Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan

Abstract

Objective: Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Prior to introduction of the SCAMP, we analyzed charges for 406 patients with chest pain, seen in 2009, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, examination, or ECG findings suggestive of a cardiac etiology for chest pain.Design: Resource utilization was reviewed for 1517 patients (7-21 years) enrolled in the SCAMP from July 2010 to April 2014.Results: Compared to the 2009 historic cohort, patients evaluated by the SCAMP had higher rates of exertional chest pain (45% vs 37%) and positive family history (5% vs 1%). The SCAMP cohort had fewer abnormal physical examination findings (1% vs 6%) and abnormal electrocardiograms (3% vs 5%). Echocardiogram use increased in the SCAMP cohort compared to the 2009 historic cohort (45% vs 41%), whereas all other ancillary testing was reduced: exercise stress testing (4% SCAMP vs 28% historic), Holter (4% vs 7%), event monitors (3% vs 10%), and MRI (1% vs 2%).Total charges were reduced by 22% ($822 625) by use of the Chest Pain SCAMP, despite a higher percentage of patients for whom echocardiogram was recommended compared to the historic cohort. Conclusions:The Chest Pain SCAMP effectively streamlines cardiac testing and reduces resource utilization. Further reductions can be made by algorithm refinement regarding echocardiograms for exertional symptoms.chest pain, quality improvement, resource reduction, SCAMP | I NTR OD U CTI ONChest pain in the pediatric population is one of the most common complaints presenting to primary caregivers as well as cardiology specialists. The majority of chest pain in this young population represents a benign symptom, with a paucity related to serious organic disease. [1][2][3][4][5][6] A cardiac etiology to chest pain in children is exceedingly rare (0.1-1%) and determining which child could be among those affected remains a challenge.1,2,5,7-11 As detailed in prior publications, the Pediatric ChestPain Standardized Clinical Assessment and Management Plan (SCAMP) was developed and implemented at Boston Children's Hospital in 2010 as a quality improvement initiative. The goals of the SCAMP are to reduce unnecessary resource utilization for chest pain assessment in the cardiology clinic and to aid in the detection of rare cardiac disease by decreasing practice variation and directing resources to signs and symptoms most suggestive of cardiac disease. 2,8,12The Chest Pain SCAMP was developed based on review of the literature and analysis of a decade of patients presenting to BostonChildren's Hospital with serious cardiac disease and chest pain as a major complaint.

Aetiological evaluation of chest pain in childhood and adolescence

“…Several algorithms have been proposed for evaluation of children with chest pain to eliminate invasive testing and to save resources. 4,6,16,18 However, we believe that it is better to eliminate the concerns of the patient and the family that the pain is caused by cardiac problems. For that purpose, we used echocardiography in all children with chest pain as a policy of our paediatric cardiology clinic.…”

“…1,2 The most common causes of chest pain in children are non-cardiac and include musculoskeletal and idiopathic origins, and cardiac diseases are found in the aetiology of chest pain in a small portion of the cases ranging from less than 1 to 10%. [3][4][5][6] Careful evaluation of medical history, and physical examination should be performed due to high mortality of cardiac-related chest pain in cases without rapid diagnosis and treatment. 3,5,7 However, there is a controversy about determining which child could be affected by a serious organic disease and which tests could be performed for an exact diagnosis.…”

“…3,5,7 However, there is a controversy about determining which child could be affected by a serious organic disease and which tests could be performed for an exact diagnosis. 4 Aetiology of chest pain may show considerable variability based on the diagnostic approaches.…”

Experience participating in the American College of Cardiology Quality NetworkTM: paediatric and adult congenital cardiology collaborative quality improvement

“…Over the past 3 years, we evaluated~500 patients with chest pain annually in our paediatric cardiology clinics; <1% had a cardiac aetiology to their complaint. [13][14][15] The magnitude of patient volume and associated high expense of care prompted an earlier quality improvement effort at our institution to standardise care and target more judicious testing to higher yield complaints through the chest pain Standardised Clinical Assessment and Management Plan®. 16 Our management strategies included obtaining detailed family history and electrocardiograms in all children complaining of chest pain, in alignment with principles in the Quality Network metrics.…”

The Relationship Between Unexplained Chest Pain in Children and Head-Up Tilt Test

“…Chest pain is a common clinical reason for seeking medical attention. It can be seen in various diseases and is one of the 14 most common symptoms in primary care ( 1 ). Its lifetime incidence among the population is 24.6% ( 1 ).…”