF for deformity are increasing at a greater rate than nondeformity PCF. The most growth was seen among deformity patients aged 65 to 74 yr. Surgical complexity is also changing with increasing use of anterior cervical fusion and extension of PCF to include thoracic levels.
Collapse
Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Cecilia L Dalle Ore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Katherine A Corso
- Medical Device Epidemiology and Real World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Jill W Ruppenkamp
- Medical Device Epidemiology and Real World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Darryl Lau
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| |
Collapse
|
22
|
Rodriguez-Granillo GA, Nieman K, Carrascosa P, Campisi R, Ambrose JA. Anatomic or functional testing in stable patients with suspected CAD: contemporary role of cardiac CT in the ISCHEMIA trial era. Int J Cardiovasc Imaging 2020; 36:1351-1362. [PMID: 32180079 DOI: 10.1007/s10554-020-01815-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/07/2020] [Indexed: 11/30/2022]
Abstract
One of the foundations of the management of patients with suspected coronary artery disease (CAD) is to avoid unnecessary invasive coronary angiography (ICA) referrals. However, the diagnostic yield of ICA following abnormal conventional stress testing is low. The ability of ischemia testing to predict subsequent myocardial infarction and death is currently being challenged, and more than half of cardiac events among stable patients with suspected CAD occur in those with normal functional tests. The optimal management of patients with stable CAD remains controversial and ischemia-driven interventions, though improving anginal symptoms, have failed to reduce the risk of hard cardiovascular events. In this context, there is an ongoing debate whether the initial diagnostic test among patients with stable suspected CAD should be a functional test or coronary computed tomography angiography. Aside from considering the specific characteristics of individual patients and local availability and conditions, the choice of the initial test relates to whether the objective concerns its role as gatekeeper for ICA, prognosis, or treatment decision-making. Therefore, the aim of this review is to provide a contemporary overview of these issues and discuss the emerging role of CCTA as the upfront imaging tool for most patients with suspected CAD.
Collapse
Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, Instituto Medico Eneri, Clinica La Sagrada Familia, Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina. .,Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina.
| | - Koen Nieman
- Stanford University School of Medicine, Cardiovascular Institute, Stanford, CA, USA
| | - Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnostico Maipu, Buenos Aires, Argentina
| | - Roxana Campisi
- Department of Nuclear Medicine, Diagnostico Maipu, Buenos Aires, Argentina
| | - John A Ambrose
- Division of Cardiology, Department of Internal Medicine, University of California San Francisco-Fresno, Fresno, USA
| |
Collapse
|
23
|
Stepinska J, Lettino M, Ahrens I, Bueno H, Garcia-Castrillo L, Khoury A, Lancellotti P, Mueller C, Muenzel T, Oleksiak A, Petrino R, Guimenez MR, Zahger D, Vrints CJ, Halvorsen S, de Maria E, Lip GY, Rossini R, Claeys M, Huber K. Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:76-89. [PMID: 31958018 DOI: 10.1177/2048872619885346] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This paper provides an update on the European Society of Cardiology task force report on the management of chest pain. Its main purpose is to provide an update on the decision algorithms and diagnostic pathways to be used in the emergency department for the assessment and triage of patients with chest pain symptoms suggestive of acute coronary syndromes.
Collapse
Affiliation(s)
- Janina Stepinska
- Department of Intensive Cardiac Therapy, Institute of Cardiology, Poland
| | | | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Germany
| | - Hector Bueno
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain and Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain
| | | | - Abdo Khoury
- Department of Emergency Medicine and Critical Care Clinical Investigation Center, University Hospital of Besançon, France
| | | | - Christian Mueller
- Cardiovascular Research Institute, University Hospital of Basel, Switzerland
| | - Thomas Muenzel
- Universitätsmedizin Mainz, Zentrum für Kardiologie, Germany
| | - Anna Oleksiak
- Department of Intensive Cardiac Therapy, Institute of Cardiology, Poland
| | | | | | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Israel
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Tharmaratnam T, Bouck Z, Sivaswamy A, Wijeysundera HC, Chu C, Yin CX, Nesbitt GC, Edwards J, Yared K, Wong B, Weinerman A, Thavendiranathan P, Rakowski H, Dorian P, Anderson G, Austin PC, Dudzinski DM, Ko DT, Weiner RB, Bhatia RS. Association Between Physicians' Appropriate Use of Echocardiography and Subsequent Healthcare Use and Outcomes in Patients With Heart Failure. J Am Heart Assoc 2020; 9:e013360. [PMID: 31870231 PMCID: PMC6988149 DOI: 10.1161/jaha.119.013360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background There is little understanding of whether a physician's tendency to order an inappropriate cardiac service is associated with the use of other cardiac services and clinical outcomes in their patients with heart failure (HF). Methods and Results We conducted a secondary analysis of 35 Ontario‐based cardiologists who participated in the control arm of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial. Transthoracic echocardiograms, ordered during the trial, were classified as rarely appropriate (rA), appropriate, or maybe appropriate on the basis of the 2011 appropriate use criteria. Cardiologists were grouped into tertiles of rA transthoracic echocardiogram ordering frequency: low ordering (bottom tertile), n=11; moderate ordering, n=12; or high ordering (top tertile), n=12. The main outcomes were measures of cardiac service use, including cardiology‐related physician visits, tests, and medications. Among 1677 patients with heart failure and an outpatient visit to 1 of 35 cardiologists, we found no significant association between rA transthoracic echocardiogram ordering frequency (by tertile) and cardiac testing use, although patients of cardiologists in the high ordering group had fewer physician visits, on average, than patients seen by low ordering cardiologists. In addition, patients of cardiologists in the highest rA ordering tertile had significantly lower odds of receiving potentially effective interventions, such as β blockers (odds ratio, 0.62; 95% CI, 0.43–0.89), than the low ordering group. Conclusions Although patients of cardiologists who frequently order rA transthoracic echocardiograms do not appear more (or less) likely to have subsequent cardiac tests, these patients have fewer follow‐up visits and lower odds of receiving evidence‐based medications. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02038101.
Collapse
Affiliation(s)
- Tharmegan Tharmaratnam
- School of Medicine Royal College of Surgeons Ireland Dublin Ireland.,Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,Dalla Lana School of Public Health University of Toronto Ontario Canada
| | | | - Harindra C Wijeysundera
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Cherry Chu
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Cindy X Yin
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | | | - Jeremy Edwards
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Kibar Yared
- The Scarborough Hospital Toronto Ontario Canada
| | - Brian Wong
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Adina Weinerman
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | | | - Harry Rakowski
- Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
| | - Paul Dorian
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Geoff Anderson
- Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - Peter C Austin
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - David M Dudzinski
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - Dennis T Ko
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Rory B Weiner
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
| |
Collapse
|
25
|
Asher A, Ghelani R, Thornton G, Rathod K, Jones D, Wragg A, Timmis A. UK perspective on the changing landscape of non-invasive cardiac testing. Open Heart 2019; 6:e001186. [PMID: 31908814 PMCID: PMC6927513 DOI: 10.1136/openhrt-2019-001186] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 11/28/2022] Open
Abstract
Objective To document UK rates of exercise treadmill testing, functional stress testing and CT coronary angiography (CTCA). Specific aims were to determine how rates have changed in the context of changing guideline recommendations within the UK and to identify regional inequalities in the utilisation of testing modalities. Secondary objectives were to compare these trends with national data on revascularisation. Methods 159 acute National Health Service trusts were served Freedom of Information (FOI) requests to provide total numbers of CTCA and functional imaging tests for each financial year from 2011–2012 to 2016–2017. Results The FOI requests yielded data from 88% of Trusts, increasing from 81.9% in 2011–2012% to 92.1% in 2016–2017. Exercise treadmill tests (ETTs) were performed by over 97% of Trusts. ETT was the most commonly performed diagnostic test in the UK across the study period despite declining by 8.4%. Utilisation of non-invasive stress imaging tests increased by 80.9% during the same period. Myocardial perfusion scintigraphy and stress echocardiography increased by 25.8% and 73.9%, respectively. The 268% increase in CTCA scans was yet greater. Trends in test utilisation during the study period showed important regional differences between devolved nations. Comparably, only small changes in rates of invasive coronary angiography and revascularisation have been reported during the study period. Conclusion Non-invasive imaging in UK Trusts has increased substantially since 2010 with only a small decline in use of the ETT and minimal changes in rates of invasive coronary angiography and revascularisation in the same time period.
Collapse
Affiliation(s)
- Alex Asher
- Cardiology, Barts Health NHS Trust, London, UK
| | | | | | | | - Daniel Jones
- Cardiology, Barts Health NHS Trust, London, UK.,Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK
| | - Andrew Wragg
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK.,Cardiology, Barts Health NHS Trust, London, UK
| | - Adam Timmis
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK.,Cardiology, Barts Health NHS Trust, London, UK
| |
Collapse
|
26
|
van Dongen DN, Ottervanger JP, Tolsma R, Fokkert M, van der Sluis A, van 't Hof AWJ, Badings E, Slingerland RJ. In-Hospital Healthcare Utilization, Outcomes, and Costs in Pre-Hospital-Adjudicated Low-Risk Chest-Pain Patients. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:875-882. [PMID: 31388939 DOI: 10.1007/s40258-019-00502-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
BACKGROUND There is increasing evidence that in patients presenting with acute chest pain, pre-hospital triage can accurately identify low-risk patients. It is, however, still unclear which diagnostics are performed in pre-hospital-adjudicated low-risk patients and what the contribution is of those diagnostic results in the healthcare process. OBJECTIVES The aim of this study was to quantify healthcare utilization, costs, and outcomes in pre-hospital-adjudicated low-risk chest-pain patients, and to extrapolate to total costs in the Netherlands. METHODS This was a prospective cohort study including 700 patients with suspected non-ST-elevation acute coronary syndrome in which pre-hospital risk stratification using the HEART score was performed by paramedics. Low risk was defined as a pre-hospital HEART score ≤ 3. Data on (results of) hospital diagnostics, costs, and discharge diagnosis were collected. RESULTS A total of 172 (25%) patients were considered as low risk. Of these low-risk patients, the mean age was 54 years, 52% were male, and 84% of patients were discharged within 12 h. Repeated electrocardiography and routine laboratory measurements, including cardiac markers, were performed in all patients. Chest X-ray was performed in 61% and echocardiography in 11% of patients. After additional diagnostics, two patients (1.2%) were diagnosed as non-ST-elevation myocardial infarction and two patients (1.2%) as unstable angina. Other diagnoses were atrial fibrillation (n = 1) and acute pancreatitis/cholecystitis (n = 2); all other patients had non-specific/non-acute discharge diagnoses. Mean in-hospital costs per patient were €1580. The estimated yearly acute healthcare cost in low-risk chest-pain patients in the Netherlands is €30,438,700. CONCLUSION In low-risk chest-pain patients according to pre-hospital risk assessment, acute healthcare utilization and costs are high, with limited added value. Possibly, if a complete risk assessment can be performed by ambulance paramedics, acute hospitalization of the majority of low-risk patients is not necessary, which can lead to substantial cost reduction. TRIAL ID Dutch Trial Register [http://www.trialregister.nl]: trial number 4205.
Collapse
Affiliation(s)
- Dominique N van Dongen
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Rudolf Tolsma
- Regional Ambulance Service IJsselland, Zwolle, The Netherlands
| | - Marion Fokkert
- Department of Clinical Chemistry, Isala Hospital, Zwolle, The Netherlands
| | | | - Arnoud W J van 't Hof
- Zuyderland MC, Heerlen, The Netherlands
- Department of Cardiology, MUMC, Maastricht, The Netherlands
| | - Erik Badings
- Department of Cardiology, Deventer Hospital, Deventer, The Netherlands
| | | |
Collapse
|
27
|
Tharmaratnam T, Bouck Z, Sivaswamy A, Wijeysundera HC, Chu C, Yin CX, Nesbitt GC, Edwards J, Yared K, Wong B, Weinerman A, Thavendiranathan P, Rakowski H, Dorian P, Anderson G, Austin PC, Dudzinski DM, Ko DT, Weiner RB, Bhatia RS. Low-Value Transthoracic Echocardiography, Healthcare Utilization, and Clinical Outcomes in Patients With Coronary Artery Disease. Circ Cardiovasc Qual Outcomes 2019; 12:e006123. [PMID: 31707824 DOI: 10.1161/circoutcomes.119.006123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes. METHODS AND RESULTS A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65-0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66-0.94]); β-blocker prescription (OR, 0.70 [95% CI, 0.55-0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22-0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04-2.28]), although all other outcomes were similar. CONCLUSIONS Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02038101.
Collapse
Affiliation(s)
- Tharmegan Tharmaratnam
- School of Medicine, Royal College of Surgeons in Ireland, Dublin (T.T.).,Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.)
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.).,Dalla Lana School of Public Health (Z.B.), University of Toronto, ON, Canada
| | - Atul Sivaswamy
- Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.)
| | - Harindra C Wijeysundera
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre (H.C.W., D.T.K.), University of Toronto, ON, Canada.,Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.).,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | - Cherry Chu
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.)
| | - Cindy X Yin
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.)
| | - Gillian C Nesbitt
- Cardiology Division, Mount Sinai Hospital, Toronto, ON, Canada (G.C.N.)
| | - Jeremy Edwards
- Division of Cardiology, St. Michael's Hospital, Toronto, ON, Canada (J.E., P.D.)
| | - Kibar Yared
- Department of Cardiology, The Scarborough Hospital, Toronto, ON, Canada (K.Y.)
| | - Brian Wong
- Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | - Adina Weinerman
- Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | | | - Harry Rakowski
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (P.T., H.R., R.S.B.)
| | - Paul Dorian
- Division of Cardiology, St. Michael's Hospital, Toronto, ON, Canada (J.E., P.D.)
| | - Geoff Anderson
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada
| | - Peter C Austin
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.)
| | - David M Dudzinski
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States (D.M.D, R.B.W.)
| | - Dennis T Ko
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre (H.C.W., D.T.K.), University of Toronto, ON, Canada.,Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.).,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | - Rory B Weiner
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States (D.M.D, R.B.W.)
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.).,Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.).,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (P.T., H.R., R.S.B.)
| |
Collapse
|
28
|
Abstract
OBJECTIVE We examined low risk (LR) patients admitted to our chest pain unit (CPU) with negative cardiac injury markers, normal electrocardiogram, and clinical stability. We hypothesized that there is a sub-group of intermediate risk (IR) patients within the larger LR population. METHODS Criteria for IR were the aforementioned 3 indicators of LR and ≥1 of the following: (1) known coronary artery disease (CAD), (2) men ≥45 yo, women ≥55 yo, and (3) ≥3 cardiac risk factors. We compared patient characteristics, use of pre-discharge testing (PDT), and major adverse cardiac events (MACE). RESULTS IR patients numbered 371, whereas LR patients totaled 70. IR patients were older (61 vs 46 years), more had known CAD (28 vs. 0%), had a higher median number of risk factors (2 vs. 1) and were less likely to be women (49 vs. 81%), all P < 0.0001. IR patients received a greater median number of tests compared with LR patients (1 vs. 0, P < 0.0001). CONCLUSIONS Among the IR group, 16 patients (4%) had a cardiac event at the index CPU visit, 2 (0.5%) experienced MACE at 30-day follow-up, and 2 (0.5%) had MACE at 6 months follow-up. No LR patients had MACE at any point in the study. Thus, the majority of CPU patients are IR, have more risk factors than LR group, and are more likely to receive PDT. IR patients were managed safely in a CPU, while maintaining low rates of MACE post-discharge.
Collapse
|
29
|
Kini V, Viragh T, Magid D, Masoudi FA, Moghtaderi A, Black B. Trends in High- and Low-Value Cardiovascular Diagnostic Testing in Fee-for-Service Medicare, 2000-2016. JAMA Netw Open 2019; 2:e1913070. [PMID: 31603486 PMCID: PMC6804029 DOI: 10.1001/jamanetworkopen.2019.13070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Owing to a rapid increase in rates of diagnostic cardiovascular testing in the 1990s and early 2000s, the Centers for Medicare & Medicaid Services implemented a series of payment changes intended to reduce overall spending on fee-for-service testing. Whether guideline-concordant testing has been subsequently affected is unknown to date. OBJECTIVE To determine whether changes in overall rates of use of diagnostic cardiovascular tests were associated with changes in high-value testing recommended by guidelines and low-value testing that is expected to provide minimal benefits. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed a national 5% random sample of Medicare fee-for-service beneficiaries aged 65 to 95 years from January 1, 1999, through December 31, 2016. Data were analyzed from February 15, 2018, through August 15, 2019. EXPOSURES Eligibility to receive high-value testing (assessment of left ventricular systolic function among patients hospitalized with acute myocardial infarction or heart failure) and low-value testing (stress testing before low-risk noncardiac surgery and routine stress testing within 2 years of coronary revascularization not associated with acute care visits). MAIN OUTCOMES AND MEASURES Age- and sex-adjusted annual rates of overall, high-value, and low-value diagnostic cardiovascular testing. RESULTS Mean (SD) age was similar over time (75.57 [7.32] years in 2000-2003; 74.82 [7.79] years in 2012-2016); the proportion of women slightly declined over time (63.23% in 2000 to 2003; 57.27% in 2012 to 2016). The rate of overall diagnostic cardiovascular testing per 1000 patient-years among the 5% sample of Medicare beneficiaries increased from 275 in 2000 to 359 in 2008 (P < .001) and then declined to 316 in 2016 (P < .001). High-value testing increased steadily over the entire study period for patients with acute myocardial infarction (85.7% to 89.5%; P < .001) and heart failure (72.6% to 80.1%; P < .001). Low-value testing among patients undergoing low-risk surgery increased from 2.4% in 2000 to 3.8% in 2008 (P < .001) but then declined to 2.5% in 2016 (P < .001). Low-value testing within 2 years of coronary revascularization slightly increased from 47.4% in 2000 to 49.2% in 2003 (P = .03) but then declined to 30.8% in 2014 (P < .001). CONCLUSIONS AND RELEVANCE Rates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably and rates of high-value testing have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines.
Collapse
Affiliation(s)
- Vinay Kini
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Timea Viragh
- Northwestern University School of Education and Social Policy, Evanston, Illinois
| | - David Magid
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Frederick A. Masoudi
- Department of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
| | - Ali Moghtaderi
- George Washington University School of Public Health, Washington, DC
| | - Bernard Black
- Institute for Policy Research and Kellogg School of Management, Northwestern University Pritzker School of Law, Chicago, Illinois
| |
Collapse
|
30
|
Booth J, Thomas JJ. Provocative testing for low-risk chest pain patients, must we continue? J Nucl Cardiol 2019; 26:1647-1649. [PMID: 29417415 DOI: 10.1007/s12350-018-1202-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 10/18/2022]
Affiliation(s)
- James Booth
- Emergency Medicine, UAB Health System, Birmingham, AL, USA
| | | |
Collapse
|
31
|
Pack QR, Priya A, Lagu T, Pekow PS, Schilling JP, Hiser WL, Lindenauer PK. Association Between Inpatient Echocardiography Use and Outcomes in Adult Patients With Acute Myocardial Infarction. JAMA Intern Med 2019; 179:1176-1185. [PMID: 31206134 PMCID: PMC6580445 DOI: 10.1001/jamainternmed.2019.1051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes. OBJECTIVE To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019. EXPOSURES Rates of transthoracic echocardiography. MAIN OUTCOMES AND MEASURES Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate. RESULTS Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P < .001) per admission compared with hospitals in the lowest quartile of use. Multiple sensitivity analyses yielded similar results. CONCLUSIONS AND RELEVANCE In patients with AMI, hospitals in the quartile with the highest rates of echocardiography showed greater hospital costs and length of stay but few differences in clinical outcomes compared with hospitals in the quartile with the lowest rates of echocardiography. These findings suggest that more selective use of echocardiography might be used without adversely affecting clinical outcomes, particularly in hospitals with high rates of echocardiography use.
Collapse
Affiliation(s)
- Quinn R Pack
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield.,Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Aruna Priya
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield
| | - Tara Lagu
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Penelope S Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Joshua P Schilling
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - William L Hiser
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| |
Collapse
|
32
|
Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. J Am Coll Cardiol 2019; 71:606-616. [PMID: 29420956 DOI: 10.1016/j.jacc.2017.11.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/30/2017] [Accepted: 11/27/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1%) for major adverse cardiac events (MACE). OBJECTIVES The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates. METHODS The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs. RESULTS A total of 118,822 patients with possible ACS were included. The 3 risk scores' accuracies were optimized using the lower limit of cTnI quantitation (<0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p < 0.0001). CONCLUSIONS Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.
Collapse
|
33
|
Shaw LJ, Blankstein R, Brown DL, Dhruva SS, Douglas PS, Genders TS, Gibbons RJ, Greenwood JP, Kwong R, Leipsic J, Mahmarian JJ, Maron D, Nagel E, Nicol E, Nieman K, Pellikka PA, Redberg RF, Weir-McCall J, Williams MC, Chandrasekhar Y. Controversies in Diagnostic Imaging of Patients With Suspected Stable and Acute Chest Pain Syndromes. JACC Cardiovasc Imaging 2019; 12:1254-1278. [DOI: 10.1016/j.jcmg.2019.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/21/2022]
|
34
|
Usefulness of Predischarge Cardiac Testing in Low Risk Women and Men for Safe, Rapid Discharge from a Chest Pain Unit. Am J Cardiol 2019; 123:1772-1775. [PMID: 30954206 DOI: 10.1016/j.amjcard.2019.02.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 12/25/2022]
Abstract
Predischarge cardiac testing (PDT) in low-risk patients evaluated for acute coronary syndrome in a chest pain unit (CPU) remains a challenge. It is unclear whether PDT varies by gender. We analyzed consecutive low-risk women and men evaluated in our CPU over a 2-year period and compared the utilization of PDT (exercise treadmill test, myocardial stress perfusion scintigraphy, exercise stress echocardiography, invasive coronary angiography, or no test), and incidence of major adverse cardiac events (MACE) at 30 days and 6 months. The study group comprised 619 patients (54% women). A large proportion of both genders did not undergo PDT, although this finding was more frequent in women (50% women vs 40% men, p = 0.01). At 30 days, there were no MACE in either gender. After 6 months of follow-up, MACE remained very low in both women and men (2 [1%] vs 2 [1%]), and in patients who did and did not receive PDT (2 [1%] vs 2 [1%]). Mean length of stay in the CPU was 5.4 hours in patients without PDT and 9.8 hours in those with PDT (p <0.0001) without altering postdischarge MACE. When referred for PDT, women more often underwent myocardial stress perfusion scintigraphy than men (22% vs 14%, p = 0.005) and less often received exercise treadmill test (20% vs 39%, p <0.0001). Yield of abnormal PDT was low in both women and men although it was lower in women (1% vs 5%, p = 0.02). In conclusion, many low-risk women and men evaluated in a CPU for acute coronary syndrome can be safely and rapidly discharged without PDT and with low risk for MACE at 30 days and at 6 months. Exclusion of PDT was associated with significantly reduced length of stay while maintaining safety in terms of postdischarge MACE.
Collapse
|
35
|
Sandoval GA, Brown AD, Wodchis WP, Anderson GM. The relationship between hospital adoption and use of high technology medical imaging and in-patient mortality and length of stay. J Health Organ Manag 2019; 33:286-303. [PMID: 31122120 DOI: 10.1108/jhom-08-2018-0232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to investigate the relationship between hospital adoption and use of computed tomography (CT) scanners, and magnetic resonance imaging (MRI) machines and in-patient mortality and length of stay. DESIGN/METHODOLOGY/APPROACH This study used panel data (2007-2010) from 124 hospital corporations operating in Ontario, Canada. Imaging use focused on medical patients accounting for 25 percent of hospital discharges. Main outcomes were in-hospital mortality rates and average length of stay. A model for each outcome-technology combination was built, and controlled for hospital structural characteristics, market factors and patient characteristics. FINDINGS In 2010, 36 and 59 percent of hospitals had adopted MRI machines and CT scanners, respectively. Approximately 23.5 percent of patients received CT scans and 3.5 percent received MRI scans during the study period. Adoption of these technologies was associated with reductions of up to 1.1 percent in mortality rates and up to 4.5 percent in length of stay. The imaging use-mortality relationship was non-linear and varied by technology penetration within hospitals. For CT, imaging use reduced mortality until use reached 19 percent in hospitals with one scanner and 28 percent in hospitals with 2+ scanners. For MRI, imaging use was largely associated with decreased mortality. The use of CT scanners also increased length of stay linearly regardless of technology penetration (4.6 percent for every 10 percent increase in use). Adoption and use of MRI was not associated with length of stay. RESEARCH LIMITATIONS/IMPLICATIONS These results suggest that there may be some unnecessary use of imaging, particularly in small hospitals where imaging is contracted out. In larger hospitals, the results highlight the need to further investigate the use of imaging beyond certain thresholds. Independent of the rate of imaging use, the results also indicate that the presence of CT and MRI devices within a hospital benefits quality and efficiency. ORIGINALITY/VALUE To the authors' knowledge, this study is the first to investigate the combined effect of adoption and use of medical imaging on outcomes specific to CT scanners and MRI machines in the context of hospital in-patient care.
Collapse
Affiliation(s)
- Guillermo A Sandoval
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Adalsteinn D Brown
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Geoffrey M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| |
Collapse
|
36
|
Pack QR, Priya A, Lagu TC, Pekow PS, Schilling JP, Hiser WL, Lindenauer PK. Inpatient Echocardiography Use for Common Cardiovascular Conditions. Circulation 2019; 137:1745-1747. [PMID: 29661954 DOI: 10.1161/circulationaha.117.032256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Quinn R Pack
- Division of Cardiovascular Medicine (Q.R.P., J.P.S., W.L.H.) .,Institute for Healthcare Delivery and Population Science and Department of Medicine (Q.R.P., A.P., T.C.L., J.P.S., W.L.H., P.K.L.).,Unversity of Massachusetts Medical School at Baystate, Springfield (Q.R.P., T.C.L., P.K.L.)
| | - Aruna Priya
- Institute for Healthcare Delivery and Population Science and Department of Medicine (Q.R.P., A.P., T.C.L., J.P.S., W.L.H., P.K.L.)
| | - Tara C Lagu
- Institute for Healthcare Delivery and Population Science and Department of Medicine (Q.R.P., A.P., T.C.L., J.P.S., W.L.H., P.K.L.).,Baystate Medical Center, Springfield, MA. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (T.C.L., P.K.L.).,Unversity of Massachusetts Medical School at Baystate, Springfield (Q.R.P., T.C.L., P.K.L.)
| | - Penelope S Pekow
- School of Public Health and Health Sciences, University of Massachusetts, Amherst (P.S.P.)
| | - Joshua P Schilling
- Division of Cardiovascular Medicine (Q.R.P., J.P.S., W.L.H.).,Institute for Healthcare Delivery and Population Science and Department of Medicine (Q.R.P., A.P., T.C.L., J.P.S., W.L.H., P.K.L.)
| | - William L Hiser
- Division of Cardiovascular Medicine (Q.R.P., J.P.S., W.L.H.).,Institute for Healthcare Delivery and Population Science and Department of Medicine (Q.R.P., A.P., T.C.L., J.P.S., W.L.H., P.K.L.)
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine (Q.R.P., A.P., T.C.L., J.P.S., W.L.H., P.K.L.).,Baystate Medical Center, Springfield, MA. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (T.C.L., P.K.L.).,Unversity of Massachusetts Medical School at Baystate, Springfield (Q.R.P., T.C.L., P.K.L.)
| |
Collapse
|
37
|
Natsui S, Sun BC, Shen E, Wu YL, Redberg RF, Lee MS, Ferencik M, Zheng C, Kawatkar AA, Gould MK, Sharp AL. Evaluation of Outpatient Cardiac Stress Testing After Emergency Department Encounters for Suspected Acute Coronary Syndrome. Ann Emerg Med 2019; 74:216-223. [PMID: 30955986 DOI: 10.1016/j.annemergmed.2019.01.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Professional guidelines recommend 72-hour cardiac stress testing after an emergency department (ED) evaluation for possible acute coronary syndrome. There are limited data on actual compliance rates and effect on patient outcomes. Our aim is to describe rates of completion of noninvasive cardiac stress testing and associated 30-day major adverse cardiac events. METHODS We conducted a retrospective analysis of ED encounters from June 2015 to June 2017 across 13 community EDs within an integrated health system in Southern California. The study population included all adults with a chest pain diagnosis, troponin value, and discharge with an order for an outpatient cardiac stress test. The primary outcome was the proportion of patients who completed an outpatient stress test within the recommended 3 days, 4 to 30 days, or not at all. Secondary analysis described the 30-day incidence of major adverse cardiac events. RESULTS During the study period, 24,459 patients presented with a chest pain evaluation requiring troponin analysis and stress test ordering from the ED. Of these, we studied the 7,988 patients who were discharged home to complete diagnostic testing, having been deemed appropriate by the treating clinicians for an outpatient stress test. The stress test completion rate was 31.3% within 3 days and 58.7% between 4 and 30 days, and 10.0% of patients did not complete the ordered test. The 30-day rates of major adverse cardiac events were low (death 0.0%, acute myocardial infarction 0.7%, and revascularization 0.3%). Rapid receipt of stress testing was not associated with improved 30-day major adverse cardiac events (odds ratio 0.92; 95% confidence interval 0.55 to 1.54). CONCLUSION Less than one third of patients completed outpatient stress testing within the guideline-recommended 3 days after initial evaluation. More important, the low adverse event rates suggest that selective outpatient stress testing is safe. In this cohort of patients selected for outpatient cardiac stress testing in a well-integrated health system, there does not appear to be any associated benefit of stress testing within 3 days, nor within 30 days, compared with those who never received testing at all. The lack of benefit of obtaining timely testing, in combination with low rates of objective adverse events, may warrant reassessment of the current guidelines.
Collapse
Affiliation(s)
- Shaw Natsui
- National Clinician Scholars Program, Department of Emergency Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Benjamin C Sun
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ernest Shen
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Yi-Lin Wu
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Rita F Redberg
- Division of Cardiology, University of California, San Francisco, San Francisco, CA
| | - Ming-Sum Lee
- Division of Cardiology, Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CA
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Chengyi Zheng
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Aniket A Kawatkar
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Michael K Gould
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Adam L Sharp
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA.
| |
Collapse
|
38
|
Nuti SV, Li SX, Xu X, Ott LS, Lagu T, Desai NR, Murugiah K, Duan M, Martin J, Kim N, Krumholz HM. Association of in-hospital resource utilization with post-acute spending in Medicare beneficiaries hospitalized for acute myocardial infarction: a cross-sectional study. BMC Health Serv Res 2019; 19:190. [PMID: 30909904 PMCID: PMC6432744 DOI: 10.1186/s12913-019-4018-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 03/18/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Efforts to decrease hospitalization costs could increase post-acute care costs. This effect could undermine initiatives to reduce overall episode costs and have implications for the design of health care under alternative payment models. METHODS Among Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with acute myocardial infarction (AMI) between July 2010 and June 2013 in the Premier Healthcare Database, we studied the association of in-hospital and post-acute care resource utilization and outcomes by in-hospital cost tertiles. RESULTS Among patients with AMI at 326 hospitals, the median (range) of each hospital's mean per-patient in-hospital risk-standardized cost (RSC) for the low, medium, and high cost tertiles were $16,257 ($13,097-$17,648), $18,544 ($17,663-$19,875), and $21,831 ($19,923-$31,296), respectively. There was no difference in the median (IQR) of risk-standardized post-acute payments across cost-tertiles: $5014 (4295-6051), $4980 (4349-5931) and $4922 (4056-5457) for the low (n = 90), medium (n = 98), and high (n = 86) in-hospital RSC tertiles (p = 0.21), respectively. In-hospital and 30-day mortality rates did not differ significantly across the in-hospital RSC tertiles; however, 30-day readmission rates were higher at hospitals with higher in-hospital RSCs: median = 17.5, 17.8, and 18.0% at low, medium, and high in-hospital RSC tertiles, respectively (p = 0.005 for test of trend across tertiles). CONCLUSIONS In our study of patients hospitalized with AMI, greater resource utilization during the hospitalization was not associated with meaningful differences in costs or mortality during the post-acute period. These findings suggest that it may be possible for higher cost hospitals to improve efficiency in care without increasing post-acute care utilization or worsening outcomes.
Collapse
Affiliation(s)
- Sudhakar V. Nuti
- Yale School of Medicine, 333 Cedar Street, New Haven, CT 06516 USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510 USA
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510 USA
| | - Xiao Xu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510 USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, 310 Cedar Street, LSOG 205B, New Haven, CT 06510 USA
| | - Lesli S. Ott
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510 USA
- Present address: Remedy Partners, 1120 Boston Post Road, Suite 3, Darien, CT 06820 USA
| | - Tara Lagu
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA USA
- Department of Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199 USA
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510 USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 789 Howard Avenue, FMP 330, New Haven, CT 06520 USA
| | - Karthik Murugiah
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510 USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 789 Howard Avenue, FMP 330, New Haven, CT 06520 USA
| | - Michael Duan
- Premier, Inc, 13034 Ballantyne Corporate Place, Charlotte, NC 28277 USA
| | - John Martin
- Premier, Inc, 13034 Ballantyne Corporate Place, Charlotte, NC 28277 USA
| | - Nancy Kim
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520 USA
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510 USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 789 Howard Avenue, FMP 330, New Haven, CT 06520 USA
- Department of Health Policy and Management, Yale School of Public Health, 60 College Street, New Haven, CT USA
| |
Collapse
|
39
|
Kumamaru KK, Kumamaru H, Yasunaga H, Matsui H, Omiya T, Hori M, Suzuki M, Wada A, Kamagata K, Takamura T, Irie R, Nakanishi A, Aoki S. Large hospital variation in the utilization of Post-procedural CT to detect pulmonary embolism/Deep Vein Thrombosis in Patients Undergoing Total Knee or Hip Replacement Surgery: Japanese Nationwide Diagnosis Procedure Combination Database Study. Br J Radiol 2019; 92:20180825. [PMID: 30835500 DOI: 10.1259/bjr.20180825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The purpose of the study was to investigate variation in the use of in-hospital CT for venous thromboembolism (VTE) detection after total knee or hip replacement (TKR/THR) among surgical patients, using a nationwide Japanese in-hospital administrative database. METHODS This retrospective study using a national administrative database (4/2012-3/2013) extracted patients who underwent TKR/THR surgeries at hospitals meeting the annual case-volume threshold of ≥ 30. Hospitals were categorized into three equally sized groups by frequency of postoperative CT use (low, middle, and high CT use group) to compare baseline patient-level and hospital-level characteristics. To further investigate between-hospital variation in CT usage, we fitted a hierarchical logistic regression model including hospital-specific random intercepts and fixed patient- and hospital-level effects. The intra class correlation coefficient was used to measure the amount of variability in CT use attributable to between-hospital variation. RESULTS A total of 39,127 patients discharged from 447 hospitals met the inclusion criteria. The median hospital stay was 25 days (interquartile range, 20 - 32) and 7,599 (19.4%) patients underwent CT for VTE. CT utilization varied greatly among the hospitals; the crude frequency ranged from 0 to 100 % (median, 7.3 %; interquartile range, 1.8 - 18.3 %). After adjustment for known hospital- and patient-level factors related to CT use, 47 % of the variation in CT use remained attributable to the behavior of individual hospitals. CONCLUSION We observed large inter hospital variability in the utilization of post-procedure CT for VTE detection in this Japanese TKR/THR cohort, suggesting that CT utilization is not optimized across the nation. ADVANCES IN KNOWLEDGE We observed significant variability in the utilization of post-procedure CT for VTE detection among inpatients who underwent TKR/THR surgeries in a large sample of Japanese hospitals. The large variation suggests that CT utilization is not optimized across the nation, and that there may be potential overutilization of the technology in the highest CT use hospitals.
Collapse
Affiliation(s)
| | - Hiraku Kumamaru
- 2 Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo , Tokyo , Japan
| | - Hideo Yasunaga
- 3 Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo , Japan
| | - Hiroki Matsui
- 3 Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo , Japan
| | - Toshinobu Omiya
- 4 Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo , Japan
| | - Masaaki Hori
- 1 Department of Radiology, Juntendo University , Tokyo , Japan
| | | | - Akihiko Wada
- 1 Department of Radiology, Juntendo University , Tokyo , Japan
| | - Koji Kamagata
- 1 Department of Radiology, Juntendo University , Tokyo , Japan
| | | | - Ryusuke Irie
- 1 Department of Radiology, Juntendo University , Tokyo , Japan
| | | | - Shigeki Aoki
- 1 Department of Radiology, Juntendo University , Tokyo , Japan
| |
Collapse
|
40
|
Lavenburg P, Cantor G, Agunloye O, Bhagat A, Taub E, Teressa G. Diagnostic and Prognostic Role of the Modified Diamond-Forrester Model in Combination With Coronary Calcium Score in Acute Chest Pain Patients. Crit Pathw Cardiol 2019; 18:32-39. [PMID: 30747763 DOI: 10.1097/hpc.0000000000000167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The aim of this study was to evaluate whether pretest probability (PTP) assessment using the Diamond-Forrester Model (DFM) combined with coronary calcium scoring (CCS) can safely rule out obstructive coronary artery disease (CAD) and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients. METHODS We retrospectively evaluated consecutive patients, age ≥18 years, with no known CAD, negative initial electrocardiogram, and troponin level. All patients had coronary computed tomographic angiography (CCTA) with CCS, and our final cohort consisted of 1988 patients. Obstructive CAD was defined as luminal narrowing of ≥50% in 1 or more vessels by CCTA. Patients were classified according to PTP as low (<10%), intermediate (10%-90%), or high (>90%). RESULTS The DFM classified 293 (14.7%), 1445 (72.7%), and 250 (12.6%) of patients as low, intermediate, and high risk, respectively, with corresponding 30-day MACE rates of 0.0%, 2.35%, and 14.8%. For patients with intermediate PTP and CCS ≤10, the negative predictive value was 99.2% (95% confidence interval: 98.7-99.8) for 30-day MACE while it was 92.62% (95% confidence interval: 87.9-97.3) for patients with high PTP. Among patients with a high PTP and CCS of zero, the prevalence of 30-day MACE and obstructive CAD remained high (7.07% and 10.1%, respectively). CONCLUSIONS In acute chest pain patients without evidence of ischemia on initial electrocardiogram and cardiac troponin, low PTP by DFM or the combination of intermediate PTP and CCS ≤10 had excellent negative predictive values to rule out 30-day MACE. CCS is not sufficient to exclude obstructive CAD and 30-day MACE in patients with high PTP.
Collapse
Affiliation(s)
- Philip Lavenburg
- From the Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Gregg Cantor
- From the Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Olufunmilayo Agunloye
- From the Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Aditi Bhagat
- From the Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Erin Taub
- From the Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Getu Teressa
- From the Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY
| |
Collapse
|
41
|
Sharp AL, Baecker AS, Shen E, Redberg R, Lee MS, Ferencik M, Natsui S, Zheng C, Kawatkar A, Gould MK, Sun BC. Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System. Ann Emerg Med 2019; 74:171-180. [PMID: 30797573 DOI: 10.1016/j.annemergmed.2019.01.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/17/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs). METHODS We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable. RESULTS A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39% (95% CI 3.72% to 5.07%) after 12 months' follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08). CONCLUSION Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.
Collapse
Affiliation(s)
- Adam L Sharp
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA.
| | - Aileen S Baecker
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Ernest Shen
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Rita Redberg
- University of California, San Francisco, Department of Cardiology, San Francisco, CA
| | - Ming-Sum Lee
- Los Angeles Medical Center, Division of Cardiology, Kaiser Permanente Southern California, Los Angeles, CA
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, OR
| | - Shaw Natsui
- University of California, Los Angeles, Department of Emergency Medicine, Los Angeles, CA
| | - Chengyi Zheng
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Aniket Kawatkar
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Michael K Gould
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Sciences University, Portland, OR
| |
Collapse
|
42
|
Stopyra JP, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, Herrington DM, Burke GL, Miller CD, Mahler SA. The HEART Pathway Randomized Controlled Trial One-year Outcomes. Acad Emerg Med 2019; 26:41-50. [PMID: 29920834 DOI: 10.1111/acem.13504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain. METHODS Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE-cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests. RESULTS A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low-risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%-100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac-related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36). CONCLUSIONS The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.
Collapse
Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Robert F. Riley
- The Christ Hospital Heart and Vascular Center and Lindner Center for Research and Education Cincinnati OH
| | - Brian C. Hiestand
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Gregory B. Russell
- Department of Biostatistical Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - James W. Hoekstra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Cedric W. Lefebvre
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Bret A. Nicks
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - David M. Cline
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Kim L. Askew
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Stephanie B. Elliott
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - David M. Herrington
- Department of Biostatistical Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - Gregory L. Burke
- Department of Internal Medicine Division of Cardiology Wake Forest School of Medicine Winston‐Salem NC
- Public Health Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - Chadwick D. Miller
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Simon A. Mahler
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
- Departments of Implementation Science and Epidemiology and Prevention Wake Forest School of Medicine Winston‐Salem NC
| |
Collapse
|
43
|
Validity of Coronary Artery Disease Consortium Models for Predicting Obstructive Coronary Artery Disease & Cardiovascular Events in Patients with Acute Chest Pain Considered for Coronary Computed Tomographic Angiography. Am J Cardiol 2018; 122:1310-1321. [PMID: 30119831 DOI: 10.1016/j.amjcard.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/02/2018] [Accepted: 07/10/2018] [Indexed: 01/05/2023]
Abstract
Although the majority of acute chest pain patients are diagnosed with noncardiac chest pain after noninvasive testing, identifying these low-risk patients before testing is challenging. The objective of this study was to validate the coronary artery disease (CAD) consortium models for predicting obstructive CAD and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients considered for coronary computed tomography angiogram, as well as to determine the pretest probability threshold that identifies low-risk patients with <1% MACE. We studied 1,981 patients with no known CAD and negative initial troponin and electrocardiogram. We evaluated CAD consortium models (basic: age, sex, and chest pain type; clinical: basic + diabetes, hypertension, dyslipidemia, and smoking; and clinical + coronary calcium score [CAC] models) for prediction of obstructive CAD (≥50% stenosis on coronary CT angiogram) and 30-day MACE (Acute Myocardial Infarction, revascularization, and mortality). The C-statistic for predicting obstructive CAD was 0.77 (95% confidence interval [CI] 0.73 to 0.77) for the basic, 0.80 (95% CI 0.77 to 0.80) for the clinical, and 0.88 (95% CI 0.85 to 0.88) for the clinical + CAC models. The C-statistic for predicting 30-day MACE was 0.82 (95% CI 0.77 to 0.87) for the basic, 0.84 (95% CI 0.79 to 0.88) for the clinical, and 0.87 (95% CI 0.83 to 0.91) for the clinical + CAC models. In 47.3% of patients for whom the clinical model predicted ≤5% probability for obstructive CAD, the observed 30-day MACE was 0.53% (95% CI 0.07% to 0.999%); in the 66.9% of patients for whom the clinical + CAC model predicted ≤5% probability, the 30-day MACE was 0.75% (95% CI 0.29% to 1.22%). We propose a chest pain evaluation algorithm based on these models that classify 63.3% of patients as low risk with 0.56% (95% CI 0.15% to 0.97%) 30-day MACE. In conclusion, CAD consortium models have excellent diagnostic and prognostic value for acute chest pain patients and can safely identify a significant proportion of low-risk patients by achieving <1% missed 30-day MACE.
Collapse
|
44
|
Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels. PLoS One 2018; 13:e0203506. [PMID: 30192899 PMCID: PMC6128560 DOI: 10.1371/journal.pone.0203506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/20/2018] [Indexed: 12/27/2022] Open
Abstract
Background Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing. Methods 918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics. Results MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95%CI:6.25–40.96), 16.43 (6.36–42.45), 2.33 (1.22–4.42) and 1.10 (1.01–1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in one-year). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease. Conclusions Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield.
Collapse
|
45
|
Timmis A, Raharja A, Archbold RA, Mathur A. Validity of inducible ischaemia as a surrogate for adverse outcomes in stable coronary artery disease. Heart 2018; 104:1733-1738. [PMID: 29875140 PMCID: PMC6241629 DOI: 10.1136/heartjnl-2018-313230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 04/25/2018] [Accepted: 05/17/2018] [Indexed: 01/09/2023] Open
Abstract
Regional myocardial ischaemia is commonly expressed as exertional angina in patients with stable coronary artery disease (CAD). It also associates with prognosis, risk tending to increase with the severity of ischaemia. The validity of myocardial ischaemia as a surrogate for adverse clinical outcomes, however, has not been well established. Thus, in cohort studies, ischaemia testing has failed to influence rates of myocardial infarction and coronary death. Moreover, in clinical studies, pharmacological and interventional treatments that are effective in correcting ischaemia have rarely been shown to reduce cardiovascular (CV) risk. This contrasts with statins and other anti-inflammatory drugs that have no direct effect on ischaemia but improve CV outcomes by modifying the atherothrombotic disease process. Despite this, and with little evidence of patient benefit, stress testing is commonly used during the follow-up of patients with stable CAD when the demonstration of ischaemic change may be seen as a target for treatment, independently of symptomatic status. Substitution of a symptom-driven management strategy has the potential to reduce rates of non-invasive stress testing, unnecessary downstream revascularisation procedures and use of valuable resources in patients with stable CAD without adverse consequences for CV risk.
Collapse
Affiliation(s)
- Adam Timmis
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK.,Department of Interventional Cardiology, Barts Heart Centre, London, UK
| | - Antony Raharja
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - R Andrew Archbold
- Department of Interventional Cardiology, Barts Heart Centre, London, UK
| | - Anthony Mathur
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK.,Department of Interventional Cardiology, Barts Heart Centre, London, UK
| |
Collapse
|
46
|
Sandoval GA, Brown AD, Wodchis WP, Anderson GM. Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework. Int J Health Plann Manage 2018; 33. [PMID: 29770971 DOI: 10.1002/hpm.2547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 11/11/2022] Open
Abstract
Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.
Collapse
Affiliation(s)
- Guillermo A Sandoval
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Adalsteinn D Brown
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Geoffrey M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| |
Collapse
|
47
|
Cohen DM, Winter M, Lindenauer PK, Walkey AJ. Echocardiogram in the Evaluation of Hemodynamically Stable Acute Pulmonary Embolism: National Practices and Clinical Outcomes. Ann Am Thorac Soc 2018; 15:581-588. [PMID: 29298088 PMCID: PMC5955052 DOI: 10.1513/annalsats.201707-577oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 01/03/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Societal guideline recommendations vary with regard to the role of routine trans-thoracic echocardiography to screen for right ventricular strain in patients with hemodynamically stable acute pulmonary embolism. OBJECTIVE To characterize national patterns in use of early trans-thoracic echocardiography for the evaluation of patients with hemodynamically stable acute pulmonary embolism and determine associations between trans-thoracic echocardiography use and patient outcomes. METHODS Retrospective cohort study using Premier, Inc. database of approximately 20% of patients hospitalized in the United States with hemodynamically stable acute pulmonary embolism between 2008 and 2011. Multivariable, risk-adjusted hierarchical regression models were used to evaluate hospital variation in use of trans-thoracic echocardiography for pulmonary embolism and associations between hospital trans-thoracic echocardiography rates and patient outcomes. Patient-level trans-thoracic echocardiography exposure was used in sensitivity analyses. RESULTS We identified 64,037 patients (mean age, 61.7 years; 54% women; 68% white) hospitalized at 363 U.S. hospitals. Trans-thoracic echocardiography rates for hemodynamically stable acute pulmonary embolism varied widely among hospitals (median trans-thoracic echocardiography rate, 41.4%; range, 0-89%; interquartile range, 32.7-51.7%). Hospital rates of trans-thoracic echocardiography were not associated with significant differences in risk-adjusted mortality (trans-thoracic echocardiography rate quartile 4 vs. quartile 1: odds ratio, 0.88; 95% confidence interval, 0.69-1.13) or use of thrombolytics (odds ratio, 1.28; 95% confidence interval, 0.84-1.96), but rates of intensive care unit admission (odds ratio, 1.57; 95% confidence interval, 1.18-2.07), hospital length of stay (relative risk, 1.08; 95% confidence interval, 1.03-1.15), and costs (relative risk, 1.15; 95% confidence interval, 1.07-1.23) were significantly higher at hospitals with high trans-thoracic echocardiography rates. Analyses of patient-level trans-thoracic echocardiography exposure produced similar results, except with higher rates of thrombolysis (odds ratio, 5.58; 95% confidence interval, 4.40-7.09) and bleeding (odds ratio, 1.37; 95% confidence interval, 1.24-1.51) among patients receiving trans-thoracic echocardiography. CONCLUSIONS Trans-thoracic echocardiography use in the evaluation of patients with hemodynamically stable acute pulmonary embolism varied widely between hospitals. Hospitals with high rates of pulmonary embolism-associated trans-thoracic echocardiography use did not achieve different patient mortality outcomes but had higher resource use and costs. Our findings support the 2016 American College of Chest Physicians guidelines for management of pulmonary embolism, which recommend selective, rather than routine, use of trans-thoracic echocardiography to risk stratify patients with hemodynamically stable pulmonary embolism.
Collapse
Affiliation(s)
| | - Michael Winter
- Department of Statistics, Boston University School of Public Health, Boston, Massachusetts
| | - Peter K. Lindenauer
- Department of Medicine and
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts; and
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Allan J. Walkey
- Division of Pulmonary and Critical Care Medicine and
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
48
|
Utility of Physician Selection of Cardiac Tests in a Chest Pain Unit to Exclude Acute Coronary Syndrome Among Patients Without a History of Coronary Artery Disease. Am J Cardiol 2018; 121:825-829. [PMID: 29452690 DOI: 10.1016/j.amjcard.2017.12.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 12/08/2017] [Accepted: 12/18/2017] [Indexed: 11/20/2022]
Abstract
There are few data on the utility of physician selection of cardiac tests, including no-test, in a chest pain unit (CPU) to rule out acute coronary syndrome in low-risk patients without a history of coronary artery disease. We analyzed consecutive low-risk patients admitted to our CPU between 2012 and 2014 and determined the proportion of patients selected for testing, the type of initial cardiac test selected, and the incidence of major adverse cardiac events (MACEs) at 30 days and 6 months. The study group comprised 619 patients: mean age 57 years (27 to 92), 332 women (54%), and 360 (58%) with multiple cardiac risk factors. Cardiac testing included 283 no-test (46%); 179 exercise treadmill (29%); 113 myocardial perfusion stress scintigraphy (18%); <10% each for exercise stress echocardiography and coronary angiography. Testing was negative in 296 (88%), nondiagnostic in 30 (9%), and positive in 10 patients (3%). There were no MACEs at 30 days in any patients, and at 6 months, MACEs were 5 (1.1%). Length of stay was less in no-test than in tested patients (5.4 hours vs 9.8 hours, p <0.0001), and there was no difference in incidence of MACE at 6 months in no-test vs tested patients (2 MACEs vs 3 MACEs). Physician selection of cardiac tests, including no-test, promptly identified patients at low risk of acute coronary syndrome who could be safely and rapidly discharged from the CPU. Exclusion of cardiac testing shortened length of stay and was not associated with increase in MACE at 6 months.
Collapse
|
49
|
Caulfield CA, Stephens JR. Things We Do for No Reason: Hospitalization for the Evaluation of Patients with Low-Risk Chest Pain. J Hosp Med 2018; 13:277-279. [PMID: 29455230 DOI: 10.12788/jhm.2939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Christopher A Caulfield
- Department of Internal Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - John R Stephens
- Department of Internal Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| |
Collapse
|
50
|
Sun BC. Defer Urgent Noninvasive Testing in Low-Risk Chest Pain Patients. Ann Emerg Med 2018; 71:465-466. [PMID: 29566887 DOI: 10.1016/j.annemergmed.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| |
Collapse
|