Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

Abstract

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.

Methodological Issues Surrounding the Use of Baseline Health-Related Quality of Life Data to Inform Trial-Based Economic Evaluations of Interventions Within Emergency and Critical Care Settings: A Systematic Literature Review

“…EQ-5D data were collected at baseline by the recruiting physician. In the remaining 15 studies, the earliest time point recorded for data collection directly from study participants varied from 2 days post-randomisation [41] to 12 months post-randomisation . The reported reasons for not assessing health-related quality of life at randomisation mostly reflected the condition of trial participants at this time point, concerns around utility measurement in these clinical settings, or reluctance to prioritise health-related quality of life assessment in studies with substantial data collection burden.…”

Parametric modelling of cost data: some simulation evidence

“…The three datasets used for empirical simulations are described below. The CPOU data: These data were constructed for an economic evaluation of a Chest Pain Observation Unit operating within the A and E department of a single large teaching hospital [16]. Patients with acute chest pain, undiagnosed by clinical assessment, electrocardiogram and chest radiograph, were recruited and followed-up to 6 months.…”

A systematic review and economic evaluation of statins for the prevention of coronary events

“…247 This was an RCT comparing care in a chest pain clinic observation unit with routine care in the emergency department of the Northern General Hospital in Sheffield, UK. As part of a costeffectiveness analysis, EQ-5D questionnaires were administered to 676 patients at 6 months following treatment.…”