title: Actual financial comparison of four strategies to evaluate patients with potential acute coronary syndromes.
abstract: OBJECTIVE
  Small studies have shown that a negative computed tomography coronary angiogram (CTA) in low-risk chest pain patients predicts a low rate of 30-day adverse events. The authors hypothesized that an immediate CTA strategy would be as effective but less costly than alternative strategies for evaluation of patients with potential acute coronary syndrome (ACS).
  
  
  METHODS
  The authors retrospectively compared four strategies for evaluation of patients after initial physician determination that the patient required admission and testing to rule out ACS. Patients were frequency-matched by age, race, gender, thrombolysis in myocardial infarction (TIMI) score, and initial electrocardiogram (ECG). The four groups were immediate CTA in the emergency department (ED) without serial markers (n = 98); clinical decision unit/observation unit (CDU) with biomarkers and CTA (n = 102); CDU evaluation with serial cardiac biomarkers and stress testing (n = 154); and usual care, defined as admission with serial biomarkers and hospitalist-directed evaluation (n = 289). The main outcomes were actual cost of care (facility direct and indirect fixed, facility variable direct labor and supply costs), length of stay (LOS), diagnosis of coronary artery disease (CAD), and safety (30-day death or myocardial infarction [MII).
  
  
  RESULTS
  Patients in each group were of similar age (mean +/- standard deviation [SD] 46 +/- 9 years), race (62% African American), and gender (57% female) and had similar TIMI scores (100% between 0-2). Comparing immediate CTA versus CDU CTA versus CDU stress versus usual care, median costs were less ($1,240 vs. 2,318 vs. 4,024 vs. 2,913; p < 0.01), and LOS was shorter (8.1 hr vs. 20.9 hr vs. 26.2 hr vs. 30.2 hr; p < 0.01). Diagnosis of CAD was similar (5.1% vs. 5.9% vs. 5.8% vs. 6.6%; p = 0.95), but fewer patients had 30-day death/MI (0% vs. 0% vs. 0.7% vs. 3.1%; p = 0.04) or 30-day readmission (0% vs. 3.2% vs. 2.3% vs. 12.2%; p < 0.01).
  
  
  CONCLUSIONS
  Compared to the other strategies, immediate CTA was as safe, identified as many patients with CAD, had the lowest cost, had the shortest LOS, and allowed discharge for the majority of patients. Larger prospective studies should confirm safety before immediate CTA replaces other strategies to rule out possible ACS.
authors.affiliation: Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. AnnaMarie.Chang@uphs.upenn.edu
authors.forename: Anna Marie
authors.initials: AM
authors.lastname: Chang
authors.forename: Frances S
authors.initials: FS
authors.lastname: Shofer
authors.forename: Mark G
authors.initials: MG
authors.lastname: Weiner
authors.forename: Marie B
authors.initials: MB
authors.lastname: Synnestvedt
authors.forename: Harold I
authors.initials: HI
authors.lastname: Litt
authors.forename: William G
authors.initials: WG
authors.lastname: Baxt
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging*; D015415:Biomarkers / Q000032:analysis; D016009:Chi-Square Distribution; D017023:Coronary Angiography / Q000191:economics*; D003365:Costs and Cost Analysis / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D014057:Tomography, X-Ray Computed / Q000191:economics*
chemical_list: D015415:Biomarkers