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Published on: February 16, 2016
A cardiac computed tomography first strategy to evaluate chest pain in a rural setting: outcomes and cost
George S Chrysant1,2, Steven Fillmore2, Richard McClain2
1Department of Cardiology, INTEGRIS Baptist Medical Center/INTEGRIS Cardiovascular Physicians, Oklahoma City.
Insights
Cardiac computed tomography angiography (CCTA) effectively diagnoses low-to-intermediate risk chest pain, reducing costs and improving patient outcomes. This strategy safely identifies high-risk patients needing further intervention.
Area of Science:
- Cardiology
- Radiology
- Health Economics
Background:
- Chest pain evaluation is a significant healthcare burden, costing over $10 billion annually.
- Missed ischemia diagnoses are a leading cause of malpractice lawsuits for emergency department physicians.
- Current diagnostic strategies can be costly and may lead to delayed or missed diagnoses.
Purpose of the Study:
- To evaluate the effectiveness and cost-efficiency of a cardiac computed tomography angiography (CCTA) first strategy for acute chest pain.
- To accurately diagnose low-to-intermediate risk chest pain and reduce overall healthcare costs.
- To ensure timely transfer of high-risk patients to specialized care.
Main Methods:
- A CCTA-first strategy was implemented for low-to-intermediate risk chest pain patients.
- Patients underwent troponin levels, ECG, and CCTA if eligible.
- High-risk patients were transferred; all patients were followed for adverse events (MI, death, revascularization) for a mean of 28 months.
Main Results:
- Of 368 patients, 29 were transferred for obstructive coronary disease; 11 required revascularization.
- Average coronary artery calcium scores were higher in transferred and revascularized patients.
- At 24 months, 2 patients underwent revascularization and 1 died suddenly, indicating a safe follow-up.
Conclusions:
- The CCTA-first strategy resulted in significant cost savings of approximately $1.2 million.
- This approach accurately identifies patients needing intervention while reducing unnecessary procedures.
- The strategy is cost-effective for self-insured health systems.
Introduction:
Chest pain continues to be a major burden on the healthcare system with more than eight million patients being evaluated in the emergency department (ED) setting annually at a cost of greater than 10 billion dollars. Missed chest pain diagnoses for ischemia are the leading cause of malpractice lawsuits for ED physicians. The use of cardiac computed tomography angiography (CCTA) to assess acute chest pain was adopted at the Chickasaw Nation Medical Center to attempt to accurately diagnose low to intermediate risk chest pain and potentially reduce the cost of chest pain evaluation to the system while still transferring appropriate high-risk patients.
Patients And Methods:
Patients presenting to the ED with low to moderate risk chest pain were evaluated with at least two negative troponin levels, an ECG, and in most instances overnight observation followed by CCTA in the morning if eligible. High-risk patients were transported to a tertiary care facility with cardiac catheterization capabilities. Medical records were checked to determine if any adverse events had occurred during follow-up. Adverse events were defined as myocardial infarction, death, and/or revascularization. Mean follow-up was 28 months.
Results:
Of the 368 patients studied, 29 patients were transferred due to findings of at least moderate obstructive disease. Of those 29 patients transferred, 11 patients underwent revascularization (10 underwent percutaneous coronary intervention and one underwent coronary artery bypass grafting). The average coronary artery calcium score for patients transferred was 96.1. The average coronary artery calcium score for patients undergoing revascularization was 174.6. Six patients had normal coronary arteries on catheterization. The remaining 12 patients had the moderate obstructive disease by catheterization that was not physiologically significant by either invasive fractional flow reserve or in two instances, negative stress perfusion testing. At 24 months, two patients had undergone revascularization and one patient had died suddenly.
Conclusion:
The cost savings associated with a CCTA first strategy to evaluate chest pain were ~$1 200 244.10. For a self-insured health system such as the Chickasaw Nation, these are very important cost savings.
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