Actual Financial Comparison of Four Strategies to Evaluate Patients with Potential Acute Coronary Syndromes

• Published in: Academic emergency medicine 2008-07, Vol.15 (7), p.649-655
• Main Authors: Chang, Anna Marie, Shofer, Frances S., Weiner, Mark G., Synnestvedt, Marie B., Litt, Harold I., Baxt, William G., Hollander, Judd E.
• Format: Article
• Language: English
• Subjects: acute coronary syndrome; Acute Coronary Syndrome - diagnostic imaging; Acute coronary syndromes; Biomarkers - analysis; Chi-Square Distribution; Comparative analysis; computed tomography coronary angiography; Coronary Angiography - economics; cost analysis; Costs and Cost Analysis - methods; Electrocardiography; Emergency medical care; Female; Heart attacks; Humans; Male; Middle Aged; observation unit; Retrospective Studies; Statistics, Nonparametric; Tomography; Tomography, X-Ray Computed - economics
• ISSN: 1069-6563; 1553-2712
• DOI: 10.1111/j.1553-2712.2008.00159.x

Objectives:  Small studies have shown that a negative computed tomography coronary angiogram (CTA) in low‐risk chest pain patients predicts a low rate of 30‐day adverse events. The authors hypothesized that an immediate CTA strategy would be as effective but less costly than alternative strategies for evaluation of patients with potential acute coronary syndrome (ACS). Methods:  The authors retrospectively compared four strategies for evaluation of patients after initial physician determination that the patient required admission and testing to rule out ACS. Patients were frequency‐matched by age, race, gender, thrombolysis in myocardial infarction (TIMI) score, and initial electrocardiogram (ECG). The four groups were immediate CTA in the emergency department (ED) without serial markers (n = 98); clinical decision unit/observation unit (CDU) with biomarkers and CTA (n = 102); CDU evaluation with serial cardiac biomarkers and stress testing (n = 154); and usual care, defined as admission with serial biomarkers and hospitalist‐directed evaluation (n = 289). The main outcomes were actual cost of care (facility direct and indirect fixed, facility variable direct labor and supply costs), length of stay (LOS), diagnosis of coronary artery disease (CAD), and safety (30‐day death or myocardial infarction [MI]). Results:  Patients in each group were of similar age (mean ± standard deviation [SD] 46 ± 9 years), race (62% African American), and gender (57% female) and had similar TIMI scores (100% between 0–2). Comparing immediate CTA versus CDU CTA versus CDU stress versus usual care, median costs were less ($1,240 vs. 2,318 vs. 4,024 vs. 2,913; p