title: Chest pain syndromes are associated with high rates of recidivism and costs in young United States Veterans.
abstract: BACKGROUND
  Recurrent chest pain is common in patients with and without coronary artery disease. The prevalence and burden of these symptoms on healthcare is unknown.
  
  
  OBJECTIVE
  To compare chest pain return visits (recidivism) in patients with unexplained chest pain (UCP) against reference group of patients with coronary artery disease (CAD) and estimate the annual cost of recurrent chest pain.
  
  
  METHODS
  In a retrospective cohort study, a Veteran Affairs (VA) administrative and clinical database of Veterans who were deployed to or served in support of the wars in Iraq or Afghanistan was queried for first disease specific ICD-9 code to form two cohorts (UCP or CAD). Patients were followed between 09/2001-09/2010 for the first and cumulative return visits for UCP or cardiac pain (ACS or angina) to clinic, emergency department or admission; or for all-cause death. Time to return was analyzed using Cox regression and negative binomial models and adjusted for age, gender, race, marital status, and risk factors (hypertension, hyperlipidemia, diabetes, smoking and obesity). Direct total costs included inpatient, outpatient and fee basis (non-VA) costs.
  
  
  RESULTS
  Of 749,036 patients, 20,521 had UCP and 5303 had CAD. UCP patients were young and had a lower burden of risk factors than CAD cohort (p < .01). Yet, these patients were likely to return earlier with any chest pain (adjusted Hazard Ratio [aHR] = 1.76; 95 % CI 1.65-1.88); or unexplained chest pain than CAD patients (aHR: 1.89; 95 % CI 1.77-2.01). UCP patients were also likely to return more frequently for any chest pain (aRate Ratio = 1.54; 95 % CI 1.43-1.64) or UCP than CAD patients (aRR =2.63; 95 % CI 2.43-2.87). Per 100 patients, the 1-year cumulative returns were 37 visits for reference group and 45 visits for UCP cohort. The annual costs for chest pain averaged $69,009 for CAD and $57,336 for UCP patients (log geometric mean ratio=1.25; 95 % CI 1.18-1.32).
  
  
  CONCLUSIONS
  Chest pain recidivism is common and costly even in patients without known CAD. We need evidence-based guidelines for these patients to minimize returns.
authors.affiliation: Department of Emergency Medicine, 464 Congress Ave, New Haven, CT, USA. Basmah.safdar@yale.edu.|VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, USA. Basmah.safdar@yale.edu.
authors.forename: Basmah
authors.initials: B
authors.lastname: Safdar
authors.affiliation: Department of Emergency Medicine, 464 Congress Ave, New Haven, CT, USA. james.dziura@yale.edu.|VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, USA. james.dziura@yale.edu.|Yale Center for Analytical Sciences, 300 George Street, Suite 555, New Haven, CT, USA. james.dziura@yale.edu.
authors.forename: James
authors.initials: J
authors.lastname: Dziura
authors.affiliation: VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, USA. harini.bathulapalli@va.gov.|Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, USA. harini.bathulapalli@va.gov.
authors.forename: Harini
authors.initials: H
authors.lastname: Bathulapalli
authors.affiliation: Penn State College of Medicine, A210, 600 Centerview Drive, Hershey, PA, USA. dlealie@phs.psu.edu.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Leslie
authors.affiliation: VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, USA. melissa.skanderson@va.gov.
authors.forename: Melissa
authors.initials: M
authors.lastname: Skanderson
authors.affiliation: Department of Emergency Medicine, 464 Congress Ave, New Haven, CT, USA. cynthia.brandt@yale.edu.|VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, USA. cynthia.brandt@yale.edu.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Brandt
authors.affiliation: VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, USA. sally.haskell@yale.edu.|Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, USA. sally.haskell@yale.edu.
authors.forename: Sally G
authors.initials: SG
authors.lastname: Haskell
mesh_terms: D000328:Adult; D002637:Chest Pain / Q000191:economics / Q000453:epidemiology* / Q000628:therapy; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D013577:Syndrome; D014481:United States / Q000453:epidemiology; D058014:Veterans Health / Q000191:economics / Q000706:statistics & numerical data*