Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System

Adam L. Sharp, Aileen S. Baecker, Ernest Shen, Rita Redberg, Ming Sum Lee, Maros Ferencik, Shaw Natsui, Chengyi Zheng, Aniket Kawatkar, Michael K. Gould, Benjamin Sun

Research output: Contribution to journalArticle

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Abstract

Study objective: We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs). Methods: We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable. Results: A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39% (95% CI 3.72% to 5.07%) after 12 months’ follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08). Conclusion: Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.

Original languageEnglish (US)
JournalAnnals of emergency medicine
DOIs
StatePublished - Jan 1 2019

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Troponin
Age Factors
Pain Management
Chest Pain
Electrocardiography
History
Hospital Emergency Service
Health
Confidence Intervals
Hospitalization
Logistic Models
Odds Ratio
Myocardial Infarction
Observation
Mortality
Quality of Health Care
Acute Coronary Syndrome
Cluster Analysis
Inpatients
Physicians

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System. / Sharp, Adam L.; Baecker, Aileen S.; Shen, Ernest; Redberg, Rita; Lee, Ming Sum; Ferencik, Maros; Natsui, Shaw; Zheng, Chengyi; Kawatkar, Aniket; Gould, Michael K.; Sun, Benjamin.

In: Annals of emergency medicine, 01.01.2019.

Research output: Contribution to journalArticle

Sharp, Adam L. ; Baecker, Aileen S. ; Shen, Ernest ; Redberg, Rita ; Lee, Ming Sum ; Ferencik, Maros ; Natsui, Shaw ; Zheng, Chengyi ; Kawatkar, Aniket ; Gould, Michael K. ; Sun, Benjamin. / Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System. In: Annals of emergency medicine. 2019.
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abstract = "Study objective: We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs). Methods: We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable. Results: A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5{\%} (before, 35.5{\%}; after, 31.8{\%}) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95{\%} confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39{\%} (95{\%} CI 3.72{\%} to 5.07{\%}) after 12 months’ follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6{\%} [before] versus 0.6{\%} [after]; odds ratio 1.02; 95{\%} CI 0.97 to 1.08). Conclusion: Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.",
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