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
|
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
|
3
|
Zaboli A, Ausserhofer D, Sibilio S, Toccolini E, Bonora A, Giudiceandrea A, Rella E, Paulmichl R, Pfeifer N, Turcato G. Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain. Am J Cardiol 2021; 161:12-18. [PMID: 34635312 PMCID: PMC9336201 DOI: 10.1016/j.amjcard.2021.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 12/01/2022]
Abstract
The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage's predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.
Collapse
|
4
|
Mark DG, Huang J, Ballard DW, Kene MV, Sax DR, Chettipally UK, Lin JS, Bouvet SC, Cotton DM, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Reed ME. Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study. J Am Heart Assoc 2021; 10:e022539. [PMID: 34743565 PMCID: PMC8751925 DOI: 10.1161/jaha.121.022539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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 Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
Collapse
Affiliation(s)
- Dustin G Mark
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Dustin W Ballard
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA
| | - Dana R Sax
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Uli K Chettipally
- Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA
| | - James S Lin
- Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Sean C Bouvet
- Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA
| | - Dale M Cotton
- Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CA
| | - Megan L Anderson
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Ian D McLachlan
- Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA
| | - Laura E Simon
- University of California San Diego School of Medicine San Diego CA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | | - David R Vinson
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Mary E Reed
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | |
Collapse
|