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Gray AJ, Roobottom C, Smith JE, Goodacre S, Oatey K, O'Brien R, Storey RF, Curzen N, Keating L, Kardos A, Felmeden D, Lee RJ, Thokala P, Lewis SC, Newby DE. Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the RAPID-CTCA RCT. Health Technol Assess 2022; 26:1-114. [PMID: 36062819 DOI: 10.3310/irwi5180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined. OBJECTIVE To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome. DESIGN A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication. SETTING Thirty-seven hospitals in the UK. PARTICIPANTS Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram. INTERVENTIONS Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year. MAIN OUTCOME MEASURE One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography ( CTCA ) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained. RESULTS Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care. LIMITATIONS The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention. FUTURE WORK The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation. CONCLUSIONS In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain. TRIAL REGISTRATION This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alasdair J Gray
- Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Carl Roobottom
- Department of Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton and Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Liza Keating
- Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Dirk Felmeden
- Department of Cardiology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Robert J Lee
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
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Martsolf GR, Nuckols TK, Fingar KR, Barrett ML, Stocks C, Owens PL. Nonspecific chest pain and hospital revisits within 7 days of care: variation across emergency department, observation and inpatient visits. BMC Health Serv Res 2020; 20:516. [PMID: 32513147 PMCID: PMC7278151 DOI: 10.1186/s12913-020-05200-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/08/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Grant R Martsolf
- University of Pittsburgh School of Nursing, 3500 Victoria St, 315B, Pittsburgh, PA, 15213, USA.,RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA.,Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker 113, Los Angeles, CA, 90048, USA
| | - Kathryn R Fingar
- IBM Watson Health, 5425 Hollister Ave, Suite 140, Santa Barbara, CA, 93111, USA
| | | | - Carol Stocks
- Affiliation during this investigation: Agency for Healthcare Research and Quality, Rockville, Maryland, USA.,Present address: West Virginia University, School of Public Health, 64 Medical Center Drive, PO Box 9190, Morgantown, WV, 26506-9190, USA
| | - Pamela L Owens
- Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD, 20857, USA.
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Taban Sadeghi M, Mahmoudian B, Ghaffari S, Moharamzadeh P, Ala A, Pourafkari L, Gureishi S, Roshanravan N, Abolhasani S, Pouraghaei M. Value of early rest myocardial perfusion imaging with SPECT in patients with chest pain and non-diagnostic ECG in emergency department. Int J Cardiovasc Imaging 2019; 35:965-971. [PMID: 30661139 DOI: 10.1007/s10554-018-01518-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 12/19/2018] [Indexed: 01/01/2023]
Abstract
Evaluation of atypical presentation of angina chest pain in emergency department is difficult. Hospitalization of this patient may impose additional costs and waste the time, early discharge may lead to miss the patients. The aim of this study was to determine volubility of Single Photon Emission Computed Tomography (SPECT) in management of patients admitted to emergency department with atypical manifestations of angina pain, un-diagnostic Electrocardiogram (ECG) and negative enzyme. Half of 100 patients admitted to emergency department with atypical chest pain and un-diagnostic ECG who were candidate for admission, underwent ECG gated resting SPECT. According to the results of SPECT, low risk patient discharged after negative stress SPECT. All discharged patients were followed up for major cardiac events (cardiac death, nonfatal myocardial infarction and repeat admission for congestive heart failure) for 12 months. According to rest SPECT Myocardial Perfusion Imaging (MPI), about 70% of patients in case group was low risk and 30% of them had moderate or high risk. Case group represented lower hospitalization rate and lower need for Coronary Artery Angiography (CAG) in comparison with control group. Mean cost in case group was significantly lower than control group (175.15$ vs. 391.33$, P < 0.001). In one year follow- up no cases of mortality or major cardiovascular events as cardiac infraction were found in discharged patients in case group. our study showed that rest SPECT fulfillment in admitted patients in emergency department was validated method for assessing patients' risk which avoids unnecessary hospitalizations and additional costs.
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Affiliation(s)
| | - Babak Mahmoudian
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Payman Moharamzadeh
- Emergency Medical Research Team, Tabriz University of Medical Sciences, POBOX: 14711, 5166614711, Tabriz, Iran
| | - Alireza Ala
- Emergency Medical Research Team, Tabriz University of Medical Sciences, POBOX: 14711, 5166614711, Tabriz, Iran
| | - Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahla Gureishi
- Emergency Medical Research Team, Tabriz University of Medical Sciences, POBOX: 14711, 5166614711, Tabriz, Iran
| | - Neda Roshanravan
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Somayeh Abolhasani
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahboub Pouraghaei
- Emergency Medical Research Team, Tabriz University of Medical Sciences, POBOX: 14711, 5166614711, Tabriz, Iran.
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Strøm C, Stefansson JS, Fabritius ML, Rasmussen LS, Schmidt TA, Jakobsen JC. Hospitalisation in short-stay units for adults with internal medicine diseases and conditions. Cochrane Database Syst Rev 2018; 8:CD012370. [PMID: 30102428 PMCID: PMC6513218 DOI: 10.1002/14651858.cd012370.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Short-stay units are hospital units that provide short-term care for selected patients. Studies have indicated that short-stay units might reduce admission rates, time of hospital stays, hospital readmissions and expenditure without compromising the quality of care. Short-stay units are often defined by a target patient category, a target function, and a target time frame. Hypothetically, short-stay units could be established as part of any department, but this review focuses on short-stay units that provide care for participants with internal medicine diseases and conditions. OBJECTIVES To assess beneficial and harmful effects of short-stay unit hospitalisation compared with usual care in people with internal medicine diseases and conditions. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to 13 December 2017 together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several grey literature sources and performed a forward citation search for included studies. SELECTION CRITERIA We included randomised trials and cluster-randomised trials, comparing hospitalisation in a short-stay unit with usual care (hospitalisation in a traditional hospital ward or other services). We defined a short-stay unit to be a hospital ward where the targeted length of stay in hospital for patients was five days or less. We included both multipurpose and specialised short-stay units. Participants were adults admitted to hospital with an internal medicine disease or condition. We excluded surgical, obstetric, psychiatric, gynaecological, and ambulatory participants. Trials were included irrespective of publication status, date, and language. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias of each included trial. We measured intervention effect sizes by meta-analyses for two primary outcomes, mortality and serious adverse events, and one secondary outcome, hospital readmission. We narratively reported the following important outcomes: quality of life, activities of daily living, non-serious adverse events, and costs. We used risk ratio differences of 15% for mortality and of 20% for serious adverse events for minimal relevant clinical consideration. We rated the certainty of the evidence and the strength of recommendations of the outcomes using the GRADE approach. MAIN RESULTS We included 19 records reporting on 14 randomised trials with a total of 2872 participants. One trial was ongoing. Thirteen trials evaluated short-stay unit hospitalisation for six specific conditions (acute decompensated heart failure (one trial), asthma (one trial), atrial fibrillation (one trial), chest pain (seven trials), syncope (two trials), and transient ischaemic attack (one trial)) and one trial investigated participants presenting with miscellaneous internal medicine disease and conditions. The components of the intervention differed among the trials as dictated by the trial participants' condition. All included trials were at high risk of bias.The certainty of the evidence for all outcomes was very low. Consequently, it is uncertain whether hospitalisation in short-stay units compared with usual care reduces mortality (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.15) 5 trials (seven additional trials reporting on 1299 participants reported no deaths in either group)); serious adverse events (RR 0.95, 95% CI 0.59 to 1.54; 7 trials (one additional trial with 108 participants reported no serious adverse events in either group)), and hospital readmission (RR 0.80, 95% CI 0.54 to 1.19, 8 trials (one additional trial with 424 participants did not report results for participants)). There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life, activities of daily living, non-serious adverse events, and costs. AUTHORS' CONCLUSIONS Overall, the quantity and the certainty of the evidence was very low. Consequently, it is uncertain whether there are any beneficial or harmful effects of short-stay unit hospitalisation for adults with internal medicine diseases and conditions - more trials comparing the effects of short-stay units with usual care are needed. Such trials ought to be conducted with low risk of bias and low risks of random errors to improve the overall confidence in the evidence.
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Affiliation(s)
- Camilla Strøm
- Holbaek Hospital, University of CopenhagenDepartment of Emergency MedicineHolbaekDenmark4300
| | - Jakob S Stefansson
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Maria Louise Fabritius
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Lars S Rasmussen
- Rigshospitalet, University of CopenhagenDepartment of Anaesthesia, Centre of Head and OrthopaedicsCopenhagenDenmark
| | - Thomas A Schmidt
- Holbaek Hospital, University of CopenhagenDepartment of Emergency MedicineHolbaekDenmark4300
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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5
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Hirst E, Irving A, Goodacre S. Patient and public involvement in emergency care research. Emerg Med J 2016; 33:665-70. [PMID: 27044949 DOI: 10.1136/emermed-2016-205700] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/05/2016] [Indexed: 11/04/2022]
Abstract
Patients participate in emergency care research and are the intended beneficiaries of research findings. The public provide substantial funding for research through taxation and charitable donations. If we do research to benefit patients and the public are funding the research, then patients and the public should be involved in the planning, prioritisation, design, conduct and oversight of research, yet patient and public involvement (or more simply, public involvement, since patients are also members of the public) has only recently developed in emergency care research. In this article, we describe what public involvement is and how it can help emergency care research. We use the development of a pioneering public involvement group in emergency care, the Sheffield Emergency Care Forum, to provide insights into the potential and challenges of public involvement in emergency care research.
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Affiliation(s)
- Enid Hirst
- Sheffield Emergency Care Forum, Sheffield, UK
| | - Andy Irving
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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MacLachlan H, Thomas R, Langtree J, Hare C, Mitchell ARJ. Is there a role for a local inpatient CT coronary angiography service in selected patients with acute coronary syndrome? A cohort analysis of inpatient tertiary centre referrals for invasive coronary angiography. Open Heart 2016; 3:e000389. [PMID: 27042324 PMCID: PMC4800760 DOI: 10.1136/openhrt-2015-000389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To conduct a retrospective analysis of inpatients referred for invasive coronary angiography (ICA) at a tertiary centre, with suspected or confirmed acute coronary syndrome (ACS). METHODS A retrospective cohort study was conducted at Jersey General Hospital. We evaluated 198 inpatients referred for ICA with suspected or confirmed ACS over a 3-year period. Patients presenting with ST elevation myocardial infarction were excluded. The primary outcome was to identify the number of patients who did not require subsequent coronary intervention following ICA. Patient variables were measured to establish those who met European Society of Cardiology (ESC) criteria for consideration of CT coronary angiography (CTCA) as an alternative to ICA. Cost of care for those referred for ICA was calculated. RESULTS ICA demonstrated evidence of coronary heart disease requiring coronary intervention in 119 (60%) of the referred patients. 28 (35%) of the patients not requiring coronary intervention at ICA met ESC criteria for preassessment with CTCA. The cost of care for this subgroup was £9089 per patient. Inpatient CTCA was calculated at £376 per patient. CONCLUSIONS Low-intermediate risk patients presenting with suspected or confirmed ACS to hospitals without onsite coronary revascularisation should be considered for in-hospital CTCA before consideration of ICA. Using CTCA as a gatekeeper for targeted ICA appears cost-effective, particularly for hospitals without the required onsite facilities.
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Affiliation(s)
| | - Ranji Thomas
- Department of Cardiology , Jersey General Hospital , Jersey , UK
| | - Jessica Langtree
- Department of Cardiology , Jersey General Hospital , Jersey , UK
| | - Chris Hare
- Department of Cardiology , Jersey General Hospital , Jersey , UK
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Fretheim A, Zhang F, Ross-Degnan D, Oxman AD, Cheyne H, Foy R, Goodacre S, Herrin J, Kerse N, McKinlay RJ, Wright A, Soumerai SB. A reanalysis of cluster randomized trials showed interrupted time-series studies were valuable in health system evaluation. J Clin Epidemiol 2015; 68:324-33. [DOI: 10.1016/j.jclinepi.2014.10.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 10/10/2014] [Accepted: 10/17/2014] [Indexed: 10/24/2022]
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Gräni C, Senn O, Bischof M, Cippà PE, Hauffe T, Zimmerli L, Battegay E, Franzen D. Diagnostic performance of reproducible chest wall tenderness to rule out acute coronary syndrome in acute chest pain: a prospective diagnostic study. BMJ Open 2015; 5:e007442. [PMID: 25631316 PMCID: PMC4316553 DOI: 10.1136/bmjopen-2014-007442] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Acute chest pain (ACP) is a leading cause of hospital emergency unit consultation. As there are various underlying conditions, ranging from musculoskeletal disorders to acute coronary syndrome (ACS), thorough clinical diagnostics are warranted. The aim of this prospective study was to assess whether reproducible chest wall tenderness (CWT) on palpation in patients with ACP can help to rule out ACS. METHODS In this prospective, double-blinded diagnostic study, all consecutive patients assessed in the emergency unit at the University Hospital Zurich because of ACP between July 2012 and December 2013 were included when a member of the study team was present. Reproducible CWT on palpation was the initial step and was recorded before further examinations were initiated. The final diagnosis was adjudicated by a study-independent physician. RESULTS 121 patients (60.3% male, median age 47 years, IQR 34-66.5 years) were included. The prevalence of ACS was 11.6%. Non-reproducible CWT had a high sensitivity of 92.9% (95% CI 66.1% to 98.8%) for ACS and the presence of reproducible CWT ruled out ACS (p=0.003) with a high negative predictive value (98.1%, 95% CI 89.9% to 99.7%). Conversely non-reproducible CWT ruled in ACS with low specificity (48.6%, 95% CI 38.8% to 58.5%) and low positive predictive value (19.1%, 95% CI 10.6% to 30.5%). CONCLUSIONS This prospective diagnostic study supports the concept that reproducible CWT helps to rule out ACS in patients with ACP in an early stage of the evaluation process. However, ACS and other diagnoses should be considered in patients with a negative CWT test. TRIAL REGISTRATION NUMBER ClinicalTrial.gov: NCT01724996.
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Affiliation(s)
- Christoph Gräni
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
| | - Manuel Bischof
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Pietro E Cippà
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Till Hauffe
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Lukas Zimmerli
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
- Center of Competence Multimorbidity and University Research Priority Program Dynamics of Healthy Aging, University of Zurich, Zurich, Switzerland
| | - Edouard Battegay
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
- Center of Competence Multimorbidity and University Research Priority Program Dynamics of Healthy Aging, University of Zurich, Zurich, Switzerland
| | - Daniel Franzen
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
- Pulmonary Division, University Hospital Zurich, Zurich, Switzerland
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[Chest pain units or chest pain algorithm?]. Med Klin Intensivmed Notfmed 2014; 109:495-503. [PMID: 25330873 DOI: 10.1007/s00063-013-0342-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND A large number of patients present to the emergency department (ED) for evaluation of acute chest pain. About 10-15% are caused by acute myocardial infarction (MI), and over 50% of cases are due to noncardiac reasons. Further improvement for chest pain evaluation appears necessary. OBJECTIVES What are current options to improve chest pain evaluation in Germany? METHODS A selective literature search was performed using the following terms: "chest pain", "emergency department", "acute coronary syndrome" and "chest pain evaluation". RESULTS AND DISCUSSION A working group of the German Society of Cardiology published recommendations for infrastructure, equipment and organisation of chest pain units in Germany, which should be separated from the ED of hospitals and be under the leadership of a cardiologist. A symptom-based decision for acute care would be preferable if all differential diagnoses of diseases could be managed by one medical specialty: However, all four main symptoms of patients with acute MI (chest pain, acute dyspnea, abdominal pain, dizziness) are also caused by diseases of different specialties. Evaluation and treatment of acute chest pain by representatives of one specialty would lead to over- or undertreatment of affected patients. Therefore we suggest a multidisciplinary evaluation of patients with acute chest pain including representatives of emergency and critical care physicians, cardiologists, internists, geriatricians, family physicians, premedics and emergency nurses. Definition of key indicators of performance and institutionalized feedback will help to further improve quality of care.
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Wood A, Hew R, McCann G. Noncardiac chest pain in a patient with cardiac pathology: the importance of an accurate history. JRSM Open 2014; 5:2042533313518916. [PMID: 25057379 PMCID: PMC4012672 DOI: 10.1177/2042533313518916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alice Wood
- Glenfield Hospital, Leicester LE3 9PQ, UK
| | - Roger Hew
- Leicester Royal Infirmary, Leicester LE1 5WW, UK
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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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Bidmead T, Goodacre S, Maheswaran R, O'Cathain A. Factors influencing unspecified chest pain admission rates in England. Emerg Med J 2014; 32:439-43. [DOI: 10.1136/emermed-2014-203678] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 05/23/2014] [Indexed: 11/03/2022]
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14
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Chest Pain Units in Deutschland. Notf Rett Med 2012. [DOI: 10.1007/s10049-012-1596-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Groarke J, O'Brien J, Go G, Susanto M, Owens P, Maree AO. Cost burden of non-specific chest pain admissions. Ir J Med Sci 2012; 182:57-61. [PMID: 22552895 DOI: 10.1007/s11845-012-0826-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 04/16/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-cardiac aetiologies are common among patients presenting with chest pain. AIM To determine the cost of non-specific chest pain admissions to a tertiary referral, teaching hospital. METHODS Thrombolysis in myocardial infarction risk (TIMI) risk score, lengths of stay (LOS), investigations and diagnoses were recorded for patients admitted with chest pain. Non-specific chest pain was defined as chest pain where cardiac, pulmonary and gastroesophageal aetiologies were excluded. Costs of admissions were calculated. RESULTS Of 80 patients, 34 (4%) and 22 (28%) were diagnosed with non-specific chest pain and acute coronary syndrome, respectively. Non-specific chest pain admissions had a mean age of 54 (11; 35-74) years, LOS of 3.8 (2.6; 1-11) days and TIMI risk score of 1.4 (1.5; 0-5). Acute coronary syndrome admissions had a mean age of 67 (14; 43-94) years, LOS of 7.7 (4.3; 2-16) days and TIMI risk score of 3.1 (1.2; 0-5). The mean cost per non-specific chest pain admission was €3,729 (2,378; 1,034-10,468), or 48% of the mean cost per acute coronary syndrome admission of €7,667 (4,279; 1,963-16,071). Bed day costs account for >90% of overall costs. Only 7% of patients were weekend discharges. The mean interval to exercise stress test was 2.7(1.5; 1-7) days. CONCLUSIONS The mean costs of admission and LOS for patients with non-specific chest pain are significant. Extrapolating findings, annual national cost is estimated at approximately €71 million for this cohort, with 73,000 bed days consumed nationally. Delays from admission to tests and low percentage of weekend discharges prolong LOS.
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Affiliation(s)
- J Groarke
- Department of Cardiology, Waterford Regional Hospital, Waterford, Ireland.
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Conti A, Poggioni C, Viviani G, Luzzi M, Vicidomini S, Zanobetti M, Innocenti F, Pini R, Padeletti L, Gensini GF. Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram. Am J Emerg Med 2012; 30:1698-705. [PMID: 22425002 DOI: 10.1016/j.ajem.2012.01.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 01/12/2012] [Accepted: 01/14/2012] [Indexed: 11/30/2022] Open
Abstract
AIM The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin. METHODS Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged. END POINT The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization. RESULTS Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001). CONCLUSIONS One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.
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Affiliation(s)
- Alberto Conti
- Department of Critical Care Medicine and Surgery, Careggi University Hospital, Florence, Italy.
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Fabbri A, Ottani F, Marchesini G, Galvani M, Vandelli A. Predicting unfavorable outcome in subjects with diagnosis of chest pain of undifferentiated origin. Am J Emerg Med 2012; 30:61-7. [DOI: 10.1016/j.ajem.2010.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 09/10/2010] [Accepted: 09/14/2010] [Indexed: 11/12/2022] Open
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Silva SA, Charon R, Wyer PC. The marriage of evidence and narrative: scientific nurturance within clinical practice. J Eval Clin Pract 2011; 17:585-93. [PMID: 21062389 DOI: 10.1111/j.1365-2753.2010.01551.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Published elaborations of evidence-based medicine (EBM) have failed to materially integrate the domains of interpersonal sensibility and relationship with tools intended to facilitate attention to biomedical research and knowledge within clinical practice. Furthermore, the elaboration of EBM skills has been confined to a narrow range of clinical research. As a result, crucial tools required to connect much clinically relevant research and practice remain hidden, and explorations of the deeper challenges faced by practitioners in their struggle to integrate sound science and shared clinical action remain elusive. METHODS We developed a model for scientifically informed, individualized, medical practice and learning that embraces the goals, resources and skills of EBM within a larger framework of practice defined by narrative process: 'attention', 'representation' and 'affiliation'. We drew from published elaborations of EBM, narrative medicine (NM) and the results of a project to develop tools for assessment of the cognitive skills embedded within a practice based EBM domain. RESULTS Within the resulting model, a tool of representation, whose components are Problem delineation, Actions, Choices and Targets, enables the clinical problem to be delineated and the patient and practitioner perspectives to be concretely defined with reference to four classes of clinical interaction: 'therapy', 'diagnosis', 'prognosis' and 'harm'. As a result, the 'information literacy' skills required to access, evaluate and apply clinical research using electronic resources are well defined but subordinated to shared appreciation of patient need. The model acknowledges the relevance of the full range and scope of scientifically derived medical knowledge. CONCLUSION A model based on integration of NM and EBM can lead to instructional tools that integrate clinical epidemiological knowledge with enforced consideration of differing patient and practitioner perspectives. It also may inform avenues for qualitative research into the processes through which such differing perspectives can be productively identified and shared.
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Acute Coronary Syndromes: Presentation with ACS. ARC and NZRC Guideline 2011. Emerg Med Australas 2011; 23:302-7. [DOI: 10.1111/j.1742-6723.2011.01422_18.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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Walters DL, Cunningham C. Managing acute coronary syndromes in the prehospital and emergency setting: New guidelines from the Australian Resuscitation Council and New Zealand Resuscitation Council. Emerg Med Australas 2011; 23:240-3. [DOI: 10.1111/j.1742-6723.2011.01424.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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22
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O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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23
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Utilizing DMAIC Six Sigma and Evidence-Based Medicine to Streamline Diagnosis in Chest Pain. Qual Manag Health Care 2010; 19:107-16. [DOI: 10.1097/qmh.0b013e3181db6432] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Furtado MV, Cardoso A, Patrício MC, Rossini APW, Campani RB, Meotti C, Nasi LA, Polanczyk CA. Influence of implementation of a chest pain unit on acute coronary syndrome outcomes. J Emerg Med 2009; 40:557-64. [PMID: 20022199 DOI: 10.1016/j.jemermed.2009.08.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 08/24/2009] [Accepted: 08/30/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Different strategies have been described to increase promptness and efficiency in the assessment and management of patients with acute chest pain and acute coronary syndrome (ACS) in the emergency department (ED). OBJECTIVE The objective of this study is to evaluate the results of implementing a Chest Pain Unit (CPU) to assist patients with ACS, and to determine its impact on quality of health care indexes and clinical outcomes. METHODS A study was conducted with a prospective cohort of patients admitted to the ED with a chief complaint of acute chest pain or suspected ACS at two different time periods: before (n = 663) and after (n = 450) introducing a CPU as part of the ED. Quality-of-care indexes analyzed in this study were adherence to a critical pathway, length of hospital stay, and hospital mortality. RESULTS There was increased adherence to a critical pathway during the CPU period compared to the period with no designated CPU area, including compliance with prescribing aspirin, beta-blockers, and angiotensin-converting enzyme inhibitor, and performing coronary angiography in high-risk patients. After adjustment to baseline characteristics, admissions to a CPU resulted in a 65% reduction in mortality (odds ratio 0.35; 95% confidence interval 0.14-0.88; p = 0.03). There was no difference in median length of hospital stay, 7 days (interquartile range [IQR] 4-12) before CPU and 6 days (IQR 4-11) after introducing the CPU (p = 0.10). CONCLUSION In the scenario of a crowded ED, implementation of a CPU was associated with greater adherence to a critical pathway for patients with ACS, with a concomitant reduction in mortality rates.
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Affiliation(s)
- Mariana V Furtado
- Graduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Loten C, Isbister G, Jamcotchian M, Hullick C, MacElduff P, Attia J, Marley J. Adverse outcomes following emergency department discharge of patients with possible acute coronary syndrome. Emerg Med Australas 2009; 21:455-64. [DOI: 10.1111/j.1742-6723.2009.01229.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Scott I, Vaughan L, Bell D. Effectiveness of acute medical units in hospitals: a systematic review. Int J Qual Health Care 2009; 21:397-407. [DOI: 10.1093/intqhc/mzp045] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Johnson M, Goodacre S, Tod A, Read S. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2009; 65:120-9. [DOI: 10.1111/j.1365-2648.2008.04849.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Oluboyede Y, Goodacre S, Wailoo A. Cost effectiveness of chest pain unit care in the NHS. BMC Health Serv Res 2008; 8:174. [PMID: 18700961 PMCID: PMC2527313 DOI: 10.1186/1472-6963-8-174] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 08/13/2008] [Indexed: 12/16/2022] Open
Abstract
Background Acute chest pain is responsible for approximately 700,000 patient attendances per year at emergency departments in England and Wales. A single centre study of selected patients suggested that chest pain unit (CPU) care could be less costly and more effective than routine care for these patients, although a more recent multi-centre study cast doubt on the generalisability of these findings. Methods Our economic evaluation involved modelling data from the ESCAPE multi-centre trial along with data from other sources to estimate the comparative costs and effects of CPU versus routine care. Cost effectiveness ratios (cost per QALY) were generated from our model. Results We found that CPU compared to routine care resulted in a non-significant increase in effectiveness of 0.0075 QALYs per patient and a non-significant cost decrease of £32 per patient and thus a negative incremental cost effectiveness ratio. If we are willing to pay £20,000 for an additional QALY then there is a 70% probability that CPU care will be considered cost-effective. Conclusion Our analysis shows that CPU care is likely to be slightly more effective and less expensive than routine care, however, these estimates are surrounded by a substantial amount of uncertainty. We cannot reliably conclude that establishing CPU care will represent a cost-effective use of health service resources given the substantial amount of investment it would require.
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Affiliation(s)
- Yemi Oluboyede
- Health Economics and Decision Science (HEDS), School of health and related research, University of Sheffield, 30 Regent Street,Sheffield, UK.
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Body R. Emergent diagnosis of acute coronary syndromes: Today's challenges and tomorrow's possibilities. Resuscitation 2008; 78:13-20. [DOI: 10.1016/j.resuscitation.2008.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Revised: 11/14/2007] [Accepted: 02/11/2008] [Indexed: 12/22/2022]
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Abstract
Trial shows no benefit overall, but success may vary as a result of operational factors that are difficult to measure
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