Cost-Effectiveness of Mandatory Stress Testing in Chest Pain Center Patients

doi:10.1016/S0196-0644(97)70314-7

Annals of Emergency Medicine

Volume 29, Issue 1, January 1997, Pages 88-98

Presented at the Society for Academic Emergency Medicine Annual Meeting, San Antonio, May 1995.

https://doi.org/10.1016/S0196-0644(97)70314-7 Get rights and content

Abstract

See related editorial, p 168.

Study objective: To determine whether emergency patients with acute chest pain and low suspicion of acute myocardial infarction (AMI) can be managed cost-effectively and safely in a dedicated chest pain center (CPC) that incorporates mandatory stress testing. Methods: We assembled a prospective observational case series of consecutive adult patients transferred from the emergency department to a nine-bed, 23-hour CPC in a 564-bed community hospital from January 13 through May 31, 1994. In our institution, all emergency patients with acute nontraumatic chest pain of unclear origin, suggestive of myocardial ischemia but with a low probability of AMI, are transferred to the CPC for further evaluation. All patients in whom AMI is ruled out undergo individually appropriate cardiac diagnostic testing in accordance with CPC clinical guidelines. Patients with end-stage coronary artery disease transferred to the CPC for a “rule-out” protocol only did not undergo further diagnostic testing. Admitted and discharged patients were followed through chart review and telephone survey, respectively. Results: Of the 502 patients transferred to the CPC, 477 (95%) completed follow-up at 14 days. Four hundred ten (86%) were discharged home. Those discharged after diagnostic evaluation yielded negative findings had 100% survival and zero diagnosis of AMI at 5-month follow-up. Overall mortality and incidence of AMI on long-term follow-up for all patients transferred to the CPC were .4% and .2%, respectively. Sixty-seven patients (13%) were admitted from the CPC, of whom 44 (66%) had a final diagnosis of ischemic heart disease (IHD) or AMI. Twenty-four patients with IHD (55%; 6% of stress-tested group) were identified only on further stress testing. Of these patients, seven underwent percutaneous transluminal coronary angioplasty or coronary artery bypass grafting during hospitalization. All were discharged home without major morbidity. Four hundred twenty-four patients (84%) underwent stress testing. The cost of mandatory stress testing to identify one patient with IHD after AMI was ruled out was $3,125. An average cost-per-case savings of 62% was achieved for each patient transferred to the CPC who would have been hospitalized before the inception of the CPC. Conclusion: Mandatory stress testing is a safe, cost-effective, and valuable diagnostic and prognostic tool in CPC patients. [Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM: Cost-effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med January 1997;29:88-98.]

Section snippets

INTRODUCTION

Nationally, nearly two thirds of the 4 million chest pain patients seen in emergency departments each year present with nondiagnostic ECG findings.1, 2, 3, 4, 5 Between 2% and 10% of patients with acute myocardial infarction (AMI) in the United States are inadvertently discharged home from the ED.6, 7, 7, 8, 9 Economic pressures have forced health care providers to develop innovative ways of managing patients at low risk of myocardial infarction. The chest pain evaluation unit has shown promise

MATERIALS AND METHODS

From its inception on January 13, 1994, through May 31, 1994, 502 consecutive adult patients were transferred from the emergency department to a dedicated nine-bed, 23-hour outpatient observation unit designated the chest pain center (CPC) at St Joseph Mercy Hospital, a 564-bed community referral teaching hospital in Ann Arbor, Michigan. All patients initially evaluated in the ED for acute chest pain of unclear origin suggestive of myocardial ischemia but with low suspicion of AMI were included

RESULTS

During the study period the average daily patient census for the CPC was 3.6. The average age was 53 years, and 54% of patients were men. The average stay was 12 hours and 45 minutes, whereas the longest stay was 23 hours and 50 minutes. Of the 502 patients transferred to the CPC, 430 (86%) were discharged home, 67 (13%) were admitted, and 5 (1%) left against medical advice.

Nondiagnostic myoglobin levels (<90 ng/mL) at presentation and 4 hours were used to rule out AMI in 416 patients (86%).

DISCUSSION

As a result of increasing financial pressures, many institutions around the country are adopting various forms of outpatient evaluation units to manage acute chest pain.10, 13, 22, 23, 24, 25, 26, 27, 28 A great deal of emphasis has been placed on the patient who is inadvertently discharged home with an AMI, yet very little emphasis is placed on the patient still at risk for an acute coronary event after AMI is ruled out. It has been stated that the 6- to 24-month prognosis of patients with

Acknowledgements

The authors thank Dr M Anthony Schork and Molly Young, MPH, for their statistical and technical assistance and the staff of the St Joseph Mercy Hospital Chest Pain Center for data acquisition.

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Citation Excerpt :
In contrast to previous practice guidelines that recommended stress testing only in patients free of symptoms for at least 48 hours,58 the American College of Cardiology (ACC) and American Heart Association (AHA) have endorsed stress testing after 6 to 8 hours of observation if repeat ECGs and serial cardiac biomarkers are normal. Numerous studies have confirmed that “early” stress testing in low-risk patients is both safe and effective.59–61 Some have even proposed protocols that stress low-risk ED chest pain patients directly from the ED without serial biomarkers.62

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^☆: From the Departments of Emergency Medicine^*, Cardiology^‡, and Primary Care^§ and the Clinical Research Office^¶, St Joseph Mercy Hospital, Ann Arbor, Michigan.

^☆☆: Address for reprints: Michael Mikhail, MD, Emergency Medicine Residency Program, University of Michigan/St Joseph Mercy Hospital, IB 95, 5305 East Huron River Drive, Ann Arbor, Michigan 48106

^★: Reprint no. 47/1/78152

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Cost-Effectiveness of Mandatory Stress Testing in Chest Pain Center Patients☆,☆☆,★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

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