title: HEART Pathway Accelerated Diagnostic Protocol Implementation: Prospective Pre-Post Interrupted Time Series Design and Methods.
abstract: BACKGROUND
  Most patients presenting to US Emergency Departments (ED) with chest pain are hospitalized for comprehensive testing. These evaluations cost the US health system >$10 billion annually, but have a diagnostic yield for acute coronary syndrome (ACS) of <10%. The history/ECG/age/risk factors/troponin (HEART) Pathway is an accelerated diagnostic protocol (ADP), designed to improve care for patients with acute chest pain by identifying patients for early ED discharge. Prior efficacy studies demonstrate that the HEART Pathway safely reduces cardiac testing, while maintaining an acceptably low adverse event rate.
  
  
  OBJECTIVE
  The purpose of this study is to determine the effectiveness of HEART Pathway ADP implementation within a health system.
  
  
  METHODS
  This controlled before-after study will accrue adult patients with acute chest pain, but without ST-segment elevation myocardial infarction on electrocardiogram for two years and is expected to include approximately 10,000 patients. Outcomes measures include hospitalization rate, objective cardiac testing rates (stress testing and angiography), length of stay, and rates of recurrent cardiac care for participants.
  
  
  RESULTS
  In pilot data, the HEART Pathway decreased hospitalizations by 21%, decreased hospital length (median of 12 hour reduction), without increasing adverse events or recurrent care. At the writing of this paper, data has been collected on >5000 patient encounters. The HEART Pathway has been fully integrated into health system electronic medical records, providing real-time decision support to our providers.
  
  
  CONCLUSIONS
  We hypothesize that the HEART Pathway will safely reduce healthcare utilization. This study could provide a model for delivering high-value care to the 8-10 million US ED patients with acute chest pain each year.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT02056964; https://clinicaltrials.gov/ct2/show/NCT02056964 (Archived by WebCite at http://www.webcitation.org/6ccajsgyu).
authors.affiliation: Wake Forest School of Medicine, Department of Emergency Medicine, Winston Salem, NC, United States. smahler@wakehealth.edu.
authors.forename: Simon A
authors.identifier: http://orcid.org/0000-0003-2199-4078
authors.initials: SA
authors.lastname: Mahler
authors.forename: Gregory L
authors.identifier: http://orcid.org/0000-0002-9347-7873
authors.initials: GL
authors.lastname: Burke
authors.forename: Pamela W
authors.identifier: http://orcid.org/0000-0002-4838-3253
authors.initials: PW
authors.lastname: Duncan
authors.forename: Larry D
authors.identifier: http://orcid.org/0000-0002-5706-4377
authors.initials: LD
authors.lastname: Case
authors.forename: David M
authors.identifier: http://orcid.org/0000-0002-7670-6400
authors.initials: DM
authors.lastname: Herrington
authors.forename: Robert F
authors.identifier: http://orcid.org/0000-0002-2444-1252
authors.initials: RF
authors.lastname: Riley
authors.forename: Brian J
authors.identifier: http://orcid.org/0000-0001-7310-6525
authors.initials: BJ
authors.lastname: Wells
authors.forename: Brian C
authors.identifier: http://orcid.org/0000-0002-0568-1269
authors.initials: BC
authors.lastname: Hiestand
authors.forename: Chadwick D
authors.identifier: http://orcid.org/0000-0002-4362-4409
authors.initials: CD
authors.lastname: Miller
keywords: acute coronary syndrome; chest pain; decision support technique; electronic medical records; implementation methods; interrupted time series analysis