Safe and rapid disposition of low-to-intermediate risk patients presenting to the emergency department with chest pain: A 1-year high-volume single-center experience

• Published in: Journal of cardiovascular computed tomography 2014-09, Vol.8 (5), p.375-383
• Main Authors: Jones, Ronald L., MD, Thomas, Dustin M., MD, Barnwell, Megan L., MD, Fentanes, Emilio, MD, Young, Adam N., MD, Barnwell, Robert, MD, Foley, Austin T., MD, Hilliard, Michael, MD, Hulten, Edward A., MD, Villines, Todd C., MD, Cury, Ricardo C., MD, Slim, Ahmad M., MD
• Format: Article
• Language: English
• Subjects: Acute chest pain; Cardiovascular; Causality; Chest Pain - diagnostic imaging; Chest Pain - economics; Chest Pain - mortality; Cohort Studies; Comorbidity; Computed tomography; Coronary Angiography - economics; Coronary Angiography - mortality; Coronary Angiography - statistics & numerical data; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - economics; Coronary Artery Disease - mortality; Coronary computed tomography angiography; Emergency disposition; Female; Health Care Costs - statistics & numerical data; Hospital Mortality; Humans; Incidence; Length of Stay - economics; Length of Stay - statistics & numerical data; Male; Middle Aged; Reproducibility of Results; Risk Assessment; Risk Factors; Sensitivity and Specificity; Survival Rate; Texas - epidemiology; Tomography, X-Ray Computed - economics; Tomography, X-Ray Computed - mortality; Tomography, X-Ray Computed - statistics & numerical data
• ISSN: 1934-5925; 1876-861X
• DOI: 10.1016/j.jcct.2014.08.003

Abstract Background Coronary CT angiography (CTA) is a powerful tool for the evaluation of chest pain in the emergency department (ED). Some debate persists regarding its cost-effectiveness in a low-to-intermediate risk population. Objective This study sought to evaluate the safety and cost-effectiveness of coronary CTA for low-to-intermediate risk patients presenting to the ED with chest pain in a closed-loop referral system. Methods Chest pain patients were evaluated in the ED via a local rapid coronary CTA protocol and tracked prospectively for ED throughput, disposition, chest pain recidivism, and cost utilization as compared with an age-matched cohort evaluated for chest pain treated with usual care. Results One hundred eighty-three patients underwent the rapid coronary CTA protocol compared with an age-matched cohort of 184 patients treated with usual care. The median follow-up period for major adverse cardiovascular events in the coronary CTA group was 9.0 months (range, 1.8–14.5 months) and 11.1 months (range, 0–14.0 months) for the age-matched cohort. The median ED length of stay (LOS) was 5.8 hours (range, 2.6–12.3 hours) for the rapid coronary CTA cohort and 12.2 hours (range, 1.7–40.3 hours) for the age-matched cohort ( P < .001). The median time to performance of coronary CTA was 2.5 hours (range, 0.4–8.7 hours) with a median time from coronary CTA performance to disposition of 2.9 hours (range, 0.8–8.6 hours). Total median hospital LOS was 5.9 hours (range, 2.7–124 hours) in the rapid coronary CTA cohort compared with 25.0 hours (range, 1.2–208 hours) in the age-matched cohort ( P < .001). Hospital admission was more common in the age-matched cohort (98.9% vs 9.3%; P < .001). There was a significant reduction in total payer cost in coronary CTA group when compared to usual care ($182,064.55 vs $685,190.77; P < .001). Conclusions Coronary CTA for ED risk stratification and disposition within a closed referral system resulted in the shortest ED LOS published to date while being safe and cost-effective.