title: Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial.
abstract: OBJECTIVE
  We determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy.
  
  
  METHODS
  Emergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups.
  
  
  RESULTS
  There were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate $588; 95% confidence interval $336 to $811); 79% were managed without hospital admission.
  
  
  CONCLUSIONS
  Compared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain.
authors.affiliation: Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
authors.forename: Chadwick D
authors.initials: CD
authors.lastname: Miller
authors.forename: Wenke
authors.initials: W
authors.lastname: Hwang
authors.forename: James W
authors.initials: JW
authors.lastname: Hoekstra
authors.forename: Doug
authors.initials: D
authors.lastname: Case
authors.forename: Cedric
authors.initials: C
authors.lastname: Lefebvre
authors.forename: Howard
authors.initials: H
authors.lastname: Blumstein
authors.forename: Brian
authors.initials: B
authors.lastname: Hiestand
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Diercks
authors.forename: Craig A
authors.initials: CA
authors.lastname: Hamilton
authors.forename: Erin N
authors.initials: EN
authors.lastname: Harper
authors.forename: W Gregory
authors.initials: WG
authors.lastname: Hundley
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000191:economics; D002637:Chest Pain / Q000175:diagnosis / Q000191:economics* / Q000209:etiology; D003365:Costs and Cost Analysis; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000191:economics*; D005080:Exercise Test / Q000191:economics; D005260:Female; D006760:Hospitalization / Q000191:economics; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000191:economics; D010043:Outcome and Process Assessment, Health Care / Q000191:economics