Cost-effectiveness of routine coagulation testing in the evaluation of chest pain in the ED.
BACKGROUND
Approximately 5% of all US emergency department (ED) visits are for chest pain, and coagulation testing is frequently utilized as part of the ED evaluation.


OBJECTIVE
The objective was to assess the cost-effectiveness of routine coagulation testing of patients with chest pain in the ED.


METHODS
We conducted a retrospective chart review of patients evaluated for chest pain in a community ED between August 1, 2010, and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with fresh frozen plasma or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or ST-elevation myocardial infarction.


RESULTS
Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of those 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. One of the 327 patients (0.31%; 95% confidence interval, 0.05%-1.7%) tested without indication had a clinically significant coagulopathy (internationalized normalization ratio >1.5, partial thromboplastin time >50 seconds), but none (0%; 95% confidence interval, 0%-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16780.


CONCLUSIONS
Coagulation testing on chest pain patients in the ED is not cost-effective and should not be routinely performed.
Department of Emergency Medicine, York Hospital, York, Pennsylvania, USA. ekochert@wellspan.org
Erik
E
Kochert
Lawrence
L
Goldhahn
Ian
I
Hughes
Kirsten
K
Gee
Barbie
B
Stahlman
D001780:Blood Coagulation Tests / Q000191:economics*; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis* / Q000209:etiology; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics*; D005260:Female; D006801:Humans; D019934:International Normalized Ratio / Q000191:economics; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time / Q000191:economics; D012189:Retrospective Studies