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Bell SK, Amat MJ, Anderson TS, Aronson MD, Benneyan JC, Fernandez L, Ricci DA, Salant T, Schiff GD, Shafiq U, Singer SJ, Sternberg SB, Zhang C, Phillips RS. Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study. J Am Med Inform Assoc 2024; 31:622-630. [PMID: 38164964 PMCID: PMC10873783 DOI: 10.1093/jamia/ocad250] [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: 10/05/2023] [Revised: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVES The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care. MATERIALS AND METHODS Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression. RESULTS Among 12 849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002). DISCUSSION AND CONCLUSION Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.
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Affiliation(s)
- Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Maelys J Amat
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Timothy S Anderson
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Mark D Aronson
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - James C Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA 02115, United States
| | - Leonor Fernandez
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Dru A Ricci
- Center for Primary Care, Harvard Medical School, Boston, MA 02115, United States
| | - Talya Salant
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
- Bowdoin Street Health Center, Dorchester, MA 02122, United States
| | - Gordon D Schiff
- Center for Primary Care, Harvard Medical School, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Umber Shafiq
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Sara J Singer
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Scot B Sternberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Cancan Zhang
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Russell S Phillips
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
- Center for Primary Care, Harvard Medical School, Boston, MA 02115, United States
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Liu C, Varady N, Chruscielski CM, Zhang D, Blazar P, Earp BE. Clinic Study Completion Rate in Orthopedic Surgery. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:12-15. [PMID: 38313622 PMCID: PMC10837181 DOI: 10.1016/j.jhsg.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/29/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose The primary aim of this study is to determine the rate of completion of clinic-based study orders. Secondarily, we attempt to determine factors associated with study incompletion. Methods This retrospective study included 591 clinic-based studies that were ordered for 510 patients at the time of clinical evaluation at a single medical center between April 8, 2018 and August 22, 2019. Inclusion criteria were studies ordered in a hand clinic for consecutive adult patients to be completed after the visit. Exclusion criteria included pediatric patients and routine radiographs obtained prior to the visit. Invasive studies were defined as studies with a significant procedural component, such as aspirations, injections and electromyography/nerve conduction (electrodiagnostic) studies (EDS). Blood tests and imaging were considered noninvasive. Patient demographics and study completion rates were collected through chart reviews. Univariate and bivariate analyses were performed, and P <.05 was considered significant. Results The overall clinic-based study completion rate was 94.2%, with the highest incompletion rates seen in invasive studies (8.3%, n = 34) compared to noninvasive studies (3.3%, n = 10). Within the invasive study category, EDS had the highest rate of incompletion (11.4%) and contributed to the majority of incompletions in the invasive cohort (20/24). The median time to study completion was 7 days (interquartile range [IQR] 2-21). Race, gender, English as primary language, marriage status, insurance type, and distance from facility were similar between completed and noncompleted studies. Conclusion Study completion rates were similar between all patients regardless of race, gender, and other social economic variables. Invasive studies, particularly EDS, had higher rates of incompletion and can be barriers to patients receiving additional care. Type of study/level of evidence Therapeutic III.
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Affiliation(s)
- Christina Liu
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nathan Varady
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
| | - Cassandra M. Chruscielski
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
| | - Dafang Zhang
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philip Blazar
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brandon E. Earp
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Musey PI, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, Hess EP, Kontos MC, Mumma BE, Probst MA, Stahl JH, Stopyra JP, Kline JA, Carpenter CR. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021; 28:718-744. [PMID: 34228849 DOI: 10.1111/acem.14296] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | | | - Suneel Upadhye
- Division of Emergency Medicine McMaster University Hamilton Canada
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
| | - Deborah B. Diercks
- Department of Emergency Medicine UT Southwestern Medical Center Dallas TX USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush Medical Center Chicago IL USA
| | - Erik P. Hess
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Michael C. Kontos
- Department of Internal Medicine Virginia Commonwealth University Richmond VA USA
| | - Bryn E. Mumma
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA USA
| | - Marc A. Probst
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NY USA
| | | | - Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐SalemNC USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University School of Medicine St. Louis MO USA
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Sutton J, Gu L, Diercks DB. Impact of Social Determinants of Health, Health Literacy, Self-perceived Risk, and Trust in the Emergency Physician on Compliance with Follow-up. West J Emerg Med 2021; 22:667-671. [PMID: 34125044 PMCID: PMC8203000 DOI: 10.5811/westjem.2020.12.48981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 12/17/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Patients presenting to the emergency department (ED) with "low-risk" acute coronary syndrome (ACS) symptoms can be discharged with outpatient follow-up. However, follow-up compliance is low for unknown nonclinical reasons. We hypothesized that a patient's social factors, health literacy, self-perceived risk, and trust in the emergency physician may impact follow-up compliance. METHODS This was a prospective study of a convenience sample of discharged ED patients presenting with chest pain and given a follow-up appointment prior to departing the ED. Patients were asked about social and demographic factors and to estimate their own risk for heart disease; they also completed the Short Assessment of Health Literacy-English (SAHL-E) and the Trust in Physician Scale (TiPS). RESULTS We enrolled146 patients with a follow-up rate of 36.3%. Patients who had a low self-perceived heart disease risk (10% or less) were significantly less likely to attend follow-up than those with a higher perceived risk (23% vs 44%, P = 0.01). Other factors did not significantly predict follow-up rates. CONCLUSION In an urban county ED, in patients who were deemed low risk for ACS and discharged, only self-perception of risk was associated with compliance with a follow-up appointment.
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Affiliation(s)
- James Sutton
- University of Texas Southwestern School of Medicine, Dallas, Texas
| | - Leon Gu
- University of Texas Southwestern School of Medicine, Dallas, Texas
| | - Deborah B Diercks
- University of Texas Southwestern, Department of Emergency Medicine, Dallas, Texas
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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.
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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.
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Michaels A, Gibbs J, Mawri S, Dirani G, Aurora L, Jacobsen G, Nowak R, McCord J. Prognostic Utility of the HEART Score in the Observation Unit. Crit Pathw Cardiol 2018; 17:179-183. [PMID: 30418247 DOI: 10.1097/hpc.0000000000000157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The evaluation of individuals with possible acute myocardial infarction (AMI) is time consuming and costly. Risk stratification early during an acute care encounter presents an opportunity for increased delivery of high-value care. We sought to evaluate if the HEART score could be used in the triage of low-risk versus high-risk patients directly home without cardiac testing. Retrospective review of 838 patients placed in an observation unit for evaluation of AMI was done at a single-center, tertiary care teaching hospital. Primary outcome was major adverse cardiac event-death, AMI, or revascularization-at 30 days from the index encounter. Participants' average age was 60.1 years, 40% were male, and 67% were African American. Complete data were available for all 838 patients, including 30-day follow-up at study completion. The primary endpoint was met in 14 patients (1.7%), all of whom were in the high-risk group, with HEART score ≥4. Of the low-risk patients, 8 (2.8%) had a positive functional study, 5 underwent subsequent coronary angiography, with none (0%) found to have obstructive coronary disease. In conclusion, our results suggest that patients with a HEART score ≤3 being evaluated for chest pain are at extremely low risk for major adverse cardiac events and may be safely discharged without provocative testing. Positive cardiac testing in this population is more likely to represent a false-positive finding, resulting in unnecessary testing. These findings should be prospectively validated.
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Affiliation(s)
- Alexander Michaels
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Joseph Gibbs
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Sagger Mawri
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - George Dirani
- Department Cardiovascular Medicine, Beaumont-Dearborn, Dearborn, MI
| | - Lindsey Aurora
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Gordon Jacobsen
- Public Health Sciences, Public Health and Statistics, Henry Ford Hospital, Detroit, MI
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - James McCord
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
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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.
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Balderston JR, Aurora T, Kontos MC, Zhang R, Gertz ZM. Performance of an outpatient stress testing protocol for low risk chest pain patients presenting to the emergency department. Am J Emerg Med 2017; 35:1759-1760. [DOI: 10.1016/j.ajem.2017.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/01/2017] [Accepted: 04/02/2017] [Indexed: 10/19/2022] Open
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Ferencik M, Mayrhofer T, Lu MT, Woodard PK, Truong QA, Peacock WF, Bamberg F, Sun BC, Fleg JL, Nagurney JT, Udelson JE, Koenig W, Januzzi JL, Hoffmann U. High-Sensitivity Cardiac Troponin I as a Gatekeeper for Coronary Computed Tomography Angiography and Stress Testing in Patients with Acute Chest Pain. Clin Chem 2017; 63:1724-1733. [PMID: 28923845 PMCID: PMC7012018 DOI: 10.1373/clinchem.2017.275552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/02/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Most patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) undergo noninvasive cardiac testing with a low diagnostic yield. We determined whether a combination of high-sensitivity cardiac troponin I (hs-cTnI) and cardiovascular risk factors might improve selection of patients for cardiac testing. METHODS We included patients from the Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) I and II trials who presented to the ED with acute chest pain and were referred for cardiac testing. Based on serial hs-cTnI measurements and cardiovascular risk factors, we derived and validated the criterion for no need of cardiac testing. We predicted the effect of this criterion on the effectiveness of patient management. RESULTS A combination of baseline hs-cTnI (<4 ng/L) and cardiovascular risk factors (<2) ruled out ACS with a negative predictive value of 100% in ROMICAT I. We validated this criterion in ROMICAT II, identifying 29% patients as not needing cardiac testing. An additional 5% of patients were identified by adding no change or a decrease between baseline and 2 h hs-cTnI as a criterion. Assuming those patients would be discharged from the ED without cardiac testing, implementation of hs-cTnI would increase ED discharge rate (24.3% to 50.2%, P < 0.001) and decrease the length of hospital stay (21.4 to 8.2 h, P < 0.001), radiation dose (10.2 to 7.7 mSv, P < 0.001), and costs of care (4066 to 3342 US$, P < 0.001). CONCLUSIONS We derived and validated a criterion for combined hs-cTnI and cardiovascular risk factors that identified acute chest pain patients with no need for cardiac testing and could improve effectiveness of patient management. ClinicalTrials.gov Identifiers: NCT00990262 and NCT01084239.
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Affiliation(s)
- Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR;
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Thomas Mayrhofer
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Michael T Lu
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Quynh A Truong
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College, New York, NY
| | - W Frank Peacock
- Division of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Fabian Bamberg
- Department of Radiology, University of Tuebingen, Tuebingen, Germany
| | - Benjamin C Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James E Udelson
- Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Department of Internal Medicine II-Cardiology, University of Ulm Medical Center, Ulm, Germany
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Predictors of obtaining follow-up care in the province of Ontario, Canada, following a new diagnosis of atrial fibrillation, heart failure, and hypertension in the emergency department. CAN J EMERG MED 2017; 20:377-391. [PMID: 28803593 DOI: 10.1017/cem.2017.371] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Patients with cardiovascular diseases are common in the emergency department (ED), and continuity of care following that visit is needed to ensure that they receive evidence-based diagnostic tests and therapy. We examined the frequency of follow-up care after discharge from an ED with a new diagnosis of one of three cardiovascular diseases. METHODS We performed a retrospective cohort study of patients with a new diagnosis of heart failure, atrial fibrillation, or hypertension, who were discharged from 157 non-pediatric EDs in Ontario, Canada, between April 2007 and March 2014. We determined the frequency of follow-up care with a family physician, cardiologist, or internist within seven and 30 days, and assessed the association of patient, emergency physician, and family physician characteristics with obtaining follow-up care using cause-specific hazard modeling. RESULTS There were 41,485 qualifying ED visits. Just under half (47.0%) had follow-up care within seven days, with 78.7% seen by 30 days. Patients with serious comorbidities (renal failure, dementia, COPD, stroke, coronary artery disease, and cancer) had a lower adjusted hazard of obtaining 7-day follow-up care (HRs 0.77-0.95) and 30-day follow-up care (HR 0.76-0.95). The only emergency physician characteristic associated with follow-up care was 5-year emergency medicine specialty training (HR 1.11). Compared to those whose family physician was remunerated via a primarily fee-for-service model, patients were less likely to obtain 7-day follow-up care if their family physician was remunerated via three types of capitation models (HR 0.72, 0.81, 0.85) or via traditional fee-for-service (HR 0.91). Findings were similar for 30-day follow-up care. CONCLUSIONS Only half of patients discharged from an ED with a new diagnosis of atrial fibrillation, heart failure, and hypertension were seen within a week of being discharged. Patients with significant comorbidities were less likely to obtain follow-up care, as were those with a family physician who was remunerated via primarily capitation methods.
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Chiu A, Shumaker K, del Corral C, George B, Kasper M, Jois P, Dipsia D, Donnelly M, Sidow L, Chau C, Ash A. Remote management of low to intermediate risk chest pain: A case series. Am J Emerg Med 2017; 35:1147-1149. [DOI: 10.1016/j.ajem.2017.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 02/13/2017] [Accepted: 02/14/2017] [Indexed: 10/20/2022] Open
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The American Telemedicine Association ATA 2017 Telehealth 2.0 Conference Abstracts. Telemed J E Health 2017; 23:A1-A78. [PMID: 28410061 DOI: 10.1089/tmj.2017.29005-a.abstracts] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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13
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Atzema CL, Maclagan LC. The Transition of Care Between Emergency Department and Primary Care: A Scoping Study. Acad Emerg Med 2017; 24:201-215. [PMID: 27797435 DOI: 10.1111/acem.13125] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 09/16/2016] [Accepted: 10/19/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge. METHODS We performed a MEDLINE search of English-language articles published between 1990 and March 2015. We created a data-charting form a priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies. RESULTS Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow-up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers (PCPs) of the ED visit (seven studies), and Patient views and PCP information requirements (one each). In the Follow-up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow-up care were the provision of a follow-up appointment time prior to ED departure and the presence of health insurance. Follow-up telephone calls to patients resulted in better follow-up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, and the barriers to follow-up care can be high. E-mail and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow-up care. CONCLUSIONS A plethora of work has been published on the transition of care from ED to primary care. To decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow-up appointment system and health insurance. Further research is needed in particular to identify the patients who actually need follow-up care and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system.
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Affiliation(s)
- Clare L. Atzema
- Institute for Clinical Evaluative Sciences University of Toronto Toronto ON Canada
- Division of Emergency Medicine University of Toronto Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
- Sunnybrook Health Sciences Centre Toronto ON Canada
- Institute of Health Policy Management and Evaluation at the University of Toronto Toronto ON Canada
| | - Laura C. Maclagan
- Institute for Clinical Evaluative Sciences University of Toronto Toronto ON Canada
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Chang AM. Low Risk Acute Coronary Syndrome-How High Is Low? Acad Radiol 2016; 23:1592-1594. [PMID: 27823656 DOI: 10.1016/j.acra.2016.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/06/2016] [Indexed: 10/20/2022]
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Sun BC, Laurie A, Fu R, Ferencik M, Shapiro M, Lindsell CJ, Diercks D, Hoekstra JW, Hollander JE, Kirk JD, Peacock WF, Gibler WB, Anantharaman V, Pollack CV. Association of Early Stress Testing with Outcomes for Emergency Department Evaluation of Suspected Acute Coronary Syndrome. Crit Pathw Cardiol 2016; 15:60-8. [PMID: 27183256 DOI: 10.1097/hpc.0000000000000068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Professional society guidelines suggest early stress testing (within 72 hours) after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS). However, there is increasing concern that current practice results in over-testing without evidence of benefit. We test the hypothesis that early stress testing improves outcomes. METHODS We analyzed prospectively collected data from 9 EDs on patients with suspected ACS, 1999-2001. We excluded patients with an ED diagnosis of ACS. The primary outcome was 30-day major adverse cardiac events (MACEs), including all-cause death, acute myocardial infarction, and revascularization. We used the HEART score to determine pretest ACS risk (low, intermediate, and high). To mitigate potential confounding, patients with and without early stress testing were matched within pretest risk strata in a 1:2 ratio using propensity scores. RESULTS Of 7127 potentially eligible patients, 895 (13%) received early stress testing. The analytic cohort included 895 patients with early stress testing matched to 1790 without early stress testing. The overall 30-day MACE rate in both the source and analytic population was 3%. There were no baseline imbalances after propensity score matching (P > 0.1 for more than 30 variables). There was no association between early stress testing and 30-day MACE [odds ratio, 1.0; 95% confidence interval (CI), 0.6-1.7]. There was no effect modification by pretest risk (low: odds ratio, 1.0; 95% CI, 0.2-3.7; intermediate: 1.2; 95% CI, 0.6-2.6; high: 0.4; 95% CI, 0.1-1.6). CONCLUSIONS Early stress testing is not associated with reduced MACE in patients evaluated for suspected ACS. Early stress testing may have limited value in populations with low MACE rate.
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Affiliation(s)
- Benjamin C Sun
- From the *Department of Emergency Medicine, †Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, OR; ‡Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; §Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX; ¶Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC; ‖Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA; **Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA; ††Department of Emergency Medicine, Baylor College of Medicine, Houston, TX; and ‡‡Department of Emergency Medicine, Singapore General Hospital, Singapore
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Robinson K, Prabhala S. Compliance with stress testing in patients discharged from the emergency department following a diagnosis of low-risk chest pain. HEART ASIA 2014; 6:116-9. [PMID: 27326183 PMCID: PMC4832738 DOI: 10.1136/heartasia-2014-010505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 06/19/2014] [Accepted: 07/08/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine rates of compliance with outpatient stress testing in patients with a diagnosis of low-risk chest pain, reasons for non-compliance and incidence of adverse cardiac events (ACE). METHODS This was a prospective study of 79 patients who were discharged from the emergency department with low-risk chest pain. Patients were followed-up by phone interview. RESULTS 36.7% of patients completed EST within 30 days, 2.5% of patients completed their EST within the recommended 72 h. A lack of time was the most common reason for non-compliance and was seen in 32.0% of patients. 20% of ESTs were cancelled by the primary care physician (PCP). 12% of patients were non-compliant, as they believed the pain to be non-cardiac. There were no documented ACEs in the study. CONCLUSIONS Compliance with EST is poor in patients with low-risk chest pain. Non-compliance is related to a number of factors including work commitments, cancellation of studies by the PCP and patients beliefs about the nature of their chest pain.
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Affiliation(s)
- Kent Robinson
- Department of Emergency Medicine , Liverpool Hospital, The University of New South Wales , Sydney, New South Wales , Australia
| | - Shreyas Prabhala
- Department of Emergency Medicine , Liverpool Hospital, The University of New South Wales , Sydney, New South Wales , Australia
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Groarke JD, Crean P, Adams N, Farrell T, Bennett K, McMahon CG. Out-of-hours exercise treadmill testing reduces length of hospital stay for chest pain admissions. J Cardiovasc Med (Hagerstown) 2014; 17:659-64. [PMID: 24978875 DOI: 10.2459/jcm.0000000000000107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The objective was to examine the impact of out-of-hours exercise treadmill tests (ETTs) on length of hospital stay (LOS) for patients admitted to a chest pain assessment unit with symptoms suggestive of acute coronary syndrome. METHODS Prospective observational study with 30-day follow-up of low-to-intermediate-risk chest pain patients undergoing out-of-hours ETT. Eligible patients had a nonischemic ECG, normal 6-12-h ST-segment monitoring, a negative 12-h troponin T assay, and no contraindications to exercise. Observed LOS was compared to expected LOS in the absence of out-of-hours ETT, using Wilcoxon rank-sum test. Estimated bed day savings and major adverse events at 30 days after discharge were examined. RESULTS Four hundred and twenty-two patients with a mean age of 52 years (SD 13 years, 25-83 years) were evaluated. Fifty-two per cent (n = 221) were men; 66% (n = 279) had one or less cardiovascular risk factors; and 79% (n = 334) of the patients presented on a Friday or Saturday. ETT was performed on a weekend day in 86% (n = 363) of the patients, facilitating same-day discharges in 71% (n = 300). The median LOS (interquartile range) was 1 day (1, 2 days) for patients assessed with out-of-hours ETT. The expected median LOS (IQR) was 3 days (2, 4 days) (P < 0.05) in the absence of out-of-hours ETT. Each out-of-hours ETT was estimated to save a mean (SD, range) of 1.6 (0.6, 1-4) bed days. Thirty-day mortality and readmission rates were 0 and 0.2% (1 of 422), respectively. CONCLUSION The availability of out-of-hours ETT facilitates safe early discharge and reduced LOS for low-to-moderate-risk patients admitted with symptoms of acute coronary syndrome.
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Affiliation(s)
- John D Groarke
- aDepartment of Cardiology bDepartment of Statistics cDepartment of Emergency Medicine, St James's Hospital, Dublin, Ireland
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Soremekun OA, Hamedani A, Shofer FS, O'Conor KJ, Svenson J, Hollander JE. Safety of a rapid diagnostic protocol with accelerated stress testing. Am J Emerg Med 2014; 32:124-8. [DOI: 10.1016/j.ajem.2013.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/05/2013] [Accepted: 10/06/2013] [Indexed: 10/26/2022] Open
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Mitra B, Cameron PA. Complete assessment before discharge: A paradigm shift on management of patients presenting with chest pain. Emerg Med Australas 2013; 25:380-1. [DOI: 10.1111/1742-6723.12107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre; The Alfred Hospital; Melbourne; Victoria; Australia
| | - Peter A Cameron
- Emergency & Trauma Centre; The Alfred Hospital; Melbourne; Victoria; Australia
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Mountain D, Brown AFT. Chest pain research in Australasian emergency medicine: Putting our mark on the world stage. Emerg Med Australas 2011; 23:395-7. [DOI: 10.1111/j.1742-6723.2011.01457.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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