Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study

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, Kaiser Permanente CREST Network Investigators [Link], 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, Ian D McLachlan, David R Vinson, Adina S Rauchwerger, Mary E Reed, 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, Kaiser Permanente CREST Network Investigators [Link], 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, Ian D McLachlan, David R Vinson, Adina S Rauchwerger, Mary E Reed

Abstract

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.

Keywords: acute coronary syndrome; diagnostic testing; prognosis.

Figures

Figure 1. Risk stratification for acute coronary…
Figure 1. Risk stratification for acute coronary syndrome‐ACS estimated risk prediction categories and accompanying recommendations.
MACE indicates major adverse cardiac event. RISTRA‐ACS, risk stratification for acute coronary syndrome.
Figure 2. Study cohort selection and stratification.
Figure 2. Study cohort selection and stratification.
ED, emergency department; KP, Kaiser Permanente, KPNC, Kaiser Permanente Northern California; MACE, major adverse cardiac event; RISTRA, risk stratification; STEMI, ST‐elevation myocardial infarction.
Figure 3. Quarterly averages of RISTRA‐ACS use…
Figure 3. Quarterly averages of RISTRA‐ACS use among study eligible patient encounters (RISTRA sites only).
RISTRA‐ACS, risk stratification for acute coronary syndrome.
Figure 4. Time trends in index visit…
Figure 4. Time trends in index visit resource utilization.
Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals. Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).
Figure 5. Time trends in 30‐day objective…
Figure 5. Time trends in 30‐day objective cardiac testing.
Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals. Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).
Figure 6. Time trends in 60‐day major…
Figure 6. Time trends in 60‐day major adverse cardiac events (MACE).
Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals. Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).
Figure 7. Time trends in 60‐day major…
Figure 7. Time trends in 60‐day major cardiac adverse events except coronary revascularization (MACE‐CR).
Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).

References

    1. Venkatesh AK, Dai Y, Ross JS, Schuur JD, Capp R, Krumholz HM. Variation in us hospital emergency department admission rates by clinical condition. Med Care. 2015;53:237–244. doi: 10.1097/MLR.0000000000000261
    1. Sabbatini AK, Nallamothu BK, Kocher KE. Reducing variation in hospital admissions from the emergency department for low‐mortality conditions may produce savings. Health Aff. 2014;33:1655–1663. doi: 10.1377/hlthaff.2013.1318
    1. Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, et al. Testing of low‐risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122:1756–1776. doi: 10.1161/CIR.0b013e3181ec61df
    1. Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, et al. 2014 AHA/ACC guideline for the management of patients with non‐ST‐elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014;130:e344–426. doi: 10.1161/CIR.0000000000000134
    1. Hsia RY, Hale Z, Tabas JA. A national study of the prevalence of life‐threatening diagnoses in patients with chest pain. JAMA Intern Med. 2016;176:1029–1032. doi: 10.1001/jamainternmed.2016.2498
    1. Napoli AM, Arrighi JA, Siket MS, Gibbs FJ. Physician discretion is safe and may lower stress test utilization in emergency department chest pain unit patients. Crit Pathw Cardiol. 2012;11:26–31. doi: 10.1097/HPC.0b013e3182457bee
    1. Aldous S, Richards AM, Cullen L, Pickering JW, Than M. The incremental value of stress testing in patients with acute chest pain beyond serial cardiac troponin testing. Emerg Med J. 2016;33:319–324. doi: 10.1136/emermed-2015-204823
    1. Hermann LK, Newman DH, Pleasant WA, Rojanasarntikul D, Lakoff D, Goldberg SA, Duvall WL, Henzlova MJ. Yield of routine provocative cardiac testing among patients in an emergency department‐based chest pain unit. JAMA Intern Med. 2013;173:1128–1133. doi: 10.1001/jamainternmed.2013.850
    1. Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, Pope JH, Hauser TH, White CS, Weiner SG, et al. Coronary CT angiography versus standard evaluation in acute chest pain. New Eng J Med. 2012;367:299–308. doi: 10.1056/NEJMoa1201161
    1. Reinhardt SW, Lin CJ, Novak E, Brown DL. Noninvasive cardiac testing vs clinical evaluation alone in acute chest pain: a secondary analysis of the romicat‐II randomized clinical trial. JAMA Intern Med. 2018;178:212–219. doi: 10.1001/jamainternmed.2017.7360
    1. Kawatkar AA, Sharp AL, Baecker AS, Natsui S, Redberg RF, Lee MS, Ferencik M, Wu YL, Shen E, Zheng C, et al. Early noninvasive cardiac testing after emergency department evaluation for suspected acute coronary syndrome. JAMA Intern Med. 2020;180:1621. doi: 10.1001/jamainternmed.2020.4325
    1. American College of Emergency Physicians Clinical Policies Subcommittee on Suspected Non STEACS , Tomaszewski CA, Nestler D, Shah KH, Sudhir A, Brown MD. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected non‐ST‐elevation acute coronary syndromes. Ann Emerg Med. 2018;72:e65–e106.
    1. Greenslade JH, Carlton EW, Van Hise C, Cho E, Hawkins T, Parsonage WA, Tate J, Ungerer J, Cullen L. Diagnostic accuracy of a new high‐sensitivity troponin I assay and five accelerated diagnostic pathways for ruling out acute myocardial infarction and acute coronary syndrome. Ann Emerg Med. 2018;71:439–451.e3. doi: 10.1016/j.annemergmed.2017.10.030
    1. Stopyra J, Snavely AC, Hiestand B, Wells BJ, Lenoir KM, Herrington D, Hendley N, Ashburn NP, Miller CD, Mahler SA. Comparison of accelerated diagnostic pathways for acute chest pain risk stratification. Heart. 2020;106:977–984. doi: 10.1136/heartjnl-2019-316426
    1. Boyle RSJ, Body R. The diagnostic accuracy of the emergency department assessment of chest pain (EDACS) score: a systematic review and meta‐analysis. Ann Emerg Med. 2021;77:433–441. doi: 10.1016/j.annemergmed.2020.10.020
    1. Mark DG, Huang J, Chettipally U, Kene MV, Anderson ML, Hess EP, Ballard DW, Vinson DR, Reed ME, Kaiser Permanente CREST Network Investigators . Performance of coronary risk scores among patients with chest pain in the emergency department. J Am Coll Cardiol. 2018;71:606–616.
    1. Mark DG, Huang J, Kene MV, Sax DR, Cotton DM, Lin JS, Bouvet SC, Chettipally UK, Anderson ML, McLachlan ID, et al. Prospective validation and comparative analysis of coronary risk stratification strategies among emergency department patients with chest pain. J Am Heart Assoc. 2021;10:e020082. doi: 10.1161/JAHA.120.020082
    1. Gordon N, Lin T. The Kaiser Permanente Northern California adult member health survey. Perm J. 2016;20:15–225. doi: 10.7812/TPP/15-225
    1. Venge P, Lagerqvist B, Diderholm E, Lindahl B, Wallentin L. Clinical performance of three cardiac troponin assays in patients with unstable coronary artery disease (a FRISC II substudy). Am J Cardiol. 2002;89:1035–1041. doi: 10.1016/S0002-9149(02)02271-3
    1. Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, Lin JS, Kene MV, Wang DH, Sax DR, et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Intern Med. 2018;169:855–865. doi: 10.7326/M18-1206
    1. Ekstrom HL, Kharbanda EO, Ballard DW, Vinson DR, Vazquez‐Benitez G, Chettipally UK, Dehmer SP, Kunisetty G, Sharma R, Rauchwerger AS, et al. Development of a clinical decision support system for pediatric abdominal pain in emergency department settings across two health systems within the HCSRN. EGEMS. 2019;7:15.
    1. Willeit P, Welsh P, Evans JDW, Tschiderer L, Boachie C, Jukema JW, Ford I, Trompet S, Stott DJ, Kearney PM, et al. High‐sensitivity cardiac troponin concentration and risk of first‐ever cardiovascular outcomes in 154,052 participants. J Am Coll Cardiol. 2017;70:558–568.
    1. Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, 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. doi: 10.1161/CIRCOUTCOMES.114.001384
    1. Flaws D, Than M, Scheuermeyer FX, Christenson J, Boychuk B, Greenslade JH, Aldous S, Hammett CJ, Parsonage WA, Deely JM, et al. External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS‐ADP). Emerg Med J: EMJ. 2016;33:618–625. doi: 10.1136/emermed-2015-205028
    1. Than M, Flaws D, Sanders S, Doust J, Glasziou P, Kline J, Aldous S, Troughton R, Reid C, Parsonage WA, et al. Development and validation of the emergency department assessment of chest pain score and 2 h accelerated diagnostic protocol. Emerg Med Australas: EMA. 2014;26:34–44.
    1. Foy AJ, Liu G, Davidson WR Jr, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Intern Med. 2015;175:428–436. doi: 10.1001/jamainternmed.2014.7657
    1. Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf MK. Cardiovascular testing and clinical outcomes in emergency department patients with chest pain. JAMA Intern Med. 2017;177:1175–1182. doi: 10.1001/jamainternmed.2017.2432
    1. Weinstock MB, Weingart S, Orth F, VanFossen D, Kaide C, Anderson J, Newman DH. Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med. 2015;175:1207–1212. doi: 10.1001/jamainternmed.2015.1674
    1. Simon LE, Rauchwerger AS, Chettipally UK, Babakhanian L, Vinson DR, Warton EM, Reed ME, Kharbanda AB, Kharbanda EO, Ballard DW. Text message alerts to emergency physicians identifying potential study candidates increase clinical trial enrollment. J Am Med Inform Assoc. 2019;26:1360–1363. doi: 10.1093/jamia/ocz118
    1. Mark DG, Huang J, Kene MV, Sax DR, Cotton DM, Lin JS, Bouvet SC, Chettipally UK, Anderson ML, McLachlan ID, et al. Automated retrospective calculation of the EDACS and heart scores in a multicenter prospective cohort of emergency department chest pain patients. Acad Emerg Med. 2020;27:1028–1038. doi: 10.1111/acem.14068
    1. Derington CG, Heath LJ, Kao DP, Delate T. Validation of algorithms to identify elective percutaneous coronary interventions in administrative databases. PLoS One. 2020;15:e0231100. doi: 10.1371/journal.pone.0231100
    1. Cullen L, Than M, Brown AF, Richards M, Parsonage W, Flaws D, Hollander JE, Christenson RH, Kline JA, Goodacre S, et al. Comprehensive standardized data definitions for acute coronary syndrome research in emergency departments in Australasia. Emerg Med Australas: EMA. 2010;22:35–55.
    1. Zhou H, Taber C, Arcona S, Li Y. Difference‐in‐differences method in comparative effectiveness research: utility with unbalanced groups. Appl Health Econ Health Policy. 2016;14:419–429. doi: 10.1007/s40258-016-0249-y
    1. Poldervaart JM, Reitsma JB, Backus BE, Koffijberg H, Veldkamp RF, ten Haaf ME, Appelman Y, Mannaerts HFJ, van Dantzig J‐M, van den Heuvel M, et al. Effect of using the heart score in patients with chest pain in the emergency department: a stepped‐wedge, cluster randomized trial. Ann Intern Med. 2017;166:689–697. doi: 10.7326/M16-1600
    1. Mahler SA, Lenoir KM, Wells BJ, Burke GL, Duncan PW, Case LD, Herrington DM, Diaz‐Garelli JF, Futrell WM, Hiestand BC, et al. Safely identifying emergency department patients with acute chest pain for early discharge. Circulation. 2018;138:2456–2468. doi: 10.1161/CIRCULATIONAHA.118.036528
    1. Sharp AL, Baecker AS, Shen E, Redberg R, Lee MS, Ferencik M, Natsui S, Zheng C, Kawatkar A, Gould MK, et al. Effect of a heart care pathway on chest pain management within an integrated health system. Ann Emerg Med. 2019;74:171–180. doi: 10.1016/j.annemergmed.2019.01.007
    1. Arrieta A, Garcia‐Prado A, Gonzalez P, Pinto‐Prades JL. Risk attitudes in medical decisions for others: an experimental approach. Health Econ. 2017;3:97–113. doi: 10.1002/hec.3628
    1. Mark DB, Federspiel JJ, Cowper PA, Anstrom KJ, Hoffmann U, Patel MR, Davidson‐Ray L, Daniels MR, Cooper LS, Knight JD, et al. Economic outcomes with anatomical versus functional diagnostic testing for coronary artery disease. Ann Intern Med. 2016;165:94–102. doi: 10.7326/M15-2639
    1. Riley RF, Miller CD, Russell GB, Harper EN, Hiestand BC, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, et al. Cost analysis of the history, ECG, age, risk factors, and initial troponin (HEART) pathway randomized control trial. Am J Emerg Med. 2017;35:77–81. doi: 10.1016/j.ajem.2016.10.005
    1. National hospital ambulatory medical care survey: 2017 emergency department summary tables . Accessed January 9, 2021.
    1. Keller T, Zeller T, Ojeda F, Tzikas S, Lillpopp L, Sinning C, Wild P, Genth‐Zotz S, Warnholtz A, Giannitsis E, et al. Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA. 2011;306:2684–2693. doi: 10.1001/jama.2011.1896
    1. Storrow AB, Christenson RH, Nowak RM, Diercks DB, Singer AJ, Wu AHB, Kulstad E, LoVecchio F, Fromm C, Headden G, et al. Diagnostic performance of cardiac troponin i for early rule‐in and rule‐out of acute myocardial infarction: results of a prospective multicenter trial. Clin Biochem. 2015;48:254–259. doi: 10.1016/j.clinbiochem.2014.08.018
    1. Scot‐Heart Investigators , Newby DE, Adamson PD, Berry C, Boon NA, Dweck MR, Flather M, Forbes J, Hunter A, Lewis S, et al. Coronary CT angiography and 5‐year risk of myocardial infarction. New Engl J Med. 2018;379:924–933.
    1. Scot‐Heart Investigators . CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT‐HEART): an open‐label, parallel‐group, multicentre trial. Lancet. 2015;385:2383–2391.
    1. Osheroff J, Teich J, Levick D, Saldana L, Velasco F, Sittig D, Rogers K, Jenders R. Improving outcomes with clinical decision support: an implementer's guide. Chicago, IL: Healthcare Information and Management Systems Society (HIMSS); 2012.

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