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National trends in chest pain visits in US emergency departments (2006–2016)
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  1. Ahmad A Aalam1,2,
  2. Awad Alsabban3,4,
  3. Jesse M Pines5
  1. 1 Department of Emergency Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
  2. 2 Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA
  3. 3 Department of Internal Medicine, Taif University College of Medicine, Taif, Saudi Arabia
  4. 4 Department of Internal Medicine, George Washington University, Washington, District of Columbia, USA
  5. 5 US Acute Care Solutions, Canton, Ohio, USA
  1. Correspondence to Dr Ahmad A Aalam, Emergency Medicine, King Abdulaziz University Faculty of Medicine, Jeddah 21441, Saudi Arabia; dr.aalam{at}hotmail.com

Abstract

Background Chest pain is a common complaint in EDs. In this study, we describe demographic, care and cost trends in US ED visits for chest pain over 11 years.

Methods This is a retrospective descriptive study of trends in utilisation and care of ED chest pain visits from 2006 to 2016) using data from the Healthcare Cost and Utilization Project database, a national sample of US ED visits and hospitalisations.

Results From 2006 to 2016, there were 42.48 million chest pain visits. Visits per 100 000 persons increased from 1140.4 in 2006 to 1611.7 in 2016 (p<0.001). The chest pain inpatient admission rate declined from 19% in 2006 to 3.9% in 2016 (p<0.001); associated inpatient hospitalisation costs declined from $10.4 billion (2006–2008) to $6.2 billion (2012–2014).

Conclusion From 2006 to 2016, ED visits in the USA for chest pain increased with a significant decline in admission rates and inpatient hospitalisation costs.

  • admission avoidance
  • emergency care systems
  • admission avoidance
  • chest
  • cardiac care
  • acute coronary syndrome
  • emergency department utilisation

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Introduction

Chest pain is a common ED complaint with many serious causes including acute myocardial infarction (AMI) and many benign causes such as costochondritis.1 ED care focuses on identifying serious causes of chest pain. Yet even after ED evaluation, some patients remain at risk for serious conditions and require hospitalisation for additional evaluation. In particular, missed AMI results in poor outcomes and malpractice litigation.2

Several factors have impacted ED care for chest pain over the past decade. Hospital policies and regulations have changed: short-term hospitalisations have increasingly been recategorised as observation stays, which pay lower rates than inpatient admissions.3 This has led to the development of observation units that increasingly care for short-stay patients.4 There has been increased focus on readmissions. Insurance coverage in ED also changed through the development of health insurance exchanges and the expansion of the Medicaid programme in 2014, a state-level programme that pays for healthcare for the poor. Clinical decisions to hospitalise after ED evaluation have also changed through increased use of chest pain decision rules such as the History, EKG, Age, Risk factors, and Troponin (HEART) score, which identifies patients at low-risk for major cardiac events who can be discharged.5 6

In this study, we report trends in visits for non-traumatic chest pain in US EDs and hospitals from 2006 to 2016. Our goal was to assess how policy changes, emerging decision rules and other factors impacted treatment patterns and costs for ED patients with chest pain over the study.

Methods

Study design

We conducted a retrospective descriptive study of ED chest pain visits and associated hospital admissions. We used 2006–2016 data from HCUPnet, which provides year-level statistics from the Healthcare Cost and Utilization Project (HCUP) database, which draws from the National Emergency Department Sample and the National Inpatient Sample.

Data collection

We included ED visits and hospital discharges for all-cause non-traumatic chest pain and associated diagnoses using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for 2006–2014 and ICD, 10 Revision (ICD-10) for 2016. Specific codes used are available in an online supplementary appendix. We divided data into four time periods (2006–2008, 2009–2011, 2012–2014 and 2016) to simplify reporting; 2015 data were excluded because of the change from ICD-9-CM to ICD-10 Clinical Modification (ICD-10-CM). Observation stays were not considered inpatient admissions.

Supplemental material

For each year, we extracted data on disposition, age, sex, payer and median income for zip code. We also extracted data on inpatient admissions originating from the ED, specifically the number of discharges, hospital length of stay, costs per admission and aggregate costs. HCUP defines cost uses as cost-to-charge ratio based on hospital accounting reports from the Centers for Medicare & Medicaid Services (CMS) and corrects dollar values for inflation.

Data analysis

Data were tabulated across time intervals. χ2 tests were used to assess proportional differences and unpaired t-tests for continuous data comparing the 2006 and 2016 data. A p value of <0.05 was considered significant. MedCalc Statistical Software VV.15.2 (Ostend, Belgium) was used.

Results

Demographics

Over the study, there were 42.5 million visits for chest pain in US EDs. Visit rates per 100 000 persons increased 37% from 1175 visits in 2006 to 1612 in 2016 (p<0.001). The proportion with private insurance decreased (41.2% in 2006–2008 vs 34.1% in 2016, p<0.001) and Medicaid increased (13.4% in 2006–2008 vs 23.2% in 2016, p<0.001). Proportions of patients seen from lower income zip codes increased: (23% in 2006–2008 vs 34.3% in 2016, p<0.001) (table 1).

Table 1

Demographics of chest pain patients in US EDs from 2006 to 2016

Trends in inpatient hospitalisations and inpatient costs

Inpatient admission rates declined (18% in 2006–2008 vs 3.9% in 2016, p<0.001) (table 2). Mean cost per admission increased ($4718 in 2006–2008 vs $6325 in 2016, p<0.001) Aggregate costs of inpatient hospitalisations declined ($3.49 billion per year in 2006–2008 vs $1.47 billion in 2016, p<0.001).

Table 2

Trends in US EDs for admitted chest pain patients from 2006 to 2016

Discussion

From 2006 to 2016, there were steady increases in the rate of chest pain ED visits, a trend mirroring overall US visit rates.7 There were insurance mix changes with shrinking proportions of privately insured and uninsured and increased Medicaid. This likely reflects increased access to insurance through Medicaid expansion and health insurance exchanges and the proliferation of alternative sites of care that preferentially draw away privately insured from EDs (eg, urgent care clinics).

The proportion of admitted chest pain patients declined. This may be attributed to changes in practice and increased use of observation stays rather than full inpatient hospitalisations. Additionally, increased use of advanced testing to rule out serious causes of chest pain, including stress tests and CT angiogram may have contributed to observed declines. The sensitivity of troponin has also improved in the past decade, allowing for increased detection of AMI.8 9 Validated clinical decision tools such as the HEART score as well as greater focus on value-based care may also account for some of the declines.6 However, given our data limitations, we were unable to decompose these effects.

For chest pain inpatient hospitalisations, average costs per hospitalisation increased, but aggregate costs declined. Higher per hospitalisation costs may have been driven by increased use of advanced technology such as interventional coronary revascularisation or alternatively increased pricing for inpatient services.10 Aggregate cost declines were likely driven by increases in discharges and increased observation stay utilisation. However, we could not estimate how total chest pain costs have changed because we could not estimate ED outpatient or observation stay costs.

Limitations

There are several study limitations. HCUPnet data do not permit for patient-level analyses. Therefore, we could not assess the impacts of comorbid conditions or multivariable effects. We also excluded 2015 as data were unreliable due to the transition from ICD-9-CM to ICD-10-CM. Several important variables were also absent from HCUPnet, including counts and costs of observation stays and ED outpatient visits.

Conclusion

From 2006 to 2016, patients presenting to US EDs with chest pain increased at the population level, while inpatient hospitalisation rates declined with aggregate costs of inpatient visits declining substantially. There were many demographic changes in visits, notably with falling private and uninsured and increasing Medicaid insurance.

Key messages

What is already known on this subject

  • Chest pain is a common presentation to EDs, which comes with a significant burden to the health care system. Admission rates for such visits were higher through history when compared to other type of ED visits, given the associated high-risk disease processes. In the past 10 years, many changes have been introduced to the process of evaluating, assessing and admitting chest pain patients. The effect of these new factors and others on the national admission and discharges trends were not demonstrated or studied.

What this study adds

  • In this study, we show the different trends of changes in incidence, demographics, disposition, and costs for patients with chest pain in the ED from 2006-2016 and related admission costs. Additionally, explore possible factors such as; observation unit, utilization of outpatient resources and improvement in troponin sensitivity and time to test results in the past decade.

Abstract translation

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

References

Footnotes

  • Handling editor Edward Carlton

  • Twitter @draalam

  • Contributors AAA and JMP planned the study. AAA and AA collected data and analysed it. All authors wrote and edited the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This study was exempted by The George Washington University Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available online as part of The Healthcare Cost and Utilization Project at (https://www.hcup-us.ahrq.gov) by The Agency for Healthcare Research and Quality's.