Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

An accelerated emergency department diagnostic protocol for chest pain reduced hospitalization and costs

ACP J Club. 1998 May-June;128:78. doi:10.7326/ACPJC-1998-128-3-078


Source Citation

Roberts RR, Zalenski RJ, Mensah EK, et al. Costs of an emergency department-based accelerated diagnostic protocol vs hospitalization in patients with chest pain. A randomized controlled trial. JAMA. 1997 Nov 26;278:1670-6. [PubMed ID: 9388086]


Abstract

Question

In selected patients presenting to the emergency departmetn (ED) with chest pain, how do the costs of an accelerated diagnostic protocol (ADP) compare with those of usual care based on hospitalization?

Design

Randomized controlled trial.

Setting

886-bed U.S. public teaching hospital.

Patients

166 patients > 20 years of age who were admitted by the ED attending physician for evaluation of chest pain, had a low probability (≥ 1 risk factor for coronary artery disease (diabetes mellitus, hypertension, or tobacco use). Follow-up was 99%.

Intervention

83 patients were allocated to the ADP intervention. Until a diagnostic end point was reached (i.e., positive creatine kinase-MB [CK-MB] level, recurrent chest pain, or electrocardiographic findings consistent with myocardial ischemia) or the protocol was completed, patients in the ADP group received rhythm monitoring (for 12 h), CK-MB level monitoring (at 0, 4, 8, and 12 h), electrocardiograms (at 0, 6, and 12 h), clinical examination and review of test results (at 0, 6, and 12 h or for any change in condition), aspirin, 2 L of oxygen by nasal cannula, and an intravenous line. 83 patients were allocated to usual care (admission to the telemetry unit, 3 sets of cardiac enzyme level studies, 2 electrocardiograms, and cardiac and clinical monitoring for 24 h). Management was at the discretion of the internal medicine attending physician.

Main cost and outcome measures

Hospital admission rate, length of hospital stay, and total direct treatment cost (fixed and variable). Admission status of patients in the ADP group was defined as ADP discharge (negative stress test result) or ADP admission (positive results before stress test or positive or indeterminate stress test results).

Main results

37 patients (45.1%) in the ADP group were admitted compared with 83 patients (100%) in the control group (P < 0.001). The mean length of stay was lower for patients in the ADP group than for those in the control group (33.1 vs 44.8 h, P < 0.01), as was the total mean cost (U.S. $1528 vs $2095, P < 0.001).

Conclusion

An accelerated diagnostic protocol for patients who presented to an ED with chest pain and had already been initially selected for admission by the ED attending physician was associated with fewer admissions, a shorter mean hospital stay, and a lower total mean cost compared with usual care based on hospitalization.

Source of funding: Agency for Health Care Policy and Research.

For article reprint: Dr. R.R. Roberts, Department of Emergency Medicine, Cook County Hospital, 1900 West Polk Street, 10th Floor, Chicago, IL 60612, USA. FAX 312-633-8189.


Commentary

Roberts and colleagues report on a well-designed, randomized controlled trial butrestrict themselves to a cost comparison. Details of the diagnostic value of the ADP have been published previously (1). These details may be even more important to clinicians.

The study adds to a growing number of reports that conclude that ED-based ADPs are safe and cost-effective alternatives to classic hospitalization of patients presenting with chest pain. It deals with several criticisms that have been raised about previous studies (e.g., problems with group comparability, inclusion of patients at low risk, and inadequate definition of costs).

The study was performed in a public institution with limited resources, and almost no invasive procedures were done in the control group (resulting in a relatively low cost). Patients at very low risk were excluded, and the standard chest pain evaluation for the control group was less aggressive than for the ADP group. These factors are likely to introduce a bias toward a null effect. Therefore, the apparent difference in favor of ADP is strengthened. As stated by Hoekstra and Gibler (2), this study provides a cost comparison that can be considered a worst-case scenario.

U.S. patients with chest pain are assessed in EDs with technologic facilities that enable observation for a period of hours or even days if necessary. In Europe and elsewhere, such patients are initially assessed by general practitioners, either at their office or at the patient's home, with less technology and less time available to make the decision. It would be worthwhile to see how elements of the ED ADP strategy can be incorporated into such outpatient clinical care.

Frank Buntinx, MD, PhD
University of Leuven and MaastrichtLeuven, Belgium

Frank Buntinx, MD, PhD
University of Leuven and Maastricht
Leuven, Belgium


References

1. Zalenski RJ, McCarren M, Roberts R, et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:1085-91. [PubMed ID: 9164374]

2. Hoekstra JW, Gibler WB. Chest pain evaluation units: an idea whose time has come. JAMA. 1997;278:1701-2. [PubMed ID: 9388093]