Rewarding teaching faculty with a reimbursement plan

OBJECTIVE

To develop a system for measuring the teaching effort of medical school faculty and to implement a payment system that is based on it.

DESIGN

An interventional study with outcomes measured before and after the intervention.

SETTING

A department of internal medicine with a university hospital and an affiliated Veterans Administration hospital.

INTERVENTION

We assigned a value in teaching units to each teaching activity in proportion to the time expended by the faculty and the intensity of their effort. We then calculated total teaching units for each faculty member in the Division of General Internal Medicine and for combined faculty effort in each subspecialty division in the Department of Medicine. After determining the dollar value for a teaching unit, we distributed discretionary teaching dollars to each faculty member in the Division of General Internal Medicine and to each subspecialty division according to total teaching units.

MEASUREMENTS AND MAIN RESULTS

The distribution of discretionary teaching dollars was determined. In the year after the intervention, there was a substantial redistribution of discretionary teaching dollars among divisions. Compared with an increase in total discretionary dollars of 11.4%, the change in allocation for individual divisions ranged from an increase of 78.2% to a decrease of -28.5%. Further changes in the second year after the intervention were modest. The distribution of teaching units among divisions was similar to the distribution of questions across subspecialties on the American College of Physicians In-Training Examination (r =.67) and the American Board of Internal Medicine Certifying Examination (r =.88).

CONCLUSIONS

It is possible to measure the value of teaching effort by medical school faculty and to distribute discretionary teaching funds among divisions according to the value of teaching effort. When this intervention was used at our institution, there were substantial changes in the amounts received by some divisions. We believe that the new distribution more closely approximates the desired distribution because it reflects the desired emphasis on knowledge as measured by two of the most experienced professional groups in internal medicine. We also believe that our method is flexible and adaptable to the needs of most clinical teaching

Development and implementation of a teaching practice plan in a department of medicine (1995-1998): relative teaching units (RTU's)

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Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain

BACKGROUND

Patients who come to the emergency department with chest pain are a heterogeneous group. Some have ischemic heart disease that may lead to serious complications, whereas others have minor disorders. We performed a study to identify clinical factors that predict which patients will have complications requiring intensive care.

METHODS

We first studied 10,682 patients with acute chest pain at seven hospitals between 1984 and 1986 (derivation set) to identify potential clinical predictors of the development of major complications. We then validated these predictors in a separate set of 4676 patients at one hospital between 1990 and 1994 (validation set).

RESULTS

In the derivation set of patients, we identified the following set of clinical features, which, if present in the emergency department, were associated with an increased risk of complications: ST-segment elevation or Q waves on the electrocardiogram thought to indicate acute myocardial infarction, other electrocardiographic changes indicating myocardial ischemia, low systolic blood pressure, pulmonary rales above the bases, or an exacerbation of known ischemic heart disease. On the basis of these criteria, the patients in the validation set were stratified into four groups, with the risk of major complications in the first 12 hours ranging from 0.15 to 8 percent. After 12 hours, the probability of a major complication could be updated on the basis of whether the patient had already had a complication of major severity, a complication of intermediate severity, or a myocardial infarction (independent relative risks, 18.9, 7.7 and 4.0, respectively, as compared with patients without prior complications or myocardial infarction).

CONCLUSIONS

The risk of major complications in patients with acute chest pain can be estimated on the basis of the clinical presentation and new clinical observations made during the hospital course. These estimates of risk help in making rational decisions about the appropriate level of medical care for patients with acute chest pain.

Relationship of age with eligibility for thrombolytic therapy and mortality among patients with suspected acute myocardial infarction

OBJECTIVE

To determine the relationship of age and the percentage of patients presenting to the emergency department with myocardial infarction who meet conventional electrocardiographic and time-to-presentation criteria for thrombolytic therapy.

DESIGN

Prospective cohort study.

SETTING

Emergency departments of three university hospitals and four community hospitals.

PATIENTS

Patients enrolled in the Multicenter Chest Pain Study, an investigation of patients aged 30 years or older presenting to the emergency department with the chief complaint of anterior, precordial, or left lateral chest pain unexplained by obvious local trauma or abnormalities on the chest radiograph.

INTERVENTIONS

None.

MEASUREMENTS

The frequency of patients who presented with conventional electrocardiographic and time-to-presentation criteria for thrombolysis.

MAIN RESULTS

Of a total of 12,140 patients who were enrolled in the Multicenter Chest Pain Study, 10,850 had information about their electrocardiogram and their time-to-presentation. Acute myocardial infarction occurred in 1,584 patients, 746 of whom were over age 65. Among patients presenting to the emergency department with acute myocardial infarction, the proportion who arrived within 6 hours of the onset of pain and had ST-segment elevation or pathologic Q-waves not known to be old decreased significantly with increasing age, from 34% in patients under 65 years to 18% for those 75 years and older. In addition, comorbidities that would have contraindicated thrombolytic therapy were present in an additional 12% of myocardial infarction patients who were older than 65 years.

CONCLUSION

Although other analyses have shown that thrombolytic therapy is cost-effective for eligible elderly patients with acute myocardial infarction, only a small percentage of very elderly patients who present to the emergency department with acute myocardial infarctions meet current eligibility criteria to receive it, so thrombolysis is unlikely to narrow the difference in mortality rates for young as compared with elderly patients with acute infarctions.

Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain

OBJECTIVE

1) To determine whether the frequencies of panic disorder (PD) and depression (DEP) in an emergency department (ED) population were comparable to those in other primary care groups; 2) to evaluate whether patients without the clinical diagnosis of acute cardiac ischemia (ACI) had higher frequencies of these disorders; and 3) to identify characteristic clinical findings in patients with PD or DEP.

SETTING

An urban teaching hospital ED.

PATIENTS

Three hundred thirty-four patients with acute chest pain were evaluated prospectively over an eight-week period. The cohort participating (69%-229/334) completed psychiatric screening measures, including the Panic Disorder Self-Rating Scale, the Beck Depression Inventory, and the Zung Self-Rating Anxiety Scale.

MEASUREMENTS AND MAIN RESULTS

A symptom profile consistent with PD was identified in 17.5% of the patients (40/229), DEP in 23.1% (53/229), and either disorder in 35% (80/229). The prevalences of PD were similar in those with and without ACI (19.4% vs 16.6%, respectively, p > 0.05). The likelihoods of one or more ED visits for chest pain in the previous year were significantly greater in those with PD (57.5% vs 36%, p < 0.05) and DEP (54% vs 35%, p < 0.05) than in those without these psychiatric disorders.

CONCLUSION

This study suggests that approximately one in three patients presenting to the ED with acute pain has symptoms consistent with a psychiatric disorder. These disorders occur frequently in both those with and those without acute cardiac ischemia, and clinical variables may help identify these frequent ED utilizers.

Effect of race on the presentation and management of patients with acute chest pain

OBJECTIVE

To compare racial differences in clinical presentation, natural history, and access to medical care and procedures among emergency-department patients with acute chest pain.

DESIGN

Prospective follow-up study of consecutive patients coming to the emergency department because of acute chest pain.

SETTING

Two university medical centers.

PATIENTS

A total of 3031 patients who were 30 years or older and who came to the emergency department with acute chest pain from 1984 to 1986.

MAIN RESULTS

African-Americans tended to have slightly, but not always significantly, lower rates of acute myocardial infarction, acute ischemic heart disease, and major complications, after adjusting for presenting symptoms and signs; the adjusted odds ratios for African-Americans were as follows: 0.77 (95% CI, 0.54 to 1.1) for acute myocardial infarction, 0.75 (CI, 0.59 to 0.95) for ischemic heart disease, and 0.79 (CI, 0.45 to 1.4) for death or major complications. Clinical factors classically associated with acute myocardial infarction were equally predictive in African-Americans and whites. After adjustments were made for multiple clinical factors, a lower proportion of African-Americans were admitted to the hospital (odds ratio, 0.69; CI, 0.56 to 0.84), and, once admitted, were somewhat less likely to be triaged to the coronary care unit (odds ratio, 0.81; CI, 0.65 to 1.0). In adjusted analyses, African-Americans were as likely to undergo cardiac catheterization as whites (odds ratio, 0.86; CI, 0.64 to 1.2) but were less likely to undergo coronary artery bypass procedures once severity of coronary disease was included in the analysis (odds ratio, 0.24; CI, 0.08 to 0.71).

CONCLUSION

African-Americans and whites had a similar presentation and natural history of acute myocardial infarction and, after adjusting for probability of clinical events, similar access to most medical care and cardiac procedures. However, the rate of coronary artery bypass procedures was much lower among African-Americans than among whites. Reasons for this difference should be studied.

Impact of physician experience on triage of emergency room patients with acute chest pain at three teaching hospitals

PURPOSE

To determine whether the experience of the physician (as measured by postgraduate training level or time during the academic year) who performs the initial evaluation affects the triage of patients with acute chest pain.

PATIENTS AND METHODS

Prospective data on the presenting clinical features, initial triage, final diagnosis, and complications were collected for 7,857 patients who presented to the emergency rooms of three teaching hospitals, including 1,118 (14%) with acute myocardial infarction (AMI), 2,477 (32%) with acute ischemic heart disease (AIHD) (i.e., AMI or unstable angina), and 335 (4%) with major complications. The experience of the evaluating physicians, who were in their first three postgraduate years in 93% of cases, was measured in three ways: (1) postgraduate training level, (2) month during the academic year, and (3) number of patients with acute chest pain previously evaluated. Multivariate logistic regression analyses that adjusted for hospital site and 20 clinical variables estimated the odds ratios for admission to the coronary care unit (CCU) and hospital associated with each incremental increase in physician experience.

RESULTS

With more experience (as measured by postgraduate training level or time during the academic year), the sensitivity of physicians for admitting patients with AMI, AIHD, or major complications to the hospital increased. For example, each incremental increase in postgraduate training level carried a 1.4 increase in the adjusted odds ratio for admission of a patient with AIHD to the hospital (p less than 0.05), corresponding to an increase in the probability of admission from 93% to 97%. However, increasing physician experience was also associated with an elevated false-positive rate in admitting patients without these diagnoses to the CCU and hospital. Thus, each incremental increase in postgraduate training level carried a 1.2 increase in the adjusted odds ratio for admission of a patient without AIHD to the CCU and hospital (p less than 0.005), corresponding to an increase in the probability of admission from 34% to 47%. By receiver operating characteristic curve (ROC) regression analyses, these changes in triage patterns were consistent with movement along a single ROC curve, rather than a shift to a new or better ROC curve.

CONCLUSIONS

As the experience of the physician who performed the initial evaluation increased, there was a lower threshold for admitting all patients with and without AMI, AIHD, or major complications to the CCU and hospital without a detectable improvement in diagnostic accuracy.

Ruling out acute myocardial infarction. A prospective multicenter validation of a 12-hour strategy for patients at low risk

BACKGROUND

Although previous investigations have suggested that 24 hours is required to exclude acute myocardial infarction in patients who are admitted to a coronary care unit for the evaluation of acute chest pain, we hypothesized that a 12-hour period might be adequate for patients with a low probability of infarction at the time of admission.

METHODS

Using a Bayesian model, we developed a strategy to identify candidates for a shorter period of observation from an analysis of a derivation set of 976 patients with acute chest pain who were admitted to three teaching and four community hospitals. In the derivation set, patients whose clinical characteristics in the emergency room predicted a low (less than or equal to 7 percent) probability of myocardial infarction had only a 0.4 percent risk of infarction if they had neither abnormal levels of cardiac enzymes nor recurrent ischemic pain during the first 12 hours of hospitalization. In an independent testing set of 2684 patients from the seven hospitals, 957 admitted patients (36 percent) were classified as candidates for this 12-hour period of observation according to a previously published multivariate algorithm. Few of these patients were actually transferred from a monitored setting at 12 hours.

RESULTS

Of the 771 candidates for a 12-hour period of observation who did not have enzyme abnormalities or recurrent pain during the first 12 hours, 4 (0.5 percent) were subsequently found to have acute myocardial infarction, and only 3 (0.4 percent) died after primary cardiac arrests, all of which occurred three to five days after admission. Rates of other major cardiovascular complications were low in the patients who might have been transferred from the coronary care unit after 12 hours with this strategy. In patients with a higher initial risk of infarction, the standard strategy of 24-hour observation identified all but 11 of 739 acute myocardial infarctions (1 percent).

CONCLUSIONS

Emergency room clinical data can be used to identify a large subgroup of patients for whom a 12-hour period of observation is normally sufficient to exclude acute myocardial infarction. Patient-specific evaluation and treatment can then proceed without the restrictions imposed by "rule-out" protocols for myocardial infarction.

Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain

STUDY OBJECTIVE

To determine whether information from a prior electrocardiogram (ECG) improves diagnostic accuracy in the emergency department (ED) evaluation of patients with acute chest pain.

DESIGN

Analysis of prospectively collected data from a cohort study.

SETTING

Emergency departments of four community and three university hospitals.

PATIENTS

5,673 patients aged greater than or equal to 30 years who presented to the EDs of participating hospitals for evaluation of acute chest pain, including 772 (14%) with acute myocardial infarction (AMI).

MEASUREMENTS AND MAIN RESULTS

After adjusting for clinical characteristics, no significant difference was found in the sensitivities of admission to the hospital or to the coronary care unit (CCU) between AMI patients with and without prior ECGs available for review. However, non-AMI patients with prior ECGs available for review were more likely to avoid CCU admission than were non-AMI patients without prior ECGs. This improvement in specificity was most marked in the 2,024 patients whose current ED ECGs had changes consistent with ischemia or infarction: when a prior ECG was available, non-AMI patients were more than twice as likely to be discharged (26% vs. 12%) and about 1.5 times as likely to avoid CCU admission (39% vs. 27%) (both p less than 0.0001). Admission rates of AMI patients with and without prior ECGs were similar.

CONCLUSION

When the current ECG is consistent with ischemia or infarction, the availability of a prior ECG for comparison to determine whether the ECG changes are old or new improves diagnostic accuracy and triage decisions by reducing the admission of patients without AMI or acute ischemic heart disease (increased specificity) without reducing the admission of patients with these diagnoses (unchanged sensitivity).

Comparison of the natural history of new onset and exacerbated chronic ischemic heart disease. The Chest Pain Study Group

To compare the natural history of patients with new onset ischemic heart disease with that of patients with exacerbations of chronic ischemic heart disease, short- and long-term outcomes of 3,465 emergency room patients with acute ischemic heart disease at four community and three university hospitals were evaluated. Acute myocardial infarction was diagnosed in 598 (33%) of the 1,835 patients with a prior history of infarction or angina and 934 (57%) of the 1,630 without such a history (p less than 0.001). Patients with new onset ischemic heart disease with acute myocardial infarction were more likely than patients with infarction and exacerbated chronic ischemic heart disease to have Q wave infarction (57% versus 36%) and to receive thrombolytic therapy (11% versus 5%); they also had higher maximal creatine kinase levels (1,088 +/- 1,299 versus 733 +/- 906 U/liter) (p less than 0.0001 for all three). After adjustment for differences in clinical presentation and initial triage, patients with new onset ischemic heart disease with acute myocardial infarction were less likely than the comparison group to have congestive complications (odds ratio 0.63, 95% confidence interval 0.47 to 0.84, p less than 0.01) but not less likely to have arrhythmic, ischemic or overall complications. Among patients with angina without acute myocardial infarction, patients with new onset ischemic heart disease were less likely to have recurrent ischemic pain and congestive heart failure. In multivariate analysis of long-term follow-up data on 457 patients from one hospital, patients with new onset ischemic heart disease had better cardiovascular survival rates.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcomes in patients with myocardial infarction who are initially admitted to stepdown units: data from the Multicenter Chest Pain Study

PURPOSE

To assess whether the admission of patients with chest pain to a stepdown unit would jeopardize the outcome of those patients who ultimately "ruled in" for a myocardial infarction.

PATIENTS AND METHODS

We compared the risk of an adverse outcome in initially uncomplicated, "rule-out myocardial infarction" patients who were admitted directly to a stepdown unit (n = 58) or to a coronary care unit (n = 409) at 6 hospitals and who then ultimately "ruled in" for a myocardial infarction.

RESULTS

An adverse outcome (death, serious complication, or invasive intervention) occurred in 16 (28%) stepdown unit patients compared with 159 (39%) coronary care unit patients. Among patients eligible for initial care in either location, the risk of an adverse outcome after controlling for clinical characteristics was similar in the two groups using each of two different multivariate approaches.

CONCLUSION

Although our study was not of sufficient size to exclude the possibility of a small benefit from initial triage to a coronary care unit, our data suggest that (1) admission of initially uncomplicated chest pain patients with a relatively low probability of acute myocardial infarction to a stepdown unit does not seriously jeopardize those who eventually "rule in" for myocardial infarction; and (2) larger observational or randomized studies, which could reduce the residual possibility of somewhat higher risk in the stepdown unit, would be ethical to perform.

Prediction of cardiac and pulmonary complications related to elective abdominal and noncardiac thoracic surgery in geriatric patients

PURPOSE

Major cardiac and pulmonary complications associated with abdominal and noncardiac thoracic surgery are a common cause of mortality and serious morbidity in elderly patients. We postulated that a simple, inexpensive bicycle exercise test could provide objective documentation of cardiopulmonary reserve and, therefore, predict perioperative pulmonary as well as cardiac complications.

PATIENTS AND METHODS

Prior to elective surgery, 177 patients aged 65 years or older had assessment of the clinical history, results of physical examination, electrocardiogram, chest radiograph, blood chemistries, pulmonary function test findings, supine exercise test results, Dripps classification, and Goldman cardiac risk factors. Observations in patients with and without major perioperative cardiac and/or pulmonary complications were compared using univariate analysis followed by a multivariate logistic regression procedure.

RESULTS

Major perioperative complications were pulmonary in 24 patients, cardiac in 25 patients, and either cardiac or pulmonary in 39 patients. By multivariate analysis, inability to perform two minutes of supine bicycle exercise raising the heart rate above 99 beats/minute was the best predictor of perioperative pulmonary, cardiac, and combined cardiopulmonary complication (p less than 0.0005). Among 108 patients who were able to achieve these exercise criteria, cardiac or pulmonary complications occurred in 10 patients (9.3%), with one death (0.9%). Among 69 patients unable to exercise satisfactorily, cardiac or pulmonary complications occurred in 29 patients (42%), with five total deaths (7.2%).

CONCLUSION

Objective measurement of exercise capacity by supine bicycle ergometry appears to be of clinical value for preoperative risk stratification for both pulmonary and cardiac complications prior to major elective abdominal or noncardiac thoracic surgery in elderly patients.

Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study)

To determine the prevalence and characteristics of acute myocardial infarction (AMI) patients who present to emergency departments with normal or nonspecific electrocardiograms (ECGs), data were analyzed from 7,115 consecutive patients in the Multicenter Chest Pain Study. AMI patients with normal or nonspecific initial ECGs (n = 107) were less likely to have a past history of coronary artery disease or to be diaphoretic on presentation (p less than 0.01) than AMI patients with initial ECGs highly suggestive of AMI (n = 811). The overall probability of AMI among patients with chest pain and initially normal or nonspecific ECGs was 3%, but ranged from less than 1 to 17% depending on the patient's age and sex and whether the patient had pressure-type pain or pain radiating to the shoulder, neck or arms. Among initially admitted patients, the time elapsed between onset of pain and presentation was similar in both groups. However, the time between onset of pain and definitive diagnosis of AMI by enzymes or clinical course was longer in patients with initially normal or nonspecific electrocardiograms (8.3 vs 7.5 hours, p less than 0.05), their peak creatine kinase levels were lower (mean 643 vs 1,032 mg/dl, p less than 0.001) and their mortality was slightly lower (6 vs 12%, p = 0.10). These findings suggest that AMI patients with initially normal or nonspecific ECGs may have a less severe short-term clinical outcome.

The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group

OBJECTIVE

To identify differences in the incidences of myocardial infarction in women and men with chest pain.

DESIGN

Prospective multicenter cohort study.

SETTING

Emergency rooms of three university and four community hospitals.

PATIENTS

7,734 emergency room patients with acute chest pain.

MEASUREMENTS AND MAIN RESULTS

Myocardial infarction was diagnosed in 10% of the 3,896 women, compared with 19% of the 3,838 men, yielding an age-adjusted relative risk of myocardial infarction for women of 0.54 (95% confidence interval 0.48, 0.60). Physicians were equally adept at admitting women and men with myocardial infarctions, but men without myocardial infarction or unstable angina were significantly more likely to be admitted than were women without these diagnoses. Most clinical and electrocardiographic features indicating a risk of myocardial infarction were present in both women and men, but several high-risk features were less commonly present in women. After adjusting for the other factors that correlate with each patient's probability of having acute myocardial infarction, the relative risk of myocardial infarction was the same in women as men when the emergency department electrocardiogram showed the classic changes associated with acute myocardial infarction, but the risk was 40% lower in women when such electrocardiographic changes were not present.

CONCLUSIONS

Clinical features that predict myocardial infarction in men predict myocardial infarction in women to a similar extent. However, female gender is associated with about a 40% lower rate of myocardial infarction except when classic electrocardiographic evidence is present on the emergency department electrocardiogram.

Candidates for thrombolysis among emergency room patients with acute chest pain. Potential true- and false-positive rates

STUDY OBJECTIVE

To assess the potential clinical impact of thrombolytic therapy for acute myocardial infarction by determining true-positive and false-positive rates of criteria for eligibility among emergency room patients with acute chest pain.

DESIGN

Prospective multicenter cohort study.

SETTING

Emergency rooms of three university and four community hospitals.

PATIENTS

Emergency room patients (7734) with acute chest pain.

MEASUREMENTS AND MAIN RESULTS

Only 261 (23%) of 1118 patients with acute myocardial infarctions were 75 years of age or younger, presented within 4 hours of the onset of pain, and had emergency room electrocardiograms showing probable acute myocardial infarction: 60 (0.9%) of the 6616 patients without infarction also met these criteria (positive predictive value, 261/321 = 81%; CI, 77% to 86%). The positive predictive value could increase to about 88% (CI, 82% to 93%) if eligibility were based on the official hospital electrocardiogram reading.

CONCLUSIONS

Because experience from published studies suggests that about one third of patients who meet these three eligibility criteria have other contraindications to thrombolysis, we estimate that about 15% of patients with acute myocardial infarction would meet the criteria for eligibility for thrombolysis that have been used in clinical trials at the time of emergency room presentation. Further, for every eight patients with true-positive results who are treated, one to two patients with false-positive results may also be treated if decisions are based on the interpretation of a single electrocardiogram.

Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the Multicenter Chest Pain Study experience

To assess whether the manifestations of acute ischemic heart disease in the elderly are less typical than in younger patients, the presenting clinical features and their associated relative risks for acute myocardial infarction (AMI) were compared in 2,625 patients greater than or equal to 65 years of age and 5,109 patients less than 65 years of age. These patients were evaluated for acute chest pain in the emergency departments of 7 hospitals. The same features were associated with increased relative risks for AMI in younger and elderly patients. The relative risks among older patients, however, were consistently closer to 1.0 for classic features, including male gender, pressure-like quality of pain, substernal location, typical pattern of pain radiation and electrocardiographic evidence of ischemia or AMI. Analyses for the endpoint "acute ischemic heart disease" (i.e., AMI or unstable angina) yielded similar findings. Elderly patients were more likely to be admitted to the hospital (56 vs 35%; p less than 0.0001) and to the coronary care unit (37 vs 23%; p less than 0.0001) in the absence of either AMI or unstable angina. These data support the hypothesis that diagnosis of acute chest pain is especially difficult in elderly patients.

Limitations of chest pain follow-up from an urban teaching hospital emergency department

Close outpatient follow-up of chest pain patients released from the emergency department (ED) has been suggested as an important means of detecting atypical presentations of cardiac ischemia. Urban teaching hospital patient populations often have limited private physician follow-up options and rely upon standard teaching hospital clinic systems. We analyzed the follow-up of 318 patients 30 or more years of age with nontraumatic chest pain released from the ED of a large urban teaching hospital. The planned disposition of the released patients was as follows: a medical clinic (136), another clinic or a private physician (76), or ED "as needed" (98); in addition, some patients left against medical advice (AMA) (8). The medical clinics received only 38% (51/136) of planned referrals. No subsequent record could be found for 13% (17/136) of referred patients. Only 17% (23/136) of referred patients were reevaluated within seven days. Two of the patients referred to medical clinics were admitted to the hospital within 24 hours for unstable angina and another was admitted from a medical clinic 16 days after ED evaluation with an acute myocardial infarction. Of patients with ED follow-up "as needed," one patient required admission for unstable angina 27 days after ED evaluation. Of the patients who left AMA, only two were reevaluated within 30 days. These findings suggest that specific measures to enhance follow-up must be instituted at urban teaching hospitals if chest pain patients are to be closely followed after ED release.

A computer protocol to predict myocardial infarction in emergency department patients with chest pain

To achieve more appropriate triage to the coronary care unit of patients presenting with acute chest pain, we used clinical data on 1379 patients at two hospitals to construct a simple computer protocol to predict the presence of myocardial infarction. When we tested this protocol prospectively in 4770 patients at two university hospitals and four community hospitals, the computer-derived protocol had a significantly higher specificity (74 vs. 71 percent) in predicting the absence of infarction than physicians deciding whether to admit patients to the coronary care unit, and it had a similar sensitivity in detecting the presence of infarction (88.0 vs. 87.8 percent). Decisions based solely on the computer protocol would have reduced the admission of patients without infarction to the coronary care unit by 11.5 percent without adversely affecting the admission of patients in whom emergent complications developed that required intensive care. Although this protocol should not be used to override careful clinical judgment in individual cases, the computer protocol for the most part yields accurate estimates of the probability of myocardial infarction. Decisions about admission to the coronary care unit based on the protocol would have been as effective as those actually made by the unaided physicians who cared for the patients, and less costly. Whether physicians who are aided by the protocol perform better than unaided physicians cannot be determined without further study.

Patients with acute chest pain who leave emergency departments against medical advice: prevalence, clinical characteristics, and natural history

The study group identified 107 patients who left against advice from the emergency departments of three university and four community hospitals after presenting for evaluation of acute chest pain. In comparison with other emergency department patients with acute chest pain, patients who left against advice had findings that suggested they were at higher risk for myocardial infarction than patients for whom admission was not recommended but at lower risk than patients who consented to be admitted. Specific follow-up plans were made at the time of evaluation for 45 patients (42%). Survival data were obtained at 48-72 hours for 104 patients (97%) and at one month for 101 patients (94%). Fourteen patients (12%) were hospitalized within three days of their original emergency department visits, and three patients had documented acute myocardial infarctions. The only death within one month was that of a patient who died suddenly out-of-hospital later on the day of his emergency department visit. The authors conclude that patients who left against medical advice had presentations and prognoses that were in between those of patients for whom admission was not recommended and those of patients who consented to be admitted.

Screening emergency room patients with atypical chest pain for depression and panic disorder

In response to recent reports relating atypical chest pain to normal coronary arteries and to various types of psychopathology, we developed a pilot study to investigate 1) the prevalence of depression and panic disorder among patients presenting to an emergency room with atypical chest pain, and 2) what the likelihood is of an emergency room physician recognizing the psychosocial factor. Of forty-nine subjects screened, 39 percent scored positively for depressive syndrome on the Center for Epidemiological Studies-Depression rating scale, 43 percent met criteria for panic attack and 16 percent met criteria for panic disorder by DSM-III. Although thirty subjects (61%) screened positively for depression or panic attack, only one received a psychiatric diagnosis of any kind. This pilot study suggests: 1) that the relationship between chest pain and psychopathology in emergency room patients deserves further rigorous study; 2) that depression and panic attacks in association with atypical chest pain may be underdiagnosed by the emergency room physician; and 3) that self-report screening measures as an aid to diagnosis in this population need to be more closely investigated.

Diagnostic implications for myocardial ischemia of the circadian variation of the onset of chest pain

To determine whether the occurrence of chest pain is randomly distributed during the day and to study whether the time of onset is useful in discriminating among causes of chest pain, patients older than 30 years who presented to 7 emergency departments with a chief complaint of chest pain unexplained by trauma or chest x-ray abnormalities were studied. A total of 7,759 patients presented during the study period; of these, 3,990 presented within 6 hours of the onset of pain and were included in the primary analysis. Chest pain caused by acute myocardial infarction, unstable angina pectoris and stable angina pectoris was more likely to begin during the period from 6 AM to noon than would be expected if the onset were uniformly distributed during the day (relative risks 1.15, 1.29 and 1.32, respectively), but chest pain that was caused by nonischemic cardiac causes and by noncardiac causes was also more likely to begin during the same time period (relative risks 1.28 and 1.17). Although chest pain from coronary arterial causes had a distinct circadian variation, the time of onset of pain was not a helpful criterion for determining the cause of chest pain.

A chest pain clinic to improve the follow-up of patients released from an urban university teaching hospital emergency department

During a 12-month period, 1,045 of 1,554 patients (67%) over age 30 seen in an urban teaching hospital emergency department with acute chest pain were released based on the clinical judgment of the examining physician. Patients who were released were offered follow-up within 24 to 72 hours in a hospital-based chest pain clinic. Of these 1,045 patients, 772 (74%) returned or were contacted by phone, and 29 were directly admitted; 14 had unstable angina, and eight had new myocardial infarctions. Because of its positive impact on the quality of care at an acceptable cost, the Chest Pain Clinic, which was originally instituted as part of a research protocol, has now become part of the routine spectrum of care provided at the University of Cincinnati Medical Center.

Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room

In a prospective multicenter investigation of emergency room patients with acute chest pain, physicians admitted 96% of patients with acute myocardial infarction (AMI) and discharged 4%. Of 35 patients who were sent home with AMI, only 11 (31%) returned to the same hospital because of persistent symptoms. Compared with a control group of 105 randomly selected patients with AMI who were admitted from the emergency room, patients in whom AMI was missed were significantly younger, had less typical symptoms and were less likely to to have had prior AMI or angina or to have electrocardiographic evidence of ischemia or infarction not known to be old. Despite the less typical presentations of patients in whom AMI was missed, after controlling for age and sex, the short-term mortality rate was significantly higher among patients in whom AMI was missed but in whom it was detected through our follow-up procedures than in admitted AMI patients. As determined by independent reviewers, 49% of the missed AMIs could have been diagnosed through improved electrocardiographic reading skills or by admission of patients with recognized ischemic pain at rest or ischemic electrocardiographic changes not known to be old.

Use of cardiac enzymes identifies patients with acute myocardial infarction otherwise unrecognized in the emergency department

Recognition of an acute myocardial infarction in the patient with chest pain is a frequent challenge to the clinician. Previous studies suggest that cardiac enzymes are of limited value in identifying patients with acute MI in the emergency department. Such studies have not evaluated the use of cardiac enzyme tests to complement decision making in the population of patients clinically designated for ED release. We studied 773 ED visits by patients age greater than or equal to 30 years presenting with chest pain unexplained by thoracic trauma or radiographic abnormalities. Cardiac enzyme levels were not available to the clinicians at the time of the initial visit and disposition of these patients was determined solely by clinical and ECG evaluation. Of the 291 admitted patients, 46 had an MI; 22 of the MI patients had a normal creatine kinase (CK) level. Of the 482 patients released from the ED, 181 patients had an elevated CK level. Among the released patients were five patients with MI. Four released MI patients had a CK level greater than or equal to 200 IU/L and three had an elevated CK-MB fraction (greater than or equal to 12 IU/L). In the population of patients scheduled for release, an elevated CK-MB had sensitivity, specificity, and positive predictive value for MI of 60%, 100%, and 60%, respectively. Although cardiac enzymes cannot be used in isolation to make admission decisions, selective use of CK-MB for final screening of patients otherwise scheduled for ED release may enhance the initial admission of patients with MI at risk for unintentional release.

Sensitivity of routine clinical criteria for diagnosing myocardial infarction within 24 hours of hospitalization

Myocardial infarction was diagnosed in 431 (30%) of 1460 patients with acute chest pain who had serial enzyme testing after admission to intensive or intermediate care units at three teaching and three community hospitals. The diagnosis was made within 12 hours of admission in 331 (77%) patients and within 24 hours in 415 (96%). Of the 16 patients with myocardial infarction who did not have enzyme abnormalities within 24 hours, 9 (56%) had recurrent ischemic pain during this 24-hour period. Of 451 patients who had neither enzyme abnormalities nor recurrent ischemic pain in the first 24 hours, only 7 (2%) ultimately met diagnostic criteria for myocardial infarction. These findings were prospectively validated in an independent testing set of 275 patients with myocardial infarction, 271 (99%) of whom either met diagnostic criteria for myocardial infarction or had recurrent ischemic pain within 24 hours of admission. These data suggest that 24 hours is nearly always a sufficient period to exclude myocardial infarction in patients without recurrent chest pain.

Cryptogenic group A streptococcal bacteremia: experience at an urban general hospital and review of the literature

The clinical features of group A beta-hemolytic streptococcal sepsis were studied in 15 consecutive patients seen at an urban general hospital over a two-year period. Although 14 of the 15 patients had underlying disease, no patient had malignancy and none had undergone immunosuppressive therapy. Only one infection was nosocomially acquired. Mortality was 20%. Bacteremia arose from a cutaneous infection in 10 cases, from pneumonia in two, and from the urinary tract in one. Streptococcal bacteremia was unexpected in the remaining patients, two women who presented with severe abdominal pain. Unlike most other patients described in the literature, neither woman had an identifiable primary focus of infection. A review of the literature for potential sources of group A streptococcal bacteremia revealed that this pathogen is not part of the indigenous flora of the normal host at any body site.