Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective. Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom. Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance. Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service. Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, -7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (-£56 to £210, P = 0.252). Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care.
In addition to previously recognized predictors of ACS, it appears that indigestion or burning type pain predicts ACS in patients attending the emergency department with acute, undifferentiated chest pain. Diagnosis of acute 'gastro-oesophageal' chest pain should be avoided in this setting.
Objectives: To establish a chest pain observation unit, monitor its performance in terms of appropriate discharge after assessment, and estimate the cost per patient. Methods: Prospective, observational, cohort study of patients attending a large, city, teaching hospital accident and emergency department between 1 March 1999 and 29 February 2000 with acute undifferentiated chest pain. Patients were managed on a chest pain observation unit, entailing two to six hours of observation, serial electrocardiograph recording, cardiac enzyme measurement, and, where appropriate, exercise stress test. Patients were discharged home if all tests were negative and admitted to hospital if tests were positive or equivocal. The following outcomes were measured-proportion of participants discharged after assessment; clinical status three days after discharge; cardiac events and procedures during the following six months; and cost of assessment and admission. Results: Twenty three participants (4.3%) had a final diagnosis of myocardial infarction. All were detected and admitted to hospital. A total of 461 patients (86.3%) were discharged after assessment, 357 (66.9%) avoided hospital admission entirely. At review three days later these patients had no new ECG changes and only one raised troponin T measurement. In the six months after assessment, three cardiac deaths, two myocardial infarctions, and two revascularisation procedures were recorded among those discharged. The mean cost of assessment and hospital admission was £221 per patient, or £323 if subsequent interventional cardiology costs were included. Conclusions: The chest pain observation unit is a practical alternative to routine care for acute chest pain in the United Kingdom. Negative assessment effectively rules out immediate, serious morbidity, but not longer term morbidity and mortality. Costs seem to be similar to routine care.
Background-Studies from the United States (US) suggest that using a chest pain observation unit (CPOU) saves from $567 to $2030 per case compared with hospital admission. These savings will only be reproduced in the United Kingdom (UK) if the cost of routine hospital admission is similar. This study aimed to review current practice to determine the proportion of patients suitable for CPOU evaluation, the cost per case of routine admission and compare this with control groups in US studies. Methods-300 patients were randomly selected from those admitted with chest pain between January and June 1998. Two independent observers reviewed the case notes to determine who would have been suitable for CPOU management. Resource use of those selected was then determined. Results-Notes were retrieved for 285 patients. A total of 106 (37.2%) were suitable for CPOU care. Mean length of stay was 51 hours (median 24). Only two patients were admitted to the coronary care unit. Interventional cardiology was limited to two angiograms, one angioplasty and one bypass graft. Estimated mean cost per patient was £458 ($733) with interventional cardiology included, £356 ($570) without. Conclusion-Potential exists for the introduction of CPOU care to reduce health service costs in the UK. However, the magnitude of cost savings demonstrated in US studies were achieved by comparison to relatively high inpatient costs and should not be extrapolated. Economic evaluation of the CPOU should be repeated in the UK. The inclusion of interventional cardiology costs is an important determinant of cost eVectiveness.
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