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Published on: August 9, 2024
Impact of HEART Score Decision Aid on Coronary Computed Tomography Angiography Utilization and Diagnostic Yield in
Brian J McMahon1, Pragati Shrestha, Henry C Thode
1From the Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY.
Insights
A HEART score-based decision aid (HSDA) integrated into electronic health records significantly reduced coronary computed tomography angiography (CCTA) use by half. This implementation also improved the diagnostic yield for obstructive coronary artery disease in emergency department patients with chest pain.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Informatics
Background:
- Emergency physicians face challenges in risk stratifying chest pain patients to optimize diagnostic testing and reduce hospital admissions.
- The HEART score-based decision aid (HSDA) aims to improve the efficiency and reliability of risk stratification for suspected acute coronary syndrome.
Purpose of the Study:
- To evaluate the impact of an HSDA integrated into the electronic health record on coronary computed tomography angiography (CCTA) utilization.
- To assess the effect of the HSDA on the diagnostic yield of obstructive coronary artery disease (CAD) in emergency department (ED) patients presenting with chest pain (CP).
Main Methods:
- A before-and-after study design was employed at a large academic center.
- Data from adult ED CP patients with suspected acute coronary syndrome were collected during two 6-month periods: before (2018) and after (2020) HSDA implementation.
- Coronary computed tomography angiography (CCTA) utilization and obstructive CAD yield were compared using statistical analyses.
Main Results:
- CCTA utilization decreased from 23.4% before HSDA to 12.6% after implementation, a reduction of 11.1%.
- The diagnostic yield for obstructive CAD (≥50%) increased from 15% to 20.1% after HSDA implementation.
- No significant differences in patient demographics (age, sex) were observed between the study periods.
Conclusions:
- Mandatory implementation of an electronic health record-integrated HSDA effectively reduced CCTA utilization in the ED.
- The HSDA improved the diagnostic yield for obstructive coronary artery disease in patients with suspected acute coronary syndrome.
- This decision aid optimizes diagnostic pathways for chest pain evaluation in the emergency department.
Objective:
Emergency physicians are challenged to efficiently and reliably risk stratify patients presenting with chest pain (CP) to optimize diagnostic testing and avoid unnecessary hospital admissions. The objective of our study was to evaluate the impact of a HEART score-based decision aid (HSDA) integrated in the electronic health record on coronary computed tomography angiography (CCTA) utilization and diagnostic yield in adult emergency department (ED) CP patients with suspected acute coronary syndrome.
Methods:
We conducted a before and after study to determine whether implementation of a mandatory computerized HSDA would reduce CCTA utilization in ED CP patients and improve the diagnostic yield of obstructive coronary artery disease (CAD) (≥50%). We included all adult ED CP patients with suspected acute coronary syndrome during the first 6 months of 2018 (before) and 2020 (after) at a large academic center. CCTA utilization and obstructive CAD yield were compared in patients before and after implementing the HSDA using χ2 tests. Secondarily, we assessed the association of HEART scores and CCTA results.
Results:
Of the 3095 CP patients during the before study period, 733 underwent CCTA. Of the 2692 CP patients during the after study period, 339 underwent CCTA. CCTA utilization before and after HSDA was 23.4% [95% confidence interval (95% CI), 22.2-25.2] and 12.6% (95% CI, 11.4-13.0), respectively; mean difference was 11.1% (95% CI, 0.9-13.0). Among 1072 patients undergoing CCTA, mean (SD) age and percent females before versus after HSDA were 54 (11) versus 56 (11) years and 50% versus 49%, respectively. We included 1014 patients (686 before and 328 after) for the yield analysis. Obstructive CAD was present in 15% (95% CI, 12.7-17.9) and 20.1% (95% CI, 16.1-24.7) before and after HSDA, respectively; mean difference was 4.9% (95% CI, 0.1-10.1).
Conclusions:
Implementation of a mandatory electronic health record HSDA aid reduced ED CCTA utilization by half and improved the diagnostic yield.
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