Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study
Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm...
| Main Authors: | , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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Wiley
2021-11-01
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| Series: | Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease |
| Subjects: | |
| Online Access: | https://www.ahajournals.org/doi/10.1161/JAHA.121.022539 |
| _version_ | 1811190554817462272 |
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| author | Dustin G. Mark Jie Huang Dustin W. Ballard Mamata V. Kene Dana R. Sax Uli K. Chettipally James S. Lin Sean C. Bouvet Dale M. Cotton Megan L. Anderson Ian D. McLachlan Laura E. Simon Judy Shan Adina S. Rauchwerger David R. Vinson Mary E. Reed |
| author_facet | Dustin G. Mark Jie Huang Dustin W. Ballard Mamata V. Kene Dana R. Sax Uli K. Chettipally James S. Lin Sean C. Bouvet Dale M. Cotton Megan L. Anderson Ian D. McLachlan Laura E. Simon Judy Shan Adina S. Rauchwerger David R. Vinson Mary E. Reed |
| author_sort | Dustin G. Mark |
| collection | DOAJ |
| description | Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA‐ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA‐ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48‐month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7‐day objective cardiac testing). Secondary outcomes were 30‐day objective cardiac testing, 60‐day major adverse cardiac events (MACE), and 60‐day MACE‐CR (MACE excluding coronary revascularization). Difference‐in‐differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30‐day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60‐day MACE risk (−2.5%, 95% CI −3.7 to −1.2%, P<0.001) and increased among patients with non‐low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (−1.0%, 95% CI −2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60‐day MACE or 60‐day MACE‐CR. Conclusions Implementation of RISTRA‐ACS was associated with better allocation of 30‐day objective cardiac testing and no change in index visit resource utilization or 60‐day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179. |
| first_indexed | 2024-04-11T14:52:59Z |
| format | Article |
| id | doaj.art-9fec98e1d8cc47f99b36ba57d3b2250d |
| institution | Directory Open Access Journal |
| issn | 2047-9980 |
| language | English |
| last_indexed | 2024-04-11T14:52:59Z |
| publishDate | 2021-11-01 |
| publisher | Wiley |
| record_format | Article |
| series | Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease |
| spelling | doaj.art-9fec98e1d8cc47f99b36ba57d3b2250d2022-12-22T04:17:21ZengWileyJournal of the American Heart Association: Cardiovascular and Cerebrovascular Disease2047-99802021-11-01102210.1161/JAHA.121.022539Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort StudyDustin G. Mark0Jie Huang1Dustin W. Ballard2Mamata V. Kene3Dana R. Sax4Uli K. Chettipally5James S. Lin6Sean C. Bouvet7Dale M. Cotton8Megan L. Anderson9Ian D. McLachlan10Laura E. Simon11Judy Shan12Adina S. Rauchwerger13David R. Vinson14Mary E. Reed15Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CADivision of Research Kaiser Permanente Northern California Oakland CADivision of Research Kaiser Permanente Northern California Oakland CADepartment of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CADepartment of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CADepartment of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CADepartment of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CADepartment of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CADepartment of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CADepartment of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CADepartment of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CAUniversity of California San Diego School of Medicine San Diego CADivision of Research Kaiser Permanente Northern California Oakland CADivision of Research Kaiser Permanente Northern California Oakland CADivision of Research Kaiser Permanente Northern California Oakland CADivision of Research Kaiser Permanente Northern California Oakland CABackground Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA‐ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA‐ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48‐month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7‐day objective cardiac testing). Secondary outcomes were 30‐day objective cardiac testing, 60‐day major adverse cardiac events (MACE), and 60‐day MACE‐CR (MACE excluding coronary revascularization). Difference‐in‐differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30‐day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60‐day MACE risk (−2.5%, 95% CI −3.7 to −1.2%, P<0.001) and increased among patients with non‐low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (−1.0%, 95% CI −2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60‐day MACE or 60‐day MACE‐CR. Conclusions Implementation of RISTRA‐ACS was associated with better allocation of 30‐day objective cardiac testing and no change in index visit resource utilization or 60‐day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.https://www.ahajournals.org/doi/10.1161/JAHA.121.022539acute coronary syndromediagnostic testingprognosis |
| spellingShingle | Dustin G. Mark Jie Huang Dustin W. Ballard Mamata V. Kene Dana R. Sax Uli K. Chettipally James S. Lin Sean C. Bouvet Dale M. Cotton Megan L. Anderson Ian D. McLachlan Laura E. Simon Judy Shan Adina S. Rauchwerger David R. Vinson Mary E. Reed Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease acute coronary syndrome diagnostic testing prognosis |
| title | Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study |
| title_full | Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study |
| title_fullStr | Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study |
| title_full_unstemmed | Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study |
| title_short | Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study |
| title_sort | graded coronary risk stratification for emergency department patients with chest pain a controlled cohort study |
| topic | acute coronary syndrome diagnostic testing prognosis |
| url | https://www.ahajournals.org/doi/10.1161/JAHA.121.022539 |
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