HEART Pathway Accelerated Diagnostic Protocol Implementation: Prospective Pre-Post Interrupted Time Series Design and Methods

Simon A Mahler, Gregory L Burke, Pamela W Duncan, Larry D Case, David M Herrington, Robert F Riley, Brian J Wells, Brian C Hiestand, Chadwick D Miller, Simon A Mahler, Gregory L Burke, Pamela W Duncan, Larry D Case, David M Herrington, Robert F Riley, Brian J Wells, Brian C Hiestand, Chadwick D Miller

Abstract

Background: Most patients presenting to US Emergency Departments (ED) with chest pain are hospitalized for comprehensive testing. These evaluations cost the US health system >$10 billion annually, but have a diagnostic yield for acute coronary syndrome (ACS) of <10%. The history/ECG/age/risk factors/troponin (HEART) Pathway is an accelerated diagnostic protocol (ADP), designed to improve care for patients with acute chest pain by identifying patients for early ED discharge. Prior efficacy studies demonstrate that the HEART Pathway safely reduces cardiac testing, while maintaining an acceptably low adverse event rate.

Objective: The purpose of this study is to determine the effectiveness of HEART Pathway ADP implementation within a health system.

Methods: This controlled before-after study will accrue adult patients with acute chest pain, but without ST-segment elevation myocardial infarction on electrocardiogram for two years and is expected to include approximately 10,000 patients. Outcomes measures include hospitalization rate, objective cardiac testing rates (stress testing and angiography), length of stay, and rates of recurrent cardiac care for participants.

Results: In pilot data, the HEART Pathway decreased hospitalizations by 21%, decreased hospital length (median of 12 hour reduction), without increasing adverse events or recurrent care. At the writing of this paper, data has been collected on >5000 patient encounters. The HEART Pathway has been fully integrated into health system electronic medical records, providing real-time decision support to our providers.

Conclusions: We hypothesize that the HEART Pathway will safely reduce healthcare utilization. This study could provide a model for delivering high-value care to the 8-10 million US ED patients with acute chest pain each year.

Clinicaltrial: Clinicaltrials.gov NCT02056964; https://ichgcp.net/clinical-trials-registry/NCT02056964 (Archived by WebCite at http://www.webcitation.org/6ccajsgyu).

Keywords: acute coronary syndrome; chest pain; decision support technique; electronic medical records; implementation methods; interrupted time series analysis.

Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
HEART Pathway Implementation prospective cohort design.
Figure 2
Figure 2
HEART Pathway algorithm.
Figure 3
Figure 3
Flow of data into the HEART Pathway Implementation Database.

References

    1. Owens PL, Barrett ML, Gibson TB, Andrews RM, Weinick RM, Mutter RL. Emergency department care in the United States: a profile of national data sources. Ann Emerg Med. 2010 Aug;56(2):150–65. doi: 10.1016/j.annemergmed.2009.11.022.
    1. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffith JL, Selker HP. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000 Apr 20;342(16):1163–70. doi: 10.1056/NEJM200004203421603.
    1. Pines JM, Isserman JA, Szyld D, Dean AJ, McCusker CM, Hollander JE. The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain. Am J Emerg Med. 2010 Sep;28(7):771–9. doi: 10.1016/j.ajem.2009.03.019.
    1. Fleischmann KE, Goldman L, Johnson PA, Krasuski RA, Bohan JS, Hartley LH, Lee TH. Critical pathways for patients with acute chest pain at low risk. J Thromb Thrombolysis. 2002 Apr;13(2):89–96.
    1. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, Carnethon MR, Dai S, de Simone SG, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Greenlund KJ, Hailpern SM, Heit JA, Ho PM, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, McDermott MM, Meigs JB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Rosamond WD, Sorlie PD, Stafford RS, Turan TN, Turner MB, Wong ND, Wylie-Rosett J, American Heart Association Statistics CommitteeStroke Statistics Subcommittee Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation. 2011 Feb 1;123(4):e18–e209. doi: 10.1161/CIR.0b013e3182009701.
    1. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO) J Am Coll Cardiol. 1996 Jul;28(1):25–33.
    1. Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, Thompson PD, American Heart Association Exercise‚ Cardiac Rehabilitation‚Prevention Committee of the Council on Clinical Cardiology‚ Council on Cardiovascular Nursing‚Interdisciplinary Council on Quality of CareOutcomes Research Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010 Oct 26;122(17):1756–76. doi: 10.1161/CIR.0b013e3181ec61df.
    1. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2–4.
    1. Asch SM, Baker DW, Keesey JW, Broder M, Schonlau M, Rosen M, Wallace PL, Keeler EB. Does the collaborative model improve care for chronic heart failure? Med Care. 2005 Jul;43(7):667–75.
    1. Vargas RB, Mangione CM, Asch S, Keesey J, Rosen M, Schonlau M, Keeler EB. Can a chronic care model collaborative reduce heart disease risk in patients with diabetes? J Gen Intern Med. 2007 Feb;22(2):215–22. doi: 10.1007/s11606-006-0072-5.
    1. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009;28(1):75–85. doi: 10.1377/hlthaff.28.1.75.
    1. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, American College of Cardiology. American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) American College of Emergency Physicians. Society for Cardiovascular AngiographyInterventions. Society of Thoracic Surgeons. American Association of CardiovascularPulmonary Rehabilitation. Society for Academic Emergency Medicine ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007 Aug 14;50(7):e1–e157. doi: 10.1016/j.jacc.2007.02.013.
    1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008 Jun;16(6):191–6.
    1. Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Mast EG, Monnink SHJ, van Tooren RM, Doevendans PAFM. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010 Sep;9(3):164–9. doi: 10.1097/HPC.0b013e3181ec36d8.
    1. Backus BE, Six AJ, Kelder JC, Bosschaert MAR, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SHJ, van Tooren TR, Mast TP, van den Akker F, Cramer MJM, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153–8. doi: 10.1016/j.ijcard.2013.01.255.
    1. Mahler SA, Hiestand BC, Goff DC, Hoekstra JW, Miller CD. 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 Sep;10(3):128–33. doi: 10.1097/HPC.0b013e3182315a85.
    1. Mahler SA, Miller CD, Hollander JE, Nagurney JT, Birkhahn R, Singer AJ, Shapiro NI, Glynn T, Nowak R, Safdar B, Peberdy M, Counselman FL, Chandra A, Kosowsky J, Neuenschwander J, Schrock JW, Plantholt S, Diercks DB, Peacock WF. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol. 2013 Sep 30;168(2):795–802. doi: 10.1016/j.ijcard.2012.10.010.
    1. Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q. 2001;79(4):579–612, iv.
    1. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002 Oct 16;288(15):1909–14.
    1. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Katus HA, Lindahl B, Morrow DA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand J, Menasché P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon J, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S. Third universal definition of myocardial infarction. Circulation. 2012 Oct 16;126(16):2020–35. doi: 10.1161/CIR.0b013e31826e1058.
    1. Miller CD, Hwang W, Hoekstra JW, Case D, Lefebvre C, Blumstein H, Hiestand B, Diercks DB, Hamilton CA, Harper EN, Hundley WG. Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial. Ann Emerg Med. 2010 Sep;56(3):209–219.e2. doi: 10.1016/j.annemergmed.2010.04.009.
    1. Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, Herrington DM, Burke GL, Miller CD. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195–203. doi: 10.1161/CIRCOUTCOMES.114.001384.
    1. Peacock WF, Nagurney J, Birkhahn R, Singer A, Shapiro N, Hollander J, Glynn T, Nowak R, Safdar B, Miller C, Peberdy M, Counselman F, Chandra A, Kosowsky J, Neuenschwander J, Schrock J, Plantholt S, Lewandrowski E, Wong V, Kupfer K, Diercks D. Myeloperoxidase in the diagnosis of acute coronary syndromes: the importance of spectrum. Am Heart J. 2011 Nov;162(5):893–9. doi: 10.1016/j.ahj.2011.08.017.
    1. Conway PH, Mostashari F, Clancy C. The future of quality measurement for improvement and accountability. JAMA. 2013 Jun 5;309(21):2215–6. doi: 10.1001/jama.2013.4929.
    1. Mooe T, Björklund F, Graipe A, Huber D, Jakobsson S, Kajermo U, Strömvall A, Ulvenstam A. The nurse-based age independent intervention to limit evolution of disease after acute coronary syndrome (NAILED ACS) risk factor trial: protocol for a randomized controlled trial. JMIR Res Protoc. 2014;3(3):e42. doi: 10.2196/resprot.3466.
    1. ED Manag Reforming emergency care: experts put focus on value, better alignment. ED Manag. 2015 Jul;27(7):73–9.
    1. Redberg RF. Coronary CT angiography for acute chest pain. N Engl J Med. 2012 Jul 26;367(4):375–6. doi: 10.1056/NEJMe1206040.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する