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Costs and outcomes of patients admitted with chest pain and essentially normal electrocardiograms
P A McCullough1, O Ayad, W W O'Neill
1Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA.
Insights
Hospital admission for low-risk chest pain patients with normal ECGs is not cost-effective. Outpatient evaluation strategies are recommended to improve cost-effectiveness and patient outcomes.
Area of Science:
- Cardiology
- Health Economics
Background:
- Many US hospitals lack dedicated chest pain centers.
- The cost of admitting low-risk chest pain patients is not well understood.
Purpose of the Study:
- To evaluate the cost-effectiveness of hospital admissions for acute chest pain patients with normal electrocardiograms (ECGs).
Main Methods:
- Reviewed 1,670 emergency department patients with chest pain over 5 months.
- Identified 567 low-risk patients based on ECG criteria alone.
Main Results:
- 7.0% of patients had acute myocardial infarction (AMI); no deaths occurred.
- 60.5% of those undergoing cardiac catheterization had significant coronary artery disease (CAD).
- Admission was found to be cost-ineffective, with an estimated $1.7 million cost per life saved.
Conclusions:
- Hospital admission for chest pain patients with normal ECGs is not cost-favorable.
- Facilities should explore outpatient chest pain evaluation strategies.
Background:
Although inroads have been made in the outpatient evaluation of chest pain, the majority of hospitals in the United States do not have chest pain centers and the direct costs associated with hospital admissions in low-risk patients is unknown.
Hypothesis:
The study was undertaken to evaluate the cost and outcomes of admission to the hospital for patients with acute chest pain and essentially normal electrocardiograms (ECGs).
Methods:
For that purpose, we reviewed 1,670 patients presenting to our emergency department with chest pain over a 5-month period in 1994. Of these, 567 [34.0%, confidence interval (CI) 95%, 31.7-36.3%] patients were considered to be low risk by ECG criteria alone.
Results:
Complete clinical and financial data were available in 445 cases of which 152 had a previous history of coronary artery disease (CAD) and 31 (7.0%, CI 95%, 4.9-9.6%) were ultimately proven to have acute myocardial infarction (AMI). There were no deaths. All patients initially underwent noninvasive evaluation, and an additional 177 (39.8%) underwent subsequent cardiac catheterization. Of those, 107 (60.5%) had significant CAD (at least one vessel > 70% stenosis). We assumed an expected mortality rate of 1% in the AMI group based on previously reported series with all the mortalities preventable by hospitalization. This yielded a valuation of $1.7 million dollars per life saved. Sensitivity analysis revealed the practice of admission and in-patient evaluation for this group of patients was cost ineffective at all assumption levels.
Conclusion:
The practice of hospital admission for patients with chest pain and essentially normal ECGs is not cost favorable, and all hospital facilities should consider outpatient chest pain evaluation strategies.