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...

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Autores principales:	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
Formato:	article
Lenguaje:	EN
Publicado:	Wiley 2021
Materias:	acute coronary syndrome diagnostic testing prognosis Diseases of the circulatory (Cardiovascular) system RC666-701
Acceso en línea:	https://doaj.org/article/9fec98e1d8cc47f99b36ba57d3b2250d
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spelling	oai:doaj.org-article:9fec98e1d8cc47f99b36ba57d3b2250d2021-11-16T10:22:43ZGraded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study10.1161/JAHA.121.0225392047-9980https://doaj.org/article/9fec98e1d8cc47f99b36ba57d3b2250d2021-11-01T00:00:00Zhttps://www.ahajournals.org/doi/10.1161/JAHA.121.022539https://doaj.org/toc/2047-9980Background 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.Dustin G. MarkJie HuangDustin W. BallardMamata V. KeneDana R. SaxUli K. ChettipallyJames S. LinSean C. BouvetDale M. CottonMegan L. AndersonIan D. McLachlanLaura E. SimonJudy ShanAdina S. RauchwergerDavid R. VinsonMary E. ReedWileyarticleacute coronary syndromediagnostic testingprognosisDiseases of the circulatory (Cardiovascular) systemRC666-701ENJournal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, Vol 10, Iss 22 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	acute coronary syndrome diagnostic testing prognosis Diseases of the circulatory (Cardiovascular) system RC666-701
spellingShingle	acute coronary syndrome diagnostic testing prognosis Diseases of the circulatory (Cardiovascular) system RC666-701 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
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.
format	article
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
title	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_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_sort	graded coronary risk stratification for emergency department patients with chest pain: a controlled cohort study
publisher	Wiley
publishDate	2021
url	https://doaj.org/article/9fec98e1d8cc47f99b36ba57d3b2250d
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Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study

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