Outcomes and Radiation Exposure of Emergency Department Patients With Chest Pain and Shortness of Breath and Ultralow Pretest Probability: A Multicenter Study

Kline, Jeffrey A.; Shapiro, Nathan I.; Jones, Alan E.; Hernandez, Jackeline; Hogg, Melanie; Troyer, Jennifer L.; Nelson, R. Darrell

doi:10.1016/j.annemergmed.2013.09.009

Cited by 35 publications

(50 citation statements)

References 36 publications

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“…15 The raw charge data were not normally distributed (p < 0.05, Shapiro-Wilk), but log 10 transformation established normality. The mean (AESD) log 10 (-charge) was $4.31 (AE$0.485).…”

Section: Discussionmentioning

confidence: 99%

Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban

2015

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“…15 The raw charge data were not normally distributed (p < 0.05, Shapiro-Wilk), but log 10 transformation established normality. The mean (AESD) log 10 (-charge) was $4.31 (AE$0.485).…”

Section: Discussionmentioning

confidence: 99%

Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban

2015

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“…1,2 The main study and this secondary analysis were funded by the Agency for Healthcare Research and Quality. This study was approved by the institutional review boards of the participating hospitals, and each patient and physician participant gave written informed consent.…”

Section: Methodsmentioning

confidence: 99%

“…1,2,10 In brief, the proportion of patients with >5 mSv to the chest and no significant cardiopulmonary diagnosis within 90 days was reduced in the intervention group, and the intervention group had significantly lower median chest radiation exposure and lower median medical costs. Adverse events were also lower in the intervention group.…”

Section: Study Setting and Populationmentioning

confidence: 98%

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Cost‐effectiveness of Quantitative Pretest Probability Intended to Reduce Unnecessary Medical Radiation Exposure in Emergency Department Patients With Chest Pain and Dyspnea

Troyer

Jones

Shapiro

et al. 2015

Academic Emergency Medicine

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Objectives: Quantitative pretest probability (qPTP) incorporated into a decision support tool with advice can reduce unnecessary diagnostic testing among patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE), reducing 30-day costs without an increase in 90-day adverse outcomes. This study estimates long-term (beyond 90-day) costs and outcomes associated with qPTP. The authors hypothesized that qPTP reduces lifetime costs and improves outcomes in low-risk patients with symptoms suggestive of ACS and PE.Methods: This was a cost-effectiveness analysis of a multicenter, randomized controlled trial of adult emergency patients with dyspnea and chest pain, in which a clinician encountering a low-risk patient with symptoms suggestive of ACS or PE conducted either the intervention (qPTP for ACS and PE with advice) or the sham (no qPTP and no advice). Effect of the intervention over a patient's lifetime was assessed using a Markov microsimulation model. Short-term costs and outcomes were from the trial; long-term outcomes and costs were from the literature. Outcomes included lifetime transition to PE, ACS, and intracranial hemorrhage (ICH); mortality from cancer, ICH, PE, ACS, renal failure, and ischemic stroke; quality-adjusted life-years (QALYs); and total medical costs compared between simulated intervention and sham groups.Results: Markov microsimulation for a 40-year-old patient receiving qPTP found lifetime cost savings of $497 for women and $528 for men, associated with small gains in QALYs (2 and 6 days, respectively) and lower rates of cancer mortality in both sexes, but a reduction in ICH only in males. Sensitivity analysis for patients aged 60 years predicted that qPTP would continue to save costs and also reduce mortality from both ICH and cancer. Use of qPTP significantly reduced the lifetime probability of PE diagnosis, with lower probability of death from PE in both sexes aged 40 to 60 years. However, use of qPTP reduced the rate of ACS diagnosis and death from ACS at age 40, but increased the death rate from ACS at age 60 for both sexes.

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“…Thus, most resources and clinical efforts are focused on the detection and treatment ACS and PE. However, between 80% and 95% of all patients presenting to EDs with complaints of chest pain do not have cardiac disease, or any other cardiopulmonary emergency by conventional testing (2)(3)(4)(5)(6). Further, previous findings indicate that up to 55% of patients with non-cardiopulmonary chest pain may be suffering from anxiety or panic disorders, and these psychiatric disorders remain undiagnosed in almost 90% of cases (7)(8)(9)(10)(11)(12)(13).…”

Section: Introductionmentioning

confidence: 99%

Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety

Musey

Kline

2017

The Journal of Emergency Medicine

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, Abstract-Background: Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%-95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders. Objective: Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes. Methods: Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism. Results: Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to ''stress'' or ''anxiety''; their mean ACS pretest probability was 4% (95% confidence interval 2.9%-5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety. Conclusions: Without prompting, 8% of patients selfidentified ''stress'' or ''anxiety'' as the etiology for their chest pain. Most had low pretest probability, were overinvestigated for ACS and PE, and not investigated for anxiety syndromes. Ó

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Outcomes and Radiation Exposure of Emergency Department Patients With Chest Pain and Shortness of Breath and Ultralow Pretest Probability: A Multicenter Study

Cited by 35 publications

References 36 publications

Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban

Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban

Cost‐effectiveness of Quantitative Pretest Probability Intended to Reduce Unnecessary Medical Radiation Exposure in Emergency Department Patients With Chest Pain and Dyspnea

Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety

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