Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.37956.664236.EE (Published 29 January 2004) Cite this as: BMJ 2004;328:254
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The idea of Chest pain observation units has come in from USA but in
UK its implementation will have to take into account the cost
effectiveness
I feel that better results can be obtained by improving the present system
in which not only the myocardial ischaemia pain but also other causes of
chest pain are excluded.
The work done by our colleagues in Sheffield is indeed commendable but
have they thought of or looked into how many patients with minor or
submassive PE have been missed, how many patients with Gastro oesophageal
Reflux Disorder (GORD) and Dyspepsia have been missed.
Once cardiac pain is ruled out in Chest Pain Observation Unit (CPOU) would
the patient be discharged without looking into other possibilities or
would the patient be again admitted to routine wards as previously for
further evaluation.
If the patient is discharged then that would increase the readmission rate
and with it the cost of health care.
If the patient is admitted again for further evaluation then it will
increase the time of stay in the hospital and cost of the health care.
Hence I think we can improve the outcome without CPOU if we improve the
standards of care and implement the benefits of CPOU in our routine
practice.
Competing interests:
None declared
Competing interests: No competing interests
The recent article by Goodacre and colleagues on the management of
patients presenting to hospital with acute chest pain provides useful
evidence on the cost-effectiveness of different approaches to managing
this frequent cause of hospital admission [1]. The authors show that the
higher costs of a chest pain observation unit compared to standard care
are more than offset by reduced costs of hospital admission and follow up.
Furthermore, this type of care was associated with improved patient
quality of life in the following six months.
These are welcome data, showing the value of careful cardiac
assessment of chest pain to both patients and healthcare providers.
However, chest pain is a heterogeneous condition with a number of non-
cardiac causes, and other forms of assessment may also be of value. While
musculoskeletal, psychiatric and oesophageal causes of chest pain are
rarely life-threatening, they are frequently chronic and can cause a
substantial impairment of patient quality of life. In a study of chest
pain patients discharged from an emergency unit, those who received a
diagnosis of myocardial infarction subsequently had better quality of life
than those who did not [2], most likely because undiagnosed and untreated
chest pain is a cause of continued discomfort and distress [3]. As a
result, up to a quarter of patients with unexplained chest pain are likely
to re-attend emergency departments in the months following discharge [4,
5], a trend reflected in the study by Goodacre and colleagues.
Unexplained chest pain, therefore, deserves to be taken seriously,
even once cardiac causes have been excluded. A recent study in Sweden has
shown that effective management of unexplained chest pain in patients
without acute myocardial infarction is likely to be cost-effective and
improve quality of life [5]. Patients who were re-evaluated in a chest
pain clinic within a week of discharge from hospital and offered advice
and further investigation of their chest pain had significantly lower
rates of readmission and rehospitalization than patients receiving routine
care (17% vs. 25% and 16% vs. 24%, respectively).
Gastro-oesophageal reflux may account for unexplained chest pain in
up to half of all patients [6], making acid suppression a potentially
valuable therapeutic approach. In studies of patients with unexplained
chest pain that is not of cardiac origin, proton pump inhibitors
significantly improve symptoms and reduce the number of days with chest
pain compared to placebo [7-10]. As a result, a short course of acid
suppression has been suggested as a cost-effective approach to diagnosing
the underlying cause of unexplained chest pain [10].
Chest pain is a common complaint, in hospital and primary care
settings, and in the community [6]. Cross-sectional studies indicate that
between a quarter and a third of the general population report chest pain
in the absence of likely cardiac causes [11, 12]. There is clearly an
opportunity to improve the management of chest pain, whether or not it
indicates underlying ischaemic heart disease, and this has the potential
to bring benefits to patients, healthcare providers and the medical
profession as a whole.
References
1. Goodacre, S., et al., Randomised controlled trial and economic
evaluation of a chest pain observation unit compared with routine care.
BMJ, 2004. 328(7434): 254.
2. Karlson, B.W., et al., Prognosis, severity of symptoms, and
aspects of well-being among patients in whom myocardial infarction was
ruled out. Clin Cardiol, 1994. 17(8): 427-31.
3. Ockene, I.S., et al., Unexplained chest pain in patients with
normal coronary arteriograms: a follow-up study of functional status. N
Engl J Med, 1980. 303(22): 1249-52.
4. Fitzpatrick, M.A., et al., The burden of non-cardiac chest pain in
Australia (abstract). Aust N Z J Med, 2000. 30: 134.
5. Karlson, B.W., et al., Impact of a chest pain clinic on recurrency
of symptoms and readmissions among patients early discharged from hospital
after acute myocardial infarction was ruled out. Eur J Emerg Med, 1998.
5(1): 29-35.
6. Eslick, G.D., D.S. Coulshed, and N.J. Talley, Review article: the
burden of illness of non-cardiac chest pain. Aliment Pharmacol Ther, 2002.
16(7): 1217-23.
7. Achem, S.R., et al., Effects of omeprazole versus placebo in
treatment of noncardiac chest pain and gastroesophageal reflux. Dig Dis
Sci, 1997. 42(10): 2138-45.
8. Xia, H.H., et al., Symptomatic response to lansoprazole predicts
abnormal acid reflux in endoscopy-negative patients with non-cardiac chest
pain. Aliment Pharmacol Ther, 2003. 17(3): 369-77.
9. Pandak, W.M., et al., Short course of omeprazole: a better first
diagnostic approach to noncardiac chest pain than endoscopy, manometry, or
24-hour esophageal pH monitoring. J Clin Gastroenterol, 2002. 35(4): 307-
14.
10. Fass, R., et al., The clinical and economic value of a short
course of omeprazole in patients with noncardiac chest pain.
Gastroenterology, 1998. 115(1): 42-9.
11. Eslick, G.D., M.P. Jones, and N.J. Talley, Non-cardiac chest
pain: prevalence, risk factors, impact and consulting--a population-based
study. Aliment Pharmacol Ther, 2003. 17(9): 1115-24.
12. Locke, G.R., 3rd, et al., Prevalence and clinical spectrum of
gastroesophageal reflux: a population-based study in Olmsted County,
Minnesota. Gastroenterology, 1997. 112(5): 1448-56.
Competing interests:
I have or have had consultancy agreements, mainly medical and scientific advice, with AstraZeneca, Abbott Laboratories and Schering-Plough.
Competing interests: No competing interests
Dear Editor: The paper of Drs Steve Goodacre, Jon Nicholl et al(1),
offers a fresh approach to the cost effective evaluation of patients with
chest pain in the emergency department utilizing chest pain unit vs
routine evaluation. However, since their premise was cost effective
medical practice it does limit some important clinical perspectives for
chest pain diagnosis and its relation to coronary artery disease
syndromes. The introduction of cost effectiveness puts some restraints on
clinical practice. To wit, a primary emphasis should be on patient history
and exam and in particular, the cardiovascular exam which so far in the
equation has beneficial economic value without cost: The examiner would
look for pulsus alternans seen in severe myocardial disease, or gallop
rhythm again seen with left ventricular failure which may result from
myocardial infarction, or paradoxical splitting of the second heart sound
which maybe secondary to left bundle branch block, or coronary artery
disease. When it comes to studies, aside from the ecg, chest x ray and
cardiac enzymes (cpk -mb, troponin 1), myoglobin determination is highly
indicative of myocardial injury. Furthermore, instead of an exercise
treadmill test, a 2 d -echocardiogram offers a better prognosis for
patients with chest pain and non diagnostic ecg S T elevation of
myocardial infarction(2), and rapidly evaluates abnormal left ventricular
wall motion seen in chest pain of coronary origin and also gives, with
doppler timed studies, an approximation of ventricular ejection fraction.
There is in no weighted evidence that being precise in pursuing chest pain
evaluation is more or less cost effective in the overall patient
evaluation.
M E Nassar, M.D.
References:
1-BMJ,doi:10.1136/bmj.37956.664236.EE(Published 14 Jan
2004).
2-Muscholl MW,Oswald M, et al. Int. J Cardiol 2002 Aug:24(2-3) 217-
225
Competing interests:
None declared
Competing interests: No competing interests
Rocke LGR, McNicholl BP, Hughes D, Dunn F. Chest Pain Observation
units – are they necessary?
Editor,
Goodacre et al(1) describe the effectiveness of a chest pain
observation unit, where patients are monitored for up to six hours.
An alternative is the use of a 90 minute rule-out method,
incorporating Myoglobin(2,3). This has a sensitivity and negative
predictive value of 100% for myocardial infarction, reduces coronary care
unit(CCU) admissions by 40%, and does not require a dedicated observation
unit(2). Patients presenting with chest pain suggestive of acute
myocardial ischaemia but with a non-diagnostic ECG are tested for
Myoglobin, Troponin I and CK-MB at the point of care. The ECG and cardiac
markers are repeated over the next 90 minutes. Patients with a rise in
myoglobin of 25% or more (even if both values are normal) or a sustained
elevation of CK-MB or Troponin I are referred to CCU. If ECGs and markers
are normal, patients may be discharged. Further management is weighted
by clinical risk assessment.
We have used a similar pathway(2), for two years, in our Emergency
Department. We found a 44% reduction in admissions and earlier and more
appropriate referrals to CCU in the first 197 patients studied. Our audit
included a 30-day follow up. One adverse event was noted in patients who
were discharged; this patient was a protocol violation. We did not need
any additional staffing to implement this pathway. Triple marker testing
costs £30 per patient, for two serial tests. The pathway works 24 hours
a day, seven days per week, and requires little additional training for
medical and nursing staff. We suggest this pathway is effective in the
Emergency Department assessment of patients with acute chest pain.
Goodacre S, Nicholl J, Dixon X, Cross E, Angelini K, Revill C, et al
. Randomized controlled trial and economic evaluation of a chest pain
observation unit compared with routine care. BMJ 2004;328:254-7.
Ng S Krishnaswamy P, Morissey R, Clapton P, Fitzgerald R, Maisel AS.
Ninety minute accelerated critical pathway for chest pain evaluation. Am J
Cardiol 2001;88:611-617.
McCord J , Nowak RM, McCullough P, Foreback C, Borzak S, Tokarski G,
et al. Ninety-minute exclusion of acute myocardial infarction by use of
quantitative point of care testing of myoglobin and Troponin I..
Circulation 2001;104:1483-1488.
Competing interests:
The test panels for the initial pilot study of 90 patients were provided by Biosite Inc., the manufacturer. LGR received part funding for one conference.
Competing interests: No competing interests
Having worked in the Emergency Department where the study has been
carried out I have to take issue with some of Dr Jones comments.
Though it may be unsatisfying for some purists/physicians that we can not
give each person a diagnostic label, in the field of Emergency medicine we
are used to managing risk. Excluding life threatening conditions i.e.
acute coronary syndromes, and in addition pulmonary embolism and
dissecting aneurysm are the main priority for emergency physicians and
takes place in the unit in Sheffield. Alternative diagnosis which do not
carry an immediate threat to life such as GORD, peptic ulcer disease, can
be left to the physicians to investigate in out patients. The vast
majority of patients had a chest x-ray performed unless there is a good
reason not to carry one out.
I suspect that most patients who are admitted more conventionally via
general medicine are managed in a similar fashion, and leave hospital
without an exact diagnosis, even after extensive investigation. This chest
pain unit has demonstrated that it can safely manage risk in a patient
population that is a significant resource issue for most emergency and
general medical departments in the UK.
Dr Jones wonders whether audit was carried out on discharged
patients. As was stated in the paper, all patients were offered follow up
following discharge, which the majority participated in. This degree of
follow up is more than most medical patients would recieve after their
"exclusion of a coronary syndrome".
Competing interests:
I have worked in the Northern General where the "Chest Pain observation unit" exists
Competing interests: No competing interests
Sir,
I read with interest the paper by Goodacre et al. However, I feel that the
name 'chest pain observation unit' is a misnomer, the unit should be
called 'exclusion of ischaemic heart disease unit'. These units, which
have appeared in various other hospitals, appear to assume that there is
only one serious cause for chest pain ie. ischaemic heart disease.
Although I agree that ischaemic heart disease is a serious disease that
needs exclusion in those attending with chest pain, the finding of a
normal ECG, troponin T and exercise tolerance test should not necessarily
prompt early discharge, as appears to be advocated by the paper, but
reassessment for an alternative cause. The chest pain unit described in
the paper excluded people with ECG changes diagnostic of acute coronary
syndrome, and therefore, the population seen in the unit were those
patients with genuine diagnostic uncertainty as to the aetiology of the
chest pain. It is precisely these patients that need an un-blinkered
approach in their assessment. I would be interested to know if a chest
Xray was performed routinely on these patients and if an audit is planned
to check that the unit is not missing other (non-coronary artery) causes
of chest pain. Perhaps there is an irony that this paper appeared in the
edition of the BMJ entitled "The epidemic of mesothelioma", I wonder how
many cases would be picked in the 'chest pain observation unit'.
Competing interests:
None declared
Competing interests: No competing interests
Sirs,
The conclusions of the paper’s authors (1) can surely be accepted
if we ignore that today it exists, beside the traditional physical
semeiotics, also the biophysical semeiotics (See webb site HONCode 233736,
www.semeioticabiofisica.it).
In fact, their conclusions would be really
different if doctors could recognize clinically the real origin
of the chest pain: cardiac, oesophageal, pulmonary, aortic, a.s.o. In other
words, care in a chest pain observation unit can improve outcomes and may
reduce costs to the health service, only if doctors know exclusively the
traditional physical examination. On the contrary, costs could be less
expensive if physicians, around the world, would learn also the new
semeiotics. In fact, nowadays, all common diagnoses, including chest pain
real causes, must be and are firstly “clinical”, and corroborated
subsequently by laboratory and/or image department (performed always in
patients rationally selected) in both chest pain unit or in ER, as allows
me to state a 46 year-long clinical experience. In addition, under such
circumstances, if a test results pathological, but clinical examination,
i.e. the clinical result of biophysical semeiotics, is normal (I ask “why”
an individual, evaluated at the bed-side in healthy condition as regards
his coronary artery (2, 3, 4), must undergo a useless instrumental or
laboratory examination) and this “patient”, moreover, is working all day
long and is even able to perform physical exercise, physician is allowed
to state that in such (really numerous) cases, laboratory and image
department are wrong. To conclude, first of all physical (or better
speaking, biophysical semeiotic) examination, and then laboratory and
image departement.
1) Goodacre S., Nicholl J., DixonS., et al. Randomised controlled
trial and economic evaluation of a chest pain observation unit compared
with routine care. BMJ 2004;328:254 (31 January),
doi:10.1136/bmj.37956.664236.EE (published 14 January 2004)
2) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos,
Preconditioning and Myocardial Oxygenation evaluated clinically with the
aid of Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease
even silent. Acta Med. Medit. 13, 109, 1997.
3) Stagnaro S. A clinical efficacious maneouvre, reliable in bed-side
diagnosing coronary artery disease, even initial or silent, as well as
“heart coronary risk”. 3rd TCVC Argentine Congress of Cardiology,
September 2003 . http://www.fac.org.ar/tcvc/marcoesp/marcos.htm
4) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica
Biofisica. Il Terreno Oncologico. Travel Factory, Rome, in press.
Competing interests:
None declared
Competing interests: No competing interests
CPOU : Reliable care of intermediate risk cardiovascular event
Less than 10% of coronary artery disease patient were discharged
inappropriately from emergency department. Chest pain observation unit
(CPOU) allows rigorous assessment of chest pain. Typically patients are
closely monitored for 6-12 hours and subjected to sensible diagnostic
test. This leads to rapid categorisation of patients.
Patient satisfaction is an essential outcome in the CPOU.The unit is
a reliable cost-effective means with intermediate risk cardiac ischemic
event. There is enough statistical evidence to persuade health authorities
to support the introduction of this new dedicated service. What we need is
now a broader randomised controlled trial to make it a conventional
reality. However let us keep in mind that there is no strong evidence that
a CPOU will improve outcome if routine practise is good.
Competing interests:
None declared
Competing interests: No competing interests