Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study

Abstract

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.

Keywords: acute coronary syndrome; diagnostic testing; prognosis.

Figure 1. Risk stratification for acute coronary syndrome‐ACS estimated risk prediction categories and accompanying recommendations.

MACE indicates major adverse cardiac event. RISTRA‐ACS, risk stratification for acute coronary syndrome.

Figure 2. Study cohort selection and stratification.

ED, emergency department; KP, Kaiser Permanente, KPNC, Kaiser Permanente Northern California; MACE, major adverse cardiac event; RISTRA, risk stratification; STEMI, ST‐elevation myocardial infarction.

Figure 3. Quarterly averages of RISTRA‐ACS use among study eligible patient encounters (RISTRA sites only).

RISTRA‐ACS, risk stratification for acute coronary syndrome.

Figure 4. Time trends in index visit resource utilization.

Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals. Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).

Figure 5. Time trends in 30‐day objective cardiac testing.

Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals. Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).

Figure 6. Time trends in 60‐day major adverse cardiac events (MACE).

Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals. Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).

Figure 7. Time trends in 60‐day major cardiac adverse events except coronary revascularization (MACE‐CR).

Outcomes are stratified by RISTRA sites (blue lines) and control sites (orange lines). Error bars represent 95% confidence intervals Figures are presented by estimated risk of 60‐day major adverse cardiac events: (A) patients with low (≤2%) estimated risk; (B) patients with non‐low (>2%) estimated risk; (C) overall (any risk).