BMJ  2004;328:254 (31 January), doi:10.1136/bmj.37956.664236.EE (published 14 January 2004)

Paper

Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

Steve Goodacre, senior lecturer in health service research and emergency medicine1, Jon Nicholl, director, Medical Care Research Unit1, Simon Dixon, senior lecturer in health economics1, Elizabeth Cross, research associate1, Karen Angelini, chest pain nurse2, Jane Arnold, chest pain nurse2, Sue Revill, chest pain nurse2, Tom Locker, specialist registrar2, Simon J Capewell, chair of clinical epidemiology4, Deborah Quinney, research fellow4, Stephen Campbell, consultant3, Francis Morris, consultant2

1 School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, 2 Emergency Department, Northern General Hospital, Sheffield S5 7AU, 3 Department of Cardiology, Northern General Hospital, 4 Department of Public Health, University of Liverpool, Liverpool L69 3GB

Correspondence to: S Goodacre s.goodacre{at}sheffield.ac.uk

Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain.

Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective.

Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom.

Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance.

Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service.

Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, -7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (-£56 to £210, P = 0.252).

Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care.


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