title: Provider-directed imaging stress testing reduces health care expenditures in lower-risk chest pain patients presenting to the emergency department.
abstract: BACKGROUND
  Among intermediate- to high-risk patients with chest pain, we have shown that a cardiac magnetic resonance (CMR) stress test strategy implemented in an observation unit (OU) reduces 1-year health care costs compared with inpatient care. In this study, we compare 2 OU strategies to determine among lower-risk patients if a mandatory CMR stress test strategy was more effective than a physicians' ability to select a stress test modality.
  
  
  RESULTS
  On emergency department arrival and referral to the OU for management of low- to intermediate-risk chest pain, 120 individuals were randomly assigned to receive (1) a CMR stress imaging test (n=60) or (2) a provider-selected stress test (n=60: stress echo [62%], CMR [32%], cardiac catheterization [3%], nuclear [2%], and coronary CT [2%]). No differences were detected in length of stay (median CMR=24.2 hours versus 23.8 hours, P=0.75), catheterization without revascularization (CMR=0% versus 3%), appropriateness of admission decisions (CMR 87% versus 93%, P=0.36), or 30-day acute coronary syndrome (both 3%). Median cost was higher among those randomly assigned to the CMR-mandated group ($2005 versus $1686, P<0.001).
  
  
  CONCLUSIONS
  In patients with lower-risk chest pain receiving emergency department-directed OU care, the ability of a physician to select a cardiac stress imaging modality (including echocardiography, CMR, or radionuclide testing) was more cost-effective than a pathway that mandates a CMR stress test. Contrary to prior observations in individuals with intermediate- to high-risk chest pain, in those with lower-risk chest pain, these results highlight the importance of physician-related choices during acute coronary syndrome diagnostic protocols.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00869245.
authors: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA. cmiller@wfubmc.edu
authors: Chadwick D
authors: CD
authors: Miller
authors: James W
authors: JW
authors: Hoekstra
authors: Cedric
authors: C
authors: Lefebvre
authors: Howard
authors: H
authors: Blumstein
authors: Craig A
authors: CA
authors: Hamilton
authors: Erin N
authors: EN
authors: Harper
authors: Simon
authors: S
authors: Mahler
authors: Deborah B
authors: DB
authors: Diercks
authors: Rebecca
authors: R
authors: Neiberg
authors: W Gregory
authors: WG
authors: Hundley
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis* / Q000191:economics; D000368:Aged; D006328:Cardiac Catheterization; D002637:Chest Pain / Q000175:diagnosis* / Q000191:economics / Q000209:etiology; D004452:Echocardiography; D004636:Emergency Service, Hospital; D005080:Exercise Test / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006321:Heart / Q000000981:diagnostic imaging; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D011877:Radionuclide Imaging; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed