In the Journals

Shorter ED visits for low-risk patients with MI symptoms confer health care savings

Tiberio M. Frisoli

Early discharge for low-risk patients with a possible acute MI, which was determined by a modified risk stratification tool, resulted in a shorter hospital stay and lower charges, according to a study published in Circulation: Cardiovascular Quality and Outcomes.

“Right now, common practice is to admit most chest pain patients to an observation unit for stress testing because this could be a sign of a heart attack, yet the majority of the time, the chest pain is in fact not due to heart disease at all,” Tiberio M. Frisoli, MD, interventional cardiologist at the Heart and Vascular Institute at Henry Ford Hospital in Detroit, told Cardiology Today. “To stress test low-risk chest pain patients is not based on any strong evidence at all and has not been shown to improve outcomes. It’s a level of evidence C recommendation by the American College of Cardiology and American Heart Association. If the HEART score were applied across the nation the way it was in our trial and in some other trials, it would dramatically change the way we triage and treat patients with low-risk chest pain in the emergency room.”

Researchers reviewed data from 105 patients (mean age, 50 years; 51% women) who presented to the ED with symptoms of an acute MI and were evaluated between February 2014 and May 2015. Patients were assigned to be discharged from the ED (n = 53) or transferred to the observation unit for cardiac testing (n = 52).

The modified HEART score was used for risk stratification and took into account risk factors, age, history, ECG and a cardiac troponin I level less than 0.04 ng/mL at 0 and 3 hours.

The primary endpoints were length of stay in the hospital and total 30-day charges. The secondary endpoint was a composite of nonfatal acute MI, all-cause death, hospital admission for acute MI evaluation, return visit to the ED for acute MI evaluation and coronary revascularization 30 days after presentation.

Patients in the early discharge group had a shorter length of stay (6.3 hours) vs. the stress testing group (25.9 hours; P < .001). Those who were discharged early also had an associated reduction in total charges of care vs. patients who were admitted for testing ($2,953 vs. $9,616; P < .001).

“The savings were very, very significant, over $6,000 and almost 20 hours, and if that were applied across a national population, it would save billions of dollars annually,” Frisoli said.

At 30 days, both groups did not have any deaths, cardiac revascularization procedures, acute MI, hospitalizations or return visits.

“This strategy of discharging low-risk chest pain patients has merit not only because it reduces cost and length of stay, which is what our study showed, but also because it potentially protects patients from exposure to unnecessary testing and all the risks that potentially come with that,” Frisoli told Cardiology Today.

“Arriving at a strategy that fully addresses each stakeholder concern, maximizes health outcomes with accompanying cost efficiency while setting up for a potentially smooth translation into widespread routine clinical practice in the ED will achieve substantial gains for what is a common and costly patient experience,” Keith E. Kocher, MD, MPH, assistant professor of emergency medicine at University of Michigan Medical School in Ann Arbor, wrote in a related editorial. – by Darlene Dobkowski

For more information:

Tiberio M. Frisoli, MD, can be reached at tfrisol1@hfhs.org.

Disclosures: Frisoli reports no relevant financial disclosures. Kocher reports he received a grant from Blue Cross Blue Shield of Michigan/Blue Care Network.

Tiberio M. Frisoli

Early discharge for low-risk patients with a possible acute MI, which was determined by a modified risk stratification tool, resulted in a shorter hospital stay and lower charges, according to a study published in Circulation: Cardiovascular Quality and Outcomes.

“Right now, common practice is to admit most chest pain patients to an observation unit for stress testing because this could be a sign of a heart attack, yet the majority of the time, the chest pain is in fact not due to heart disease at all,” Tiberio M. Frisoli, MD, interventional cardiologist at the Heart and Vascular Institute at Henry Ford Hospital in Detroit, told Cardiology Today. “To stress test low-risk chest pain patients is not based on any strong evidence at all and has not been shown to improve outcomes. It’s a level of evidence C recommendation by the American College of Cardiology and American Heart Association. If the HEART score were applied across the nation the way it was in our trial and in some other trials, it would dramatically change the way we triage and treat patients with low-risk chest pain in the emergency room.”

Researchers reviewed data from 105 patients (mean age, 50 years; 51% women) who presented to the ED with symptoms of an acute MI and were evaluated between February 2014 and May 2015. Patients were assigned to be discharged from the ED (n = 53) or transferred to the observation unit for cardiac testing (n = 52).

The modified HEART score was used for risk stratification and took into account risk factors, age, history, ECG and a cardiac troponin I level less than 0.04 ng/mL at 0 and 3 hours.

The primary endpoints were length of stay in the hospital and total 30-day charges. The secondary endpoint was a composite of nonfatal acute MI, all-cause death, hospital admission for acute MI evaluation, return visit to the ED for acute MI evaluation and coronary revascularization 30 days after presentation.

Patients in the early discharge group had a shorter length of stay (6.3 hours) vs. the stress testing group (25.9 hours; P < .001). Those who were discharged early also had an associated reduction in total charges of care vs. patients who were admitted for testing ($2,953 vs. $9,616; P < .001).

“The savings were very, very significant, over $6,000 and almost 20 hours, and if that were applied across a national population, it would save billions of dollars annually,” Frisoli said.

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At 30 days, both groups did not have any deaths, cardiac revascularization procedures, acute MI, hospitalizations or return visits.

“This strategy of discharging low-risk chest pain patients has merit not only because it reduces cost and length of stay, which is what our study showed, but also because it potentially protects patients from exposure to unnecessary testing and all the risks that potentially come with that,” Frisoli told Cardiology Today.

“Arriving at a strategy that fully addresses each stakeholder concern, maximizes health outcomes with accompanying cost efficiency while setting up for a potentially smooth translation into widespread routine clinical practice in the ED will achieve substantial gains for what is a common and costly patient experience,” Keith E. Kocher, MD, MPH, assistant professor of emergency medicine at University of Michigan Medical School in Ann Arbor, wrote in a related editorial. – by Darlene Dobkowski

For more information:

Tiberio M. Frisoli, MD, can be reached at tfrisol1@hfhs.org.

Disclosures: Frisoli reports no relevant financial disclosures. Kocher reports he received a grant from Blue Cross Blue Shield of Michigan/Blue Care Network.