A Comparison Trial for Stratifying Intermediate-Risk Chest Pain
Chest pain of uncertain etiology (intermediate-risk chest pain [IR-CP]) constitutes a majority of acute chest pain presentations to emergency departments (EDs). A before- and-after trial of 2197 IR-CP patients transferred from the hospital's ED to one of three units -- ED-based observation center (ED-OC), inpatient observation center (IN-OC), and inpatient units -- compared mean cost, length of stay, and safety over a 2-year period. The mean per patient cost for management of IR-CP was lower in the ED-OC ($1642) than the IN-OC ($1910) or the inpatient units ($2785). The mean length of stay was shorter in the ED-OC (0.75 days) than in the IN-OC (1.18 days) or the inpatient units (2.16 days). Return rates were lower in the ED-OC at 7 days (0%) and at 6 months (0.45%) than the IN-OC (0% and 1.22%) or the inpatient units (0.77% and 3.67%). Overall hospital costs for managing IR-CP dropped significantly (12.5%) after the ED-OC was opened. ED-OCs provide a safe and cost-effective alternative to admission of IR-CP patients.
Acute chest pain remains one of the most common presenting complaints in emergency departments (EDs). Over 40% of people who experience a heart attack in a given year will die from it, making coronary heart disease the number one killer of Americans. From 1979-1998, the number of Americans discharged from short-stay centers with cardiovascular disease as the first listed diagnosis increased by 28 percent.
Although there are an estimated 12.4 million acute coronary heart disease patients identified annually in the United States, less than 20% of chest pain evaluated in EDs is immediately identified as high-risk disease, such as acute cardiac ischemia. The remaining cases of acute chest pain are considered to represent intermediate risk for coronary heart disease until confirmatory studies stratify them as a low cardiac risk. The etiology of intermediate-risk chest pain (IR-CP) is difficult to distinguish on initial presentation, and requires a process for excluding acute ischemia. Emergency physicians recognize the difficulties in determining the etiology of IR-CP, while acknowledging that there is little public tolerance for missed acute myocardial infarction (AMI) in this group. In light of the high settlement rates for missed AMI, ED physicians are likely to admit patients with acute chest pain.
ED physicians are burdened with identifying those patients who have acute ischemia from the full complement of patients who present with chest pain. This results in large numbers of IR-CP patients being admitted to cardiac care units and telemetry beds, thereby increasing costs. A more cost-effective approach would be to develop a means of risk-stratifying chest pain patients and placing them into an appropriate setting (cardiac care unit, inpatient unit, or outpatient observation unit).
The high admission rate of IR-CP patients significantly increases medical costs and hospital expenses. It is estimated that direct costs for managing acute heart disease will exceed $153 billion in 2001. Several mechanisms have been developed to lower costs. In 1981, the St. Agnes Hospital in Baltimore, MD developed a strategy for stratifying acute chest pain through the first ED-based chest pain center. More than 3000 centers are estimated to be operating today. A number of trials have compared chest pain observation centers (OCs) to traditional inpatient admission in terms of cost and resource reduction. This study reports the reduction in resource utilization and the economic benefit of establishing an ED-based observation center (ED-OC) when an inpatient observation center (IN-OC) already existed and what influence this ED-OC had on IR-CP admissions. In addition, our study compared an ED-OC to the various admission alternatives for IR-CP patients on the basis of cost, length of stay, and safety.
Chest pain of uncertain etiology (intermediate-risk chest pain [IR-CP]) constitutes a majority of acute chest pain presentations to emergency departments (EDs). A before- and-after trial of 2197 IR-CP patients transferred from the hospital's ED to one of three units -- ED-based observation center (ED-OC), inpatient observation center (IN-OC), and inpatient units -- compared mean cost, length of stay, and safety over a 2-year period. The mean per patient cost for management of IR-CP was lower in the ED-OC ($1642) than the IN-OC ($1910) or the inpatient units ($2785). The mean length of stay was shorter in the ED-OC (0.75 days) than in the IN-OC (1.18 days) or the inpatient units (2.16 days). Return rates were lower in the ED-OC at 7 days (0%) and at 6 months (0.45%) than the IN-OC (0% and 1.22%) or the inpatient units (0.77% and 3.67%). Overall hospital costs for managing IR-CP dropped significantly (12.5%) after the ED-OC was opened. ED-OCs provide a safe and cost-effective alternative to admission of IR-CP patients.
Acute chest pain remains one of the most common presenting complaints in emergency departments (EDs). Over 40% of people who experience a heart attack in a given year will die from it, making coronary heart disease the number one killer of Americans. From 1979-1998, the number of Americans discharged from short-stay centers with cardiovascular disease as the first listed diagnosis increased by 28 percent.
Although there are an estimated 12.4 million acute coronary heart disease patients identified annually in the United States, less than 20% of chest pain evaluated in EDs is immediately identified as high-risk disease, such as acute cardiac ischemia. The remaining cases of acute chest pain are considered to represent intermediate risk for coronary heart disease until confirmatory studies stratify them as a low cardiac risk. The etiology of intermediate-risk chest pain (IR-CP) is difficult to distinguish on initial presentation, and requires a process for excluding acute ischemia. Emergency physicians recognize the difficulties in determining the etiology of IR-CP, while acknowledging that there is little public tolerance for missed acute myocardial infarction (AMI) in this group. In light of the high settlement rates for missed AMI, ED physicians are likely to admit patients with acute chest pain.
ED physicians are burdened with identifying those patients who have acute ischemia from the full complement of patients who present with chest pain. This results in large numbers of IR-CP patients being admitted to cardiac care units and telemetry beds, thereby increasing costs. A more cost-effective approach would be to develop a means of risk-stratifying chest pain patients and placing them into an appropriate setting (cardiac care unit, inpatient unit, or outpatient observation unit).
The high admission rate of IR-CP patients significantly increases medical costs and hospital expenses. It is estimated that direct costs for managing acute heart disease will exceed $153 billion in 2001. Several mechanisms have been developed to lower costs. In 1981, the St. Agnes Hospital in Baltimore, MD developed a strategy for stratifying acute chest pain through the first ED-based chest pain center. More than 3000 centers are estimated to be operating today. A number of trials have compared chest pain observation centers (OCs) to traditional inpatient admission in terms of cost and resource reduction. This study reports the reduction in resource utilization and the economic benefit of establishing an ED-based observation center (ED-OC) when an inpatient observation center (IN-OC) already existed and what influence this ED-OC had on IR-CP admissions. In addition, our study compared an ED-OC to the various admission alternatives for IR-CP patients on the basis of cost, length of stay, and safety.
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