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Posted by Ishani Ganguli April 20, 2012 07:00 AM
This year, about six million American adults will come to an Emergency Department (ED) with chest pain. Some of them will have full-blown heart attacks, a few will have life-threatening blood clots in their lungs. The vast majority will have acid reflux, muscle strain, or anxiety. It’s up to the ED doctor to separate the scary medical issues from the ones that require Tums.
As an internist working in the ED, I was reminded frequently that my job there was to focus on the most dangerous medical problem rather than the most likely. In the effort to catch the “Don’t Miss” diagnosis, many patients who are unlikely to have a cardiac cause for their chest pain languish in the ED hallway or get admitted to a medical floor to rule out a heart attack: get a three-part series of blood tests and heart tracings every six to eight hours, maybe even undergo a cardiac stress test. Most of these patients turn out to have no heart damage.
We pay a hefty price for such admissions: not just the escalating monetary costs associated with inpatient care, but the possibility of false positive stress tests and needless downstream procedures. If only there was a faster, better way...
One emerging way to triage patients with chest pain is coronary CT angiography - a scan of the heart and its blood vessels that, when normal, can tell you with near certainty that you don’t have plaque clogging the vessels of your heart (but is less reliable in detecting if you do). In a study published last week, researchers randomly assigned 1370 patients coming into five U.S. emergency rooms with chest pain but low-to-intermediate risk of a true heart attack to get either a CT scan or traditional care. They found that patients who got a CT scan were more likely to get discharged from the ED (50%) than those who got the usual care (23%) and spent less time in the hospital (18 vs. 25 hrs). More importantly, the method was safe: none of the 640 patients with a negative CT scan died or had a heart attack within 30 days of their ED visit. The downsides? Radiation exposure, and the risk (again) of unleashing a stream of diagnostic tests for an incidental or inconclusive finding on the CT scan.
Researchers from the Mayo Clinic in Minnesota have found another, lower tech way to triage patients with chest pain more efficiently: ask them what they want. In a study published earlier this month, they randomized more than 200 patients who came to the ED with chest pain who were low risk for heart attack to go down one of two paths: either the doctor made the call as usual (ie. standard treatment), or the patient got a “decision aid” explaining the pros and cons of either being admitted for stress testing or going home and following-up with an outpatient doctor within one to three days. They found that patients who used the decision aid were less likely to be admitted for stress testing (58% versus 77%) and were no more likely to have a major cardiac problem within a month of discharge than the patients who received standard care.
So much hangs in the balance of the decision to admit, yet I’ve seen firsthand how arbitrary that decision process can be. These research efforts are an important step in efficiently triaging a symptom that is scary and costly but doesn’t always have to be. And most of us stand to gain from the results: as a country, we will pay less for health care as we shift care to the outpatient setting. Hospitals and doctors adopting the Accountable Care model will benefit from strategies that deliver better care at lower costs. Most importantly, more patients can go home, to chew on Tums from the comfort of their couches.
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