title: A time and imaging cost analysis of low-risk ED observation patients: a conservative 64-section computed tomography coronary angiography "triple rule-out" compared to nuclear stress test strategy.
abstract: OBJECTIVE
  The study aimed to examine time and imaging costs of 2 different imaging strategies for low-risk emergency department (ED) observation patients with acute chest pain or symptoms suggestive of acute coronary syndrome. We compared a "triple rule-out" (TRO) 64-section multidetector computed tomography protocol with nuclear stress testing.
  
  
  METHODS
  This was a prospective observational cohort study of consecutive ED patients who were enrolled in our chest pain observation protocol during a 16-month period. Our standard observation protocol included a minimum of 2 sets of cardiac enzymes at least 6 hours apart followed by a nuclear stress test. Once a week, observation patients were offered a TRO (to evaluate for coronary artery disease, thoracic dissection, and pulmonary embolus) multidetector computed tomography with the option of further stress testing for those patients found to have evidence of coronary artery disease.
  
  
  RESULTS
  We analyzed 832 consecutive observation patients including 214 patients who underwent the TRO protocol. Mean total length of stay was 16.1 hours for TRO patients, 16.3 hours for TRO plus other imaging test, 22.6 hours for nuclear stress testing, 23.3 hours for nuclear stress testing plus other imaging tests, and 23.7 hours for nuclear stress testing plus TRO (P < .0001 for TRO and TRO + other test compared to stress test ± other test). Mean imaging times were 3.6, 4.4, 5.9, 7.5, and 6.6 hours, respectively (P < .05 for TRO and TRO + other test compared to stress test ± other test). Mean imaging costs were $1307 for TRO patients vs $945 for nuclear stress testing.
  
  
  CONCLUSIONS
  Triple rule-out reduced total length of stay and imaging time but incurred higher imaging costs. A per-hospital analysis would be needed to determine if patient time savings justify the higher imaging costs.
authors.affiliation: Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA. kevin.takakuwa@jefferson.edu
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Takakuwa
authors.forename: Ethan J
authors.initials: EJ
authors.lastname: Halpern
authors.forename: Frances S
authors.initials: FS
authors.lastname: Shofer
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000191:economics; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000191:economics; D017023:Coronary Angiography / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics* / Q000592:standards; D005080:Exercise Test / Q000191:economics* / Q000379:methods; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008297:Male; D008875:Middle Aged; D019370:Observation; D015143:Philadelphia; D011446:Prospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000379:methods