Utilization of diagnostic resources and costs in patients with suspected cardiac chest pain.

AIMS: Non-acute chest pain is a common complaint and can be caused by various conditions. With the rising healthcare expenditures of today, it is necessary to use our healthcare resources effectively. This study aims to give insight into the diagnostic effort and costs for patients with non-acute chest pain. METHODS AND RESULTS: Financial data of patients without a cardiac history from four hospitals (January 2012-October 2018), who were registered with the national diagnostic code 'no cardiac pathology' (ICD-10 Z13.6), 'chest wall syndrome' (ICD-10 R07.4), or 'stable angina pectoris' (ICD-10 I20.9) were extracted. In total, 74 091 patients were included for analysis and divided into the following final diagnosis groups: no cardiac pathology: N = 19 688 (age 53 ± 18), 46% male; chest wall syndrome: N = 40 858 (age 56 ± 15), 45% male; and stable angina pectoris (AP): N = 13 545 (age 67 ± 11), 61% male. A total of approximately €142.7 million was spent during diagnostic work-up. The total expenditure during diagnostic effort was €1.97, €8.13, and €10.7 million, respectively for no cardiac pathology, chest wall syndrome, and stable AP per year. After 8 years of follow-up, ≥95% of the patients diagnosed with no cardiac pathology or chest wall syndrome had an (cardiac) ischaemic-free survival. CONCLUSION: The diagnostic expenditure and clinical effort to ascertain non-cardiac chest pain are high. We should define what we as society find acceptable as 'assurance costs' with an increasing pressure on the healthcare system and costs.

Mortality differences in acute myocardial infarction patients in the Netherlands: The weekend-effect.

Objective: Several studies have shown that patients admitted with an acute myocardial infarction during the weekends have a higher mortality rate than those admitted during weekdays, possibly attributable to less trained personnel available and a lower use of medical procedures. The current study aimed to assess this 'weekend-effect' in a nationwide registry. Methods: In the Netherlands, all inhabitants are, by law, obliged to have health insurance and all claim data are centrally registered. In 2012 and 2013, all national diagnose-codings of STEMI and NSTEMI patients were acquired. One-year mortality rates and treatment with percutaneous coronary intervention (PCI) were compared between weekdays and weekends (holidays included). Results: In total, 59,534 patients (67 ± 13 years, 39,545(66%) male) were included of whom 33,904(57%) had a NSTEMI. Overall 6857(12%) patients died in the year following the acute myocardial infarction registration. In STEMI patients, no differences in one-year mortality rates were observed between admission on weekdays or weekends. In NSTEMI patients, one-year mortality was higher in those admitted during weekends (weekdays 11% versus weekends 13%, P < .001). Furthermore, STEMI patients admitted during weekends were more often treated with PCI (weekdays 77% versus weekends 81%, P < .001). Conversely, NSTEMI patients admitted during weekends were less often treated with PCI (weekdays 35% versus weekends 32%, P < .001). Conclusion: Differences in treatment and mortality rates exist between acute myocardial infarction patients admitted during weekdays and weekends. NSTEMI patients admitted during weekends are less often treated with PCI and have a higher mortality rate than patients admitted during weekdays.

Age and gender differences in medical adherence after myocardial infarction: Women do not receive optimal treatment - The Netherlands claims database.

Background Following myocardial infarction, medication is, besides lifestyle interventions, the cornerstone treatment to improve survival and minimize the occurrence of new cardiovascular events. Still, data on nationwide medication adherence are scarce. This study assesses medical adherence during one year following myocardial infarction, stratifying per type of infarct, age and gender. Design Retrospective cohort study. Methods In The Netherlands, all inhabitants are by law obliged to have health insurance and all claims data are centrally registered. In 2012 and 2013, all national diagnosis-codings of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) were acquired. Furthermore, information on retrieved medication was extracted from the Dutch Pharmacy Information System. Twelve months after discharge, the retrieved medication at the pharmacy of each pharmacological therapy (aspirin-species, P2Y12-inhibitor, statin, beta-blocker, angiotensin-converting enzyme-/angiotensin 2-inhibitor, vitamin-K antagonists or novel oral anticoagulant) were analysed. Results In total, 59,534 patients (67 ± 13 years, 39,545 (66%) male, 57% NSTEMI) were included, of whom 52,672 (88%) patients were analysed for one-year medical adherence. STEMI patients more often achieved optimal medical adherence than NSTEMI patients (60% vs. 40%, p ≤ 0.001). In both STEMI and NSTEMI, use of all five indicated drugs was higher in male patients compared with female (STEMI male 61% vs. female 57%, p ≤ 0.001; NSTEMI male 43% vs. female 37%, p ≤ 0.001. With increasing age, a gradual decrease was observed in the use of aspirin, P2Y12-inhibitors and statins. Conclusion Age and gender differences existed in medical adherence after myocardial infarction. Medical adherence was lower in women, young patients and elderly patients, specifically in NSTEMI patients.

Comparison of the diagnostic accuracy of four smartphone-compatible blood pressure monitors in post-myocardial infarction patients.

Introduction Smartphone-compatible blood pressure devices may be a good alternative to enable self-measurement of blood pressure by patients. Furthermore, automatic transferral of data to the hospital allows for remote monitoring. To our knowledge, no study has compared four of these smartphone-compatible blood pressure devices. Methods Patients who were followed up for acute myocardial infarction were asked to participate during their outpatient clinic visit. After five minutes of rest, six blood pressure devices were applied. The order was randomised. Four devices were smartphone-compatible. One device was an automated oscillometric device. One device was a handheld aneroid sphygmomanometer (reference device). All measurements were compared using a linear mixed model. Results A total of 43 patients (62.7 ± 11.3 years, 79% male) were included. Compared to the reference device, four blood pressure monitors yielded a significant higher mean systolic blood pressure and four monitors yielded a significant higher diastolic BP. One device yielded a non-significant lower mean systolic blood pressure and one device yielded a non-significant higher mean diastolic blood pressure. Except for one blood pressure device, all mean differences were smaller than 5 mmHg. Conclusion In this study, average inter-device variability was shown to be statistically significant, however four devices remained within the predefined range of 5 mmHg for both systolic and diastolic blood pressures.

Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands.

OBJECTIVE: Numerous studies have shown that a substantial number of patients suffer from adverse events (AEs) as a result of hospital care. However, specific data on AEs in acute cardiac care are scarce. The current manuscript describes the development and validation of a specific instrument to evaluate patient safety of a predefined care track for patients with acute myocardial infarction (AMI). DESIGN: Retrospective patient record review study. SETTING AND PARTICIPANTS: A total of 879 hospital admissions treated in a tertiary care centre for an AMI (age 64±12 years, 71% male). MAIN OUTCOME MEASURE: In the first phase, the medical records of patients with AMI warranting coronary angiography or coronary intervention were analysed for process deviations. In the second phase, the medical records of these patients were checked for any harm that had occurred which was caused by the healthcare provider or the healthcare organisation (AE) and whether the harm that occurred was preventable. RESULTS: Of all 879 patients included in the analysis, 40% (n=354) had 1 or more process deviation. Of these 354 patients, 116 (33%) had an AE. Patients with AE experienced more process deviations compared with patients without AE (2±1.7 vs 1.5±0.9 process deviations per patient, p=0.005). Inter-rater reliability in assessing a causal relation of healthcare with the origin of an AE showed a κ of 0.67 (95% CI 0.51 to 0.83). CONCLUSIONS: This study shows that it is possible to develop a reliable method, which can objectively assess process deviations and the occurrence of AEs in a specified population. This method could be a starting point for developing an electronic tracking system for continuous monitoring in strictly predefined care tracks.