A comprehensive strategy for the evaluation and triage of the chest pain patient: a cost comparison study.
BACKGROUND
Our objective was to determine the cost-effectiveness of a comprehensive, risk-based triage system, composed of multiple critical pathways, with the use of early myocardial perfusion imaging (MPI) in low-risk patients. We found previously that a chest pain evaluation system that uses MPI in low-risk patients was safe and effective, but the cost-effectiveness of this approach was not studied.


RESULTS
We compared two groups. The Acute Cardiac Team (ACT) group (n = 874) was assigned prospectively to 1 of 4 risk levels by emergency department (ED) physicians. Level 1, 2, and 3 patients were admitted; level 4 patients were evaluated in the ED. Level 3 and 4 patients underwent ED MPI. The control group (n = 713) represented consecutive patients evaluated in the prior year according to standard care and assigned retrospectively to an ACT level based on the presenting electrocardiographic and clinical data. Record and hospital administrative data were assessed for clinical variables, outcomes, lengths of stay, and all expenses incurred within 30 days of the index visit. The baseline characteristics of the two groups were similar, including age, sex, myocardial infarction prevalence, and 30-day revascularization rates within each level or between the two groups. Mean costs per encounter were reduced for the ACT patients for each level, which was significant when all patients were compared ($5,030 +/- $7,081 vs $6,044 +/- $10,432, P =.02). Use of MPI in the low-risk patients was associated with reduced costs (level 3, $4,958 +/- $4,948 vs $5,051 +/- $7,036; level 4, $1,529 +/- $2,664 vs $1,794 +/- $6,854) and was associated with a significantly lower angiography rate and shorter length of stay.


CONCLUSIONS
Implementation of a comprehensive strategy for chest pain evaluation and triage reduced overall costs for patients with chest pain on presentation. Acute MPI in the ED setting did not increase net cost.
Kontos
Michael C
MC
Department of Radiology, Virginia Commonwealth University, Medical College of Virginia Hospital and Physicians of the Virginia Commonwealth, University Health Systems, Richmond, VA 23298-0051, USA. mkontos@hsc.vcu.edu
Schmidt
Kristin L
KL
McCue
Michael
M
Rossiter
Louis F
LF
Jurgensen
Michael
M
Nicholson
Christopher S
CS
Jesse
Robert L
RL
Ornato
Joseph P
JP
Tatum
James L
JL
D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000209:etiology*; D003365:Costs and Cost Analysis; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000191:economics; D005260:Female; D017721:Hospital Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000000981:diagnostic imaging*; D009943:Organophosphorus Compounds; D015609:Organotechnetium Compounds; D017063:Outcome Assessment, Health Care; D019275:Radiopharmaceuticals; D012307:Risk Factors; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics*; D014218:Triage / Q000379:methods
D009943:Organophosphorus Compounds; D015609:Organotechnetium Compounds; D019275:Radiopharmaceuticals; C078700:technetium tc-99m tetrofosmin