title: Safe and rapid disposition of low-to-intermediate risk patients presenting to the emergency department with chest pain: a 1-year high-volume single-center experience.
abstract: BACKGROUND
  Coronary CT angiography (CTA) is a powerful tool for the evaluation of chest pain in the emergency department (ED). Some debate persists regarding its cost-effectiveness in a low-to-intermediate risk population.
  
  
  OBJECTIVE
  This study sought to evaluate the safety and cost-effectiveness of coronary CTA for low-to-intermediate risk patients presenting to the ED with chest pain in a closed-loop referral system.
  
  
  METHODS
  Chest pain patients were evaluated in the ED via a local rapid coronary CTA protocol and tracked prospectively for ED throughput, disposition, chest pain recidivism, and cost utilization as compared with an age-matched cohort evaluated for chest pain treated with usual care.
  
  
  RESULTS
  One hundred eighty-three patients underwent the rapid coronary CTA protocol compared with an age-matched cohort of 184 patients treated with usual care. The median follow-up period for major adverse cardiovascular events in the coronary CTA group was 9.0 months (range, 1.8-14.5 months) and 11.1 months (range, 0-14.0 months) for the age-matched cohort. The median ED length of stay (LOS) was 5.8 hours (range, 2.6-12.3 hours) for the rapid coronary CTA cohort and 12.2 hours (range, 1.7-40.3 hours) for the age-matched cohort (P < .001). The median time to performance of coronary CTA was 2.5 hours (range, 0.4-8.7 hours) with a median time from coronary CTA performance to disposition of 2.9 hours (range, 0.8-8.6 hours). Total median hospital LOS was 5.9 hours (range, 2.7-124 hours) in the rapid coronary CTA cohort compared with 25.0 hours (range, 1.2-208 hours) in the age-matched cohort (P < .001). Hospital admission was more common in the age-matched cohort (98.9% vs 9.3%; P < .001). There was a significant reduction in total payer cost in coronary CTA group when compared to usual care ($182,064.55 vs $685,190.77; P < .001).
  
  
  CONCLUSIONS
  Coronary CTA for ED risk stratification and disposition within a closed referral system resulted in the shortest ED LOS published to date while being safe and cost-effective.
authors.affiliation: Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 78234-6200, USA.
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Jones
authors.affiliation: Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 78234-6200, USA.
authors.forename: Dustin M
authors.initials: DM
authors.lastname: Thomas
authors.affiliation: Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 78234-6200, USA.
authors.forename: Megan L
authors.initials: ML
authors.lastname: Barnwell
authors.affiliation: Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 78234-6200, USA.
authors.forename: Emilio
authors.initials: E
authors.lastname: Fentanes
authors.affiliation: Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 78234-6200, USA.
authors.forename: Adam N
authors.initials: AN
authors.lastname: Young
authors.affiliation: Emergency Department, San Antonio Military Medical Center, San Antonio, TX, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Barnwell
authors.affiliation: Emergency Department, San Antonio Military Medical Center, San Antonio, TX, USA.
authors.forename: Austin T
authors.initials: AT
authors.lastname: Foley
authors.affiliation: Emergency Department, San Antonio Military Medical Center, San Antonio, TX, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Hilliard
authors.affiliation: Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Hulten
authors.affiliation: Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Villines
authors.affiliation: Department of Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA.
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Cury
authors.affiliation: Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 78234-6200, USA. Electronic address: ahmad.slim@us.army.mil.
authors.forename: Ahmad M
authors.initials: AM
authors.lastname: Slim
mesh_terms: D015984:Causality; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000191:economics* / Q000401:mortality; D015331:Cohort Studies; D015897:Comorbidity; D017023:Coronary Angiography / Q000191:economics* / Q000401:mortality / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000191:economics* / Q000401:mortality; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007902:Length of Stay / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D015996:Survival Rate; D013781:Texas / Q000453:epidemiology; D014057:Tomography, X-Ray Computed / Q000191:economics* / Q000401:mortality / Q000706:statistics & numerical data
keywords: Acute chest pain; Computed tomography; Coronary computed tomography angiography; Emergency disposition