Development and validation of a comprehensive early risk prediction model for patients with undifferentiated acute chest pain

Dawson, L.; Andrew, Emily; Nehme, Ziad; Bloom, Jason; Liew, Danny; Cox, Sue; Anderson, Damon Lindsay; Stephenson, Michael; Lefkovits, Jeffrey; Taylor, Andrew J.; Kaye, D.; Cullen, Louise; Smith, Karen

doi:10.1016/j.ijcha.2022.101043

Cited by 3 publications

(4 citation statements)

References 24 publications

(41 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…For risk categorization in pathway 3, we assessed 2 risk scores, including the history, electrocardiogram, age, risk factors, and troponin (HEART) risk score, which has been validated for cohorts with suspected ACS in the prehospital setting, and the Early Chest Pain Admission Mortality and Myocardial Infarction (ECAMM) score, which is designed for undifferentiated chest pain presentations (rather than suspected ACS) but has not yet been prospectively validated . Risks of missing serious non-ACS diagnoses (eg, pulmonary embolism, heart failure, aortic dissection, pneumonia) are accounted for in a similar manner to standard ED pathways, with patients requiring classification as suspected ACS by paramedics and low-risk patients considered for prehospital discharge if clinical observations are normal (eMethods in Supplement 1), if pain has resolved, and after assessment by a virtual ED clinician.…”

Section: Methodsmentioning

confidence: 99%

“…Branch probabilities were estimated based on a systematic review of the literature (eMethods in Supplement 1) and using the Ambulance Victoria–linked chest pain cohort (Table 1). Given that the Ambulance Victoria chest pain cohort represented an undifferentiated chest pain cohort, we estimated the probability of patients undergoing a suspected ACS assessment pathway by dividing the myocardial infarction rate in the Ambulance Victoria cohort by the myocardial infarction rate in the Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department With High-Sensitivity Troponin T Study (RAPID-TnT) cohort, an Australian trial that enrolled patients planned to undergo a suspected ACS pathway . Probabilities of patients being classified as low risk by either the ECAMM or HEART scores were determined by calculating these scores using Ambulance Victoria comprehensive clinical data .…”

Section: Methodsmentioning

confidence: 99%

“… Given that the Ambulance Victoria chest pain cohort represented an undifferentiated chest pain cohort, we estimated the probability of patients undergoing a suspected ACS assessment pathway by dividing the myocardial infarction rate in the Ambulance Victoria cohort by the myocardial infarction rate in the Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department With High-Sensitivity Troponin T Study (RAPID-TnT) cohort, an Australian trial that enrolled patients planned to undergo a suspected ACS pathway . Probabilities of patients being classified as low risk by either the ECAMM or HEART scores were determined by calculating these scores using Ambulance Victoria comprehensive clinical data . Probabilities of patients avoiding admission due to a more rapid diagnosis were estimated based on studies assessing prehospital blood collection and trials comparing different hsTn algorithms (eMethods in Supplement 1), but to account for the uncertainty in this assumption, we used a more conservative range of 0% to 15%.…”

Section: Methodsmentioning

confidence: 99%

See 2 more Smart Citations

Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

Dawson

Nehme

et al. 2023

JAMA Intern Med

Self Cite

View full text Add to dashboard Cite

ImportancePrehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear.ObjectiveTo analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways.Design, Setting, and ParticipantsIn this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019.InterventionsParamedic risk stratification and point-of-care troponin testing.Main Outcomes and MeasuresThe outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways.ResultsA total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations).Conclusions and RelevancePrehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.

show abstract

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

Dawson

Nehme

et al. 2023

JAMA Intern Med

Self Cite

View full text Add to dashboard Cite

show abstract

“…Cost per capita per annum was estimated by dividing the total cost during the study period by the person-years at risk in Victoria, Australia, during the study period. To further understand the breakdown of estimated costs across the spectrum of chest pain presentations, we categorised patients according to the Early Chest pain Admission, Myocardial infarction, and Mortality (ECAMM) risk score,14which classifies risk of mortality, myocardial infarction and admission to the hospital for any cause among patients with undifferentiated chest pain and presented mean episode and total annual costs for each category. Risk scores available for suspected ACS (HEART score15 and EDACS score16) were not used, given the cohort represents patients with undifferentiated chest pain.…”

Section: Methodsmentioning

confidence: 99%

Healthcare cost burden of acute chest pain presentations

et al. 2023

View full text Add to dashboard Cite

BackgroundThis study aimed to estimate the direct healthcare cost burden of acute chest pain attendances presenting to ambulance in Victoria, Australia, and to identify key cost drivers especially among low-risk patients.MethodsState-wide population-based cohort study of consecutive adult patients attended by ambulance for acute chest pain with individual linkage to emergency and hospital admission data in Victoria, Australia (1 January 2015–30 June 2019). Direct healthcare costs, adjusted for inflation to 2020–2021 ($A), were estimated for each component of care using a casemix funding method.ResultsFrom 241 627 ambulance attendances for chest pain during the study period, mean chest pain episode cost was $6284, and total annual costs were estimated at $337.4 million ($68 per capita per annum). Total annual costs increased across the period ($310.5 million in 2015 vs $384.5 million in 2019), while mean episode costs remained stable. Cardiovascular conditions (25% of presentations) were the most expensive (mean $11 523, total annual $148.7 million), while a non-specific pain diagnosis (49% of presentations) was the least expensive (mean $3836, total annual $93.4 million). Patients classified as being at low risk of myocardial infarction, mortality or hospital admission (Early Chest pain Admission, Myocardial infarction, and Mortality (ECAMM) score) represented 31%–57% of the cohort, with total annual costs estimated at $60.6 million–$135.4 million, depending on the score cut-off used.ConclusionsTotal annual costs for acute chest pain presentations are increasing, and a significant proportion of the cost burden relates to low-risk patients and non-specific pain. These data highlight the need to improve the cost-efficiency of chest pain care pathways.

show abstract

POCUS shock management: point-of-care ultrasound in the integrated management of chest pain

Cibinel¹

2023

Ital J Emerg Med

View full text Add to dashboard Cite

Development and validation of a comprehensive early risk prediction model for patients with undifferentiated acute chest pain

Cited by 3 publications

References 24 publications

Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

Healthcare cost burden of acute chest pain presentations

POCUS shock management: point-of-care ultrasound in the integrated management of chest pain

Contact Info

Product

Resources

About