title: Electronic risk alerts to improve primary care management of chest pain: a randomized, controlled trial.
abstract: BACKGROUND
  The primary care evaluation of chest pain represents a significant diagnostic challenge.
  
  
  OBJECTIVE
  To determine if electronic alerts to physicians can improve the quality and safety of chest pain evaluations.
  
  
  METHODS
  Randomized, controlled trial conducted between November 2008 and January 2010 among 292 primary care clinicians caring for 7,083 adult patients with chest pain and no history of cardiovascular disease.
  
  
  METHODS
  Clinicians received alerts within the electronic health record during office visits for chest pain. One alert recommended performance of an electrocardiogram and administration of aspirin for high risk patients (Framingham Risk Score (FRS) ≥ 10%), and a second alert recommended against performance of cardiac stress testing for low risk patients (FRS < 10%).
  
  
  METHODS
  The primary outcomes included performance of an electrocardiogram and administration of aspirin therapy for high risk patients; and avoidance of cardiac stress testing for low risk patients.
  
  
  RESULTS
  The majority (81%) of patients with chest pain were classified as low risk. High risk patients were more likely than low risk patients to be evaluated in the emergency department (11% versus 5%, p < 0.01) and to be hospitalized (7% versus 3%, p < 0.01). Acute myocardial infarction occurred among 26 (0.4%) patients, more commonly among high risk compared to low risk patients (1.1% versus 0.2%, p < 0.01). Among high risk patients, there was no difference between the intervention and control groups in rates of performing electrocardiograms (51% versus 48%, p = 0.33) or administering aspirin (20% versus 18%, p = 0.43). Among low risk patients, there was no difference between intervention and control groups in rates of cardiac stress testing (10% versus 9%, p = 0.40).
  
  
  CONCLUSIONS
  Primary care management of chest pain is suboptimal for both high and low risk patients. Electronic alerts do not increase risk-appropriate care for these patients.
authors: Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA. tsequist@partners.org
authors: Thomas D
authors: TD
authors: Sequist
authors: Shane M
authors: SM
authors: Morong
authors: Amy
authors: A
authors: Marston
authors: Carol A
authors: CA
authors: Keohane
authors: E Francis
authors: EF
authors: Cook
authors: E John
authors: EJ
authors: Orav
authors: Thomas H
authors: TH
authors: Lee
mesh_terms: D002637:Chest Pain / Q000175:diagnosis* / Q000517:prevention & control; D056902:Clinical Alarms; D016001:Confidence Intervals; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000517:prevention & control; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D018570:Risk Assessment; D013223:Statistics as Topic; D014481:United States