Identifying patients for early discharge: performance of decision rules among patients with acute chest pain.

BACKGROUND: The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. METHODS AND RESULTS: A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR. CONCLUSIONS: The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.

Myeloperoxidase in the diagnosis of acute coronary syndromes: the importance of spectrum.

BACKGROUND: Myeloperoxidase (MPO) is proposed for risk stratification in patients with suspected acute coronary syndromes (ACSs). We determined if MPO has diagnostic value in patients being evaluated for ACS. METHOD: MIDAS was an 18-center prospective study enrolling suspected ACS emergency department patients who presented <8 hours after symptom onset and in whom serial cardiac markers and objective cardiac perfusion testing were planned. Blinded MPO (Biosite, Inc, San Diego, CA) and troponin I (Triage Cardio 3; Biosite, Inc) were drawn at arrival, and Troponin I (TnI) was measured at 90, 180, and 360 minutes. Final diagnoses were adjudicated by the local investigator blinded to study assay. RESULTS: Of 1,018 patients, 54% were male, 26% black, with a mean age of 58 ± 13 years. Diagnoses were ACS in 288 (23%) and noncardiac chest pain (NCCP) in 788 (77%). Of patients with ACS, 94 (9.2%) had a myocardial infarction (MI) at presentation (69 non-ST-elevation MI, 25 ST-elevation MI), and 136 had unstable angina. Using a cutpoint of 210 ng/mL to provide 90% specificity, MPO had a sensitivity of 0.18; negative predictive value, 0.69; positive predictive value, 0.47; negative likelihood ratio, 0.91; and a positive likelihood ratio of 1.83 to differentiate ACS and NCCP. Because of the large overlap of quartiles, MPO was not clinically useful to predict serial TnI changes. The C statistics ± 95% CI for MPO differentiating ACS from NCCP and for AMI versus NCCP were 0.629 ± 0.04 and 0.666 ± 0.06, respectively. CONCLUSIONS: Myeloperoxidase has insufficient accuracy for decision making in patients with suspected ACS.

Efficacy of multidisciplinary outpatient management (MOM) program in long term heart failure care.

BACKGROUND: Heart failure (HF) management programs worldwide have reported conflicting outcomes in the past. OBJECTIVES: We sought to determine retrospectively whether the multidisciplinary outpatient management (MOM) program [heart failure clinic (HFC)], decreased readmission rates (RR), duration of hospital stay, and/or mortality in HF patients. METHODS: Records of 138 HF patients who had their first encounter either as admission for HF at St. Agnes Hospital or visit to HFC during the period June 2005 through June 2006 were evaluated for outcomes through September 2007. Twenty-seven patients were followed in the HFC and 111 were in the non-HFC group. During follow up, 39 of the non-HFC group patients crossed over to the HFC group. All baseline parameters, except age (P = 0.006), were similar in both groups. RESULTS: In the HFC group 4 patients had a total of 5 readmissions, whereas 85 patients had a total of 187 readmissions (P < 0.001) in the non-HFC group. Average lengths of hospitalization were 5.2 +/- 4.8 days and 4.2 +/- 3.2 days (P = 0.18) and the number of readmissions/patient/year was 0.3 and 1.45 (P < 0.001) in the HFC and non-HFC groups, respectively. In the subgroup analysis of cross overs (n = 39), there was a 60% reduction in the readmission rate after crossing over to the HFC group. The significance of decreased mortality in the HFC group could not be assessed due to the small sample size. CONCLUSION: The study suggests that the MOM program can significantly reduce RR secondary to HF.

Explaining racial differences in receipt of coronary angiography: the role of physician referral and physician specialty.

The authors examine three hypotheses regarding race differences in utilization of coronary angiography (CA): (1) patients with a cardiology consultation are more likely to obtain a referral for CA, (2) African American patients are less likely to have a cardiology consultation, and (3) among patients referred for CA, there is no difference by race in receipt of the procedure. To determine if they obtained a referral for or received CA, 2.623 candidates for CA were followed. Multivariate models were estimated using logistic regression. Cardiology consultation was associated with referral for CA (OR = 5.1, p < .001). White patients had higher odds of cardiology consultation (OR = 2.2, p < .001). The racial disparity was reduced among patients who received a referral (OR = 1.4, p < .05). Researchers must eliminate racial differences in access to specialty care and variation in referral patterns by physician specialty, and efforts must be targeted to those specialties where greater disparities exist.

The cardiac access longitudinal study. A study of access to invasive cardiology among African American and white patients.

OBJECTIVES: We sought to identify factors contributing to racial disparity in the receipt of coronary angiography (CA). BACKGROUND: Numerous studies have demonstrated that African American patients are less likely to receive needed diagnostic and therapeutic coronary procedures than white patients. This report summarizes the methods and findings of a study linking medical records with patient and physician interviews to address racial disparities in the utilization of CA. METHODS: This is a retrospective, cross-sectional study conducted in three urban hospitals in Maryland. A total of 9,275 medical records were reviewed, representing all 7,058 cardiac patients admitted in a two-year period. We identified 2,623 patients who, according to American College of Cardiology guidelines, were candidates for receiving CA. A total of 1,669 patients (721 African Americans and 948 whites) and 74% of their physicians were successfully interviewed. Multivariate and hierarchical multivariate logistic regression were used to construct a model of receipt of CA within one year of the hospitalization. RESULTS: The unadjusted odds of white patients receiving CA was three times greater than the odds for African American patients (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.4 to 3.7). Adjusting for patients' clinical and social characteristics resulted in a 13% reduction in the OR for race. Adjusting for physician and health care system characteristics reduced the OR by 43%, to 1.7 (95% CI 1.3 to 2.4). CONCLUSIONS: Racial disparity in the utilization of CA is a function of differences in the health care system "context" in which African American and white patients obtain care, combined with differences in the specific clinical characteristics of patients.

Physician referral patterns and race differences in receipt of coronary angiography.

OBJECTIVE: This study addresses the following research questions: (1) Is race a predictor of obtaining a referral for coronary angiography (CA) among patients who are appropriate candidates for the procedure? (2) Is there a race disparity in obtaining CA among patients who obtain a referral for the procedure? STUDY SETTING: Three community hospitals in Baltimore, Maryland. STUDY DESIGN: We abstracted hospital records of 7,927 patients from three hospitals to identify 2,653 patients who were candidates for CA. Patients were contacted by telephone to determine if they received a referral for CA. Logistic regression was used to assess whether racial differences in obtaining a referral were affected by adjustment for several potential confounders. A second set of analyses examined race differences in use of the procedure among a subsample of patients that obtained a referral. PRINCIPAL FINDINGS: After controlling for having been hospitalized at a hospital with in-house catheterization facilities, ACC/AHA (American College of Cardiology/American Heart Association) classification, sex, age, and health insurance status, race remained a significant determinant of referral (OR = 3.0, p < .05). Additionally, we found no significant race differences in receipt of the procedure among patients who obtained a referral. CONCLUSIONS: Our results demonstrate that race differences in utilization of CA tend to occur during the process of determining the course of treatment. Once a referral is obtained, African American patients are not less likely than white patients to follow through with the procedure. Thus, future research should seek to better understand the process by which the decision is made to refer or not refer patients.