Use of Self-Reported Computerized Medical History Taking for Acute Chest Pain in the Emergency Department - the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS): Prospective Cohort Study

Abstract

Background: Chest pain is one of the most common chief complaints in emergency departments (EDs). Collecting an adequate medical history is challenging but essential in order to use recommended risk scores such as the HEART score (based on history, electrocardiogram, age, risk factors, and troponin). Self-reported computerized history taking (CHT) is a novel method to collect structured medical history data directly from the patient through a digital device. CHT is rarely used in clinical practice, and there is a lack of evidence for utility in an acute setting.

Objective: This substudy of the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS) aimed to evaluate whether patients with acute chest pain can interact effectively with CHT in the ED.

Methods: Prospective cohort study on self-reported medical histories collected from acute chest pain patients using a CHT program on a tablet. Clinically stable patients aged 18 years and older with a chief complaint of chest pain, fluency in Swedish, and a nondiagnostic electrocardiogram or serum markers for acute coronary syndrome were eligible for inclusion. Patients unable to carry out an interview with CHT (eg, inadequate eyesight, confusion or agitation) were excluded. Effectiveness was assessed as the proportion of patients completing the interview and the time required in order to collect a medical history sufficient for cardiovascular risk stratification according to HEART score.

Results: During 2017-2018, 500 participants were consecutively enrolled. The age and sex distribution (mean 54.3, SD 17.0 years; 213/500, 42.6% women) was similar to that of the general chest pain population (mean 57.5, SD 19.2 years; 49.6% women). Common reasons for noninclusion were language issues (182/1000, 18.2%), fatigue (158/1000, 15.8%), and inability to use a tablet (152/1000, 15.2%). Sufficient data to calculate HEART score were collected in 70.4% (352/500) of the patients. Key modules for chief complaint, cardiovascular history, and respiratory history were completed by 408 (81.6%), 339 (67.8%), and 291 (58.2%) of the 500 participants, respectively, while 148 (29.6%) completed the entire interview (in all 14 modules). Factors associated with completeness were age 18-69 years (all key modules: Ps<.001), male sex (cardiovascular: P=.04), active workers (all key modules: Ps<.005), not arriving by ambulance (chief complaint: P=.03; cardiovascular: P=.045), and ongoing chest pain (complete interview: P=.002). The median time to collect HEART score data was 23 (IQR 18-31) minutes and to complete an interview was 64 (IQR 53-77) minutes. The main reasons for discontinuing the interview prior to completion (n=352) were discharge from the ED (101, 28.7%) and tiredness (95, 27.0%).

Conclusions: A majority of patients with acute chest pain can interact effectively with CHT on a tablet in the ED to provide sufficient data for risk stratification with a well-established risk score. The utility was somewhat lower in patients 70 years and older, in patients arriving by ambulance, and in patients without ongoing chest pain. Further studies are warranted to assess whether CHT can contribute to improved management and prognosis in this large patient group.

Trial registration: ClinicalTrials.gov NCT03439449; https://ichgcp.net/clinical-trials-registry/NCT03439449.

International registered report identifier (irrid): RR2-10.1136/bmjopen-2019-031871.

Keywords: chest pain; computerized history taking; coronary artery disease; eHealth; emergency department; health informatics; medical history; risk management.

Conflict of interest statement

Conflicts of Interest: DZ is the inventor on US patents for technology related to the CLEOS program. All patent rights and copyrights to technology, language, images, and knowledge content are assigned without royalty rights by DZ to Karolinska Institutet, Stockholm, Sweden, which is a public university. Apart from Karolinska Institutet and its subsidiaries, no individuals or companies may be owners or receive royalties or other revenue from use of CLEOS technology, language, images, or knowledge content or from clinical insights or computer algorithms generated from analysis of data acquired by the program. JS is speaker honoraria and on advisory board for AstraZeneca, Bayer, NovoNordisk.

©Helge Brandberg, Carl Johan Sundberg, Jonas Spaak, Sabine Koch, David Zakim, Thomas Kahan. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 27.04.2021.

Figures

Figure 1

User interface of the Clinical Expert Operating System software with examples of a clickable image and multiple-choice question.

Figure 2

Age and sex distribution of the study population (n=500). Total number of patients in each age group—18-29: 48, 30-39: 56, 40-49: 95, 50-59: 104, 60-69: 91, 70-79: 74, 80 years or older: 32.

Figure 3

Median durations with IQRs (in minutes) for completed modules and complete interview, excluding pauses >2 minutes. CC: chief complaint module; Completed: completed interview; CV: cardiovascular module; Respiratory: respiratory module.

Figure 4

Fractions (with 95% CIs) of completed key modules and completed interviews, stratified by age.

Figure 5

Fractions (with 95% CIs) of completed key modules and completed interviews, stratified by occupational status (320 active workers, 38 not at work, 142 retired). Active worker: employed or student; not at work: unemployed or on sick leave.

Figure 6

Fractions (with 95% CIs) of completed key modules and completed interviews, stratified by ongoing chest pain or not (264 with ongoing chest pain and 187 without).