Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis

A Nieuwets, J M Poldervaart, J B Reitsma, S Buitendijk, A J Six, B E Backus, A W Hoes, P A Doevendans, A Nieuwets, J M Poldervaart, J B Reitsma, S Buitendijk, A J Six, B E Backus, A W Hoes, P A Doevendans

Abstract

Objective: To investigate which risk score (TIMI score or HEART score) identifies the largest population of low-risk patients at the emergency department (ED). Furthermore, we retrospectively calculated the corresponding expected decrease in medical consumption if these patients would have been discharged from the ED.

Methods: We performed analyses in two hospitals of the multicentre prospective validation study of the HEART score, executed in 2008 and 2009. Patients with chest pain presenting to the ED were included and information was collected on major adverse cardiac events (MACEs) and on hospital admissions and diagnostic procedures within 6 weeks. The TIMI and HEART score were calculated for each patient.

Results: We analysed 640 patients (59% male, mean age of 60, cumulative incidence of MACE 17%). An estimated total of €763 468 was spent during follow-up on hospital admission and diagnostic procedures. In total, 256 (40%) patients had a HEART score of 0-3 and were considered low risk (miss rate 1.6%), a total of €64 107 was spent on diagnostic procedures and hospital admission after initial presentation in this group. In comparison, 105 (16%) patients with TIMI score of 0 were considered low risk (miss rate 0%), with a total of €14 670 spent on diagnostic procedures and initial hospital admission costs. With different cut-offs for low risk, HEART 0-2 (miss rate 0.7%), would have resulted in a total of €25 365 in savings, compared with €71 905 when an alternative low risk cut-off for TIMI of TIMI≤1 would be used (miss rate 3.0%).

Conclusions: The HEART score identifies more patients as low risk compared with the TIMI score, which may lead to a larger reduction in diagnostic procedures and costs in this low-risk group. Future studies should prospectively investigate whether adhering to the HEART score in clinical practice and early discharge of low-risk patients is safe and leads to a reduction in medical consumption.

Keywords: HEALTH ECONOMICS.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
Patient flow chart.

References

    1. Goodacre S, Cross E, Arnold J et al. . The health care burden of acute chest pain. Heart 2005;91:229–30. 10.1136/hrt.2003.027599
    1. Pope JH, Aufderheide TP, Ruthazer R. et al. . Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163–70.
    1. Hollander JE. Risk stratification of emergency department patients with chest pain: the need for standardized reporting guidelines. Ann Emerg Med 2004;43:68–70.
    1. Penumetsa SC, Mallidi J, Friderici JL et al. . Outcomes of patients admitted for observation of chest pain. Arch Intern Med 2012;172:873–7. 10.1001/archinternmed.2012.940
    1. Brace-McDonnell SJ, Laing S. When is low-risk chest pain acceptable risk chest pain? Heart 2014;100:1402–3. 10.1136/heartjnl-2014-306177
    1. Jneid H, Anderson JL, Wright RS et al. . 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012;60:645–81. 10.1016/j.jacc.2012.06.004
    1. Hamm CW, Bassand JP, Agewall S et al. , ESC Committee for Practice Guidelines. Guidelines. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. 10.1093/eurheartj/ehr236
    1. Antman EM, Cohen M, Bernink PJ et al. . The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835–42.
    1. Marcoon S, Chang AM., Lee B et al. . HEART score to further risk stratify patients with low TIMI scores. Cric Pathw Cardiol 2013;12:1–5. 10.1097/HPC.0b013e31827377e1
    1. Thygesen K, Alpert JS, White HD et al. , Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Circulation 2007;116:2634–53.
    1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J 2008;16:191–6.
    1. Backus BE, Six AJ, Kelder JC et al. . Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol 2010;9:164–9. 10.1097/HPC.0b013e3181ec36d8
    1. Fesmire FM, Martin EJ, Cao Y et al. . Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score. Am J Emerg Med 2012;30:1829–37. 10.1016/j.ajem.2012.03.017
    1. Mahler SA, Miller CD, Hollander JE et al. . Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol 2013;168:795–802. 10.1016/j.ijcard.2012.10.010
    1. Backus BE, Six AJ, Kelder JC et al. . A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013;168:2153–8. 10.1016/j.ijcard.2013.01.255
    1. Six AJ, Cullen L, Backus BE et al. . The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol 2013;12:121–6. 10.1097/HPC.0b013e31828b327e
    1. Six AJ, Backus BE, Kingma A et al. . Consumption of diagnostic procedures and other cardiology care in chest pain patients after presentation at the emergency department. Neth Heart J 2012;20:499–504. 10.1007/s12471-012-0322-6
    1. Leite L., Baptista R., Leitao J. et al. . Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score. BMC Cardiovasc Disord 2015;15:48 10.1186/s12872-015-0049-6
    1. Mahler SA, Hiestand BC, Goff DC et al. . Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Crit Pathw Cardiol 2011;10:128–33. 10.1097/HPC.0b013e3182315a85
    1. Carlton EW, Khattab A, Greaves K. Identifying patients suitable for discharge after a single-presentation high-sensitivity troponin result: a comparison of five established risk scores and two high-sensitivity assays. Ann Emerg Med 2015;66:635–645.e1. 10.1016/j.annemergmed.2015.07.006
    1. Cullen L, Mueller C, Parsonage WA et al. . Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol 2013;62:1242–9. 10.1016/j.jacc.2013.02.078
    1. Universitair Medisch Centrum Groningen. Tarieven Onderlinge Dienstverlening. (accessed 17 Aug 2015).
    1. Hakkaart-van Roijen L, Tan SS, Bouwmans CAM. Handleiding voor Kostenonderzoek; Instituut voor Medical Technology Assesment. The Netherlands: Institut voor Medical Technology, 2010.
    1. Mahler SA, Riley RF, Hiestand BC et al. . The HEART pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 2015;8:195–203. 10.1161/CIRCOUTCOMES.114.001384
    1. Pollack CV Jr, Sites FD, Shofer FS et al. . Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med 2006;13:13–18.
    1. Than M, Herbert M, Flaws D et al. . What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge form the Emergency Department? A clinical survey Int J Cardiol 2013;166:752–4. 10.1161/CIRCOUTCOMES.114.001384
    1. Kline JA, Johnson CL, Pollack CV Jr et al. . Pretest probability assessment derived from attribute matching. BMC Med Inform Decis Mak 2005;5:26 10.1186/1472-6947-5-26

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir