The impact of the HEART score on the prevalence of cardiac testing and patient outcomes in a rural emergency department.

INTRODUCTION: This study was conducted to examine the use of the HEART score for risk stratification of chest pain patients presenting to rural Ontario emergency departments (EDs), assessing both its validity in a rural context and its utility in health-care resource management. METHODS: This study was a retrospective chart review of adult patients presenting to the ED with chest pain. The HEART score was assessed for its ability to risk-stratify patients (high, moderate and low) in terms of the likelihood of a major adverse cardiac event (MACE) within 6 weeks. The prevalence of follow-up testing for each risk category of patients was then determined such that the potential impact on health resource management was estimated based on the number of tests ordered in low-risk patients. RESULTS: Of the 215 charts included, 24 (11.2%) patients experienced a MACE within 6 weeks. None of the patients with a low HEART score experienced a MACE. In comparison, the incidence of MACE in moderate- and high-risk groups was calculated to be 13.9% (95% confidence interval [CI] [5.91% and 21.89%, respectively]) and 66.7% (95% CI [46.54% and 86.86%, respectively]). Eighteen percent of the low-risk patients received follow-up testing with no positive results suggestive of acute coronary syndrome. CONCLUSION: Our results provide external validation of the predictive value of the HEART score in determining the risk of MACE in patients presenting to a rural ED with chest pain. Our results also suggest that rates of follow-up testing in low-risk patients may be reduced in communities with limited access to resources.

Résumé Introduction: Examiner le recours au score HEART pour stratifier le risque lié à la douleur thoracique chez les patients qui se présentent aux services d'urgence des régions rurales de l'Ontario, en en évaluant la validité dans un contexte rural et l'utilité dans la gestion des ressources de santé. Méthodologie: Examen rétrospectif des dossiers de patients adultes s'étant présentés à l'urgence pour une douleur thoracique. Le score HEART a été évalué pour sa capacité de stratifier les patients en fonction du risque (élevé, modéré, faible) d'événement cardiaque indésirable majeur (ÉCIM) dans les 6 semaines suivantes. La prévalence des tests de suivi pour chaque catégorie de risque a ensuite été déterminée afin d'estimer l'impact potentiel sur la gestion des ressources de santé selon le nombre de tests demandés chez les patients à faible risque. Résultats: Sur les 215 dossiers inclus, 24 (11,2 %) patients ont subi un ÉCIM dans les 6 semaines suivantes. Aucun des patients ayant obtenu un faible score HEART n'a subi un ÉCIM. Par ailleurs, l'incidence d'ÉCIM dans les groupes à risque modéré et élevé s'est élevée à respectivement 13,9 % (IC à 95 % [5,91; 21,89 %]) et 66,7 % (IC à 95 % [46,54; 86,86 %]). Dix-huit pour cent des patients à faible risque ont subi un test de suivi sans résultat évoquant un syndrome coronarien aigu. Conclusion: Nos résultats ont validé de façon externe la valeur prédictive du score HEART dans la détermination du risque d'ÉCIM chez les patients qui se présentent à l'urgence rurale pour une douleur thoracique. Nos résultats laissent également croire que le taux de tests de suivi chez les patients à faible risque serait réduit dans les communautés dont l'accès aux ressources est limité. Mots-clés: médecine rurale, médecine d'urgence, maladie cardiaque ischémique, score HEART.

Improving diabetes management with a patient portal: a qualitative study of diabetes self-management portal.

BACKGROUND: Effective management and care of diabetes is crucial to reducing associated risks such as heart disease and kidney failure. With increasing access and use of the Internet, online chronic disease management is being explored as a means of providing patients with support and the necessary tools to monitor and manage their disease. OBJECTIVE: The objective of our study was to evaluate the experience of patients and providers using an online diabetes management portal for patients. METHODS: Participants were recruited from a large sample population of 887 for a follow-up questionnaire to be completed after 6 months of using the patient portal. Participants were presented with the option to participate in an additional interview and, if the participant agreed, a time and date was scheduled for the interview. A 5-item, open-ended questionnaire was used to capture providers' opinions of the patient portal. Providers included general practitioners (GPs), nurses, nurse practitioners (NPs), dieticians, diabetes educators (DECs), and other clinical staff. RESULTS: A total of 854 patients were consented for the questionnaire. Seventeen (8 male, 9 female) patients agreed to participate in a telephone interview. Sixty-four health care providers completed the five open-ended questions; however, an average of 48.2 responses were recorded per question. Four major themes were identified and will be discussed in this paper. These themes have been classified as: facilitators of disease management, barriers to portal use, patient-provider communication and relationship, and recommendations for portal improvements. CONCLUSIONS: This qualitative study shows that online chronic disease management portals increase patient access to information and engagement in their health care, but improvements in the portal itself may improve usability and reduce attrition. Furthermore, this study identifies a grey area that exists in the roles that GPs and AHPs should play in the facilitation of online disease management.