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1.
Pneumologie ; 75(11): 901-909, 2021 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-34788891

RESUMO

Acute chest pain is one of the most important cardinal symptoms in medicine. There are several important differential diagnoses for chest pain. Therefore, a thorough history and physical examination, as well as the 12-lead ECG and laboratory tests are crucial. In clinical practice, it is useful to distinguish between cardiac chest pain and other forms of chest pain in order to treat patients appropriately and to exclude potentially life-threatening conditions.


Assuntos
Dor no Peito , Eletrocardiografia , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Dor no Peito/terapia , Diagnóstico Diferencial , Humanos
2.
BMC Emerg Med ; 21(1): 112, 2021 10 07.
Artigo em Inglês | MEDLINE | ID: mdl-34620086

RESUMO

BACKGROUND: Currently, the risk stratification of critically ill patient with chest pain is a challenge. We aimed to use machine learning approach to predict the critical care outcomes in patients with chest pain, and simultaneously compare its performance with HEART, GRACE, and TIMI scores. METHODS: This was a retrospective, case-control study in patients with acute non-traumatic chest pain who presented to the emergency department (ED) between January 2017 and December 2019. The outcomes included cardiac arrest, transfer to ICU, and death during treatment in ED. In the randomly sampled training set (70%), a LASSO regression model was developed, and presented with nomogram. The performance was measured in both training set (70% participants) and testing set (30% participants), and findings were compared with the three widely used scores. RESULTS: We proposed a LASSO regression model incorporating mode of arrival, reperfusion therapy, Killip class, systolic BP, serum creatinine, creatine kinase-MB, and brain natriuretic peptide as independent predictors of critical care outcomes in patients with chest pain. Our model significantly outperformed the HEART, GRACE, TIMI score with AUC of 0.953 (95%CI: 0.922-0.984), 0.754 (95%CI: 0.675-0.832), 0.747 (95%CI: 0.664-0.829), 0.735 (95%CI: 0.655-0.815), respectively. Consistently, our model demonstrated better outcomes regarding the metrics of accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F1 score. Similarly, the decision curve analysis elucidated a greater net benefit of our model over the full ranges of clinical thresholds. CONCLUSION: We present an accurate model for predicting the critical care outcomes in patients with chest pain, and provide substantial support to its application as a decision-making tool in ED.


Assuntos
Dor no Peito , Resultados de Cuidados Críticos , Aprendizado de Máquina , Idoso , Estudos de Casos e Controles , Dor no Peito/terapia , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Estudos Retrospectivos , Triagem
4.
Emerg Med J ; 38(11): 814-819, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34373266

RESUMO

OBJECTIVES: The History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital. METHODS: In 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018. RESULTS: Among 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4-99.3), a positive predictive value (PPV) of 35.5% (31.8-39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78-0.85). The preHEART Score had an NPV of 99.3% (98.1-99.8), a PPV of 49.4% (42.0-56.9) and an AUC of 0.85 (0.82-0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort. CONCLUSIONS: The HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting.


Assuntos
Dor no Peito/terapia , Gestão de Riscos/métodos , Idoso , Área Sob a Curva , Dor no Peito/complicações , Dor no Peito/epidemiologia , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Estudos Prospectivos , Curva ROC , Medição de Risco/métodos , Fatores de Risco , Gestão de Riscos/estatística & dados numéricos
5.
Acad Emerg Med ; 28(7): 718-744, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34228849

RESUMO

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.


Assuntos
Síndrome Coronariana Aguda , Dor no Peito , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Adulto , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Dor no Peito/terapia , Angiografia Coronária , Serviço Hospitalar de Emergência , Teste de Esforço , Hospitalização , Humanos , Medição de Risco
6.
Open Heart ; 8(1)2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34083391

RESUMO

OBJECTIVE: We surveyed UK practice of National Institute for Health and Care Excellence (NICE) "Recent onset chest pain" guidance (CG95, 2016), stratified by sex. We looked for sex-related differences in referral to computed tomographic coronary angiography (CTCA) and subsequent functional imaging (FI), invasive coronary angiography (ICA) and revascularisation. METHODS: This was a prospective analysis of CTCA practice in 8 UK centres between 2018 and 2020. Coronary artery disease (CAD) was recorded with the CAD-reporting and data system. Local electronic records/archiving/communication systems were used to collect data regarding subsequent FI, ICA and revascularisation. RESULTS: 2301 women, 2326 men underwent CTCA; women were older (58±11 vs 55±12 years, p<0.001) but more likely to have normal coronary arteries (46% (1047) vs 29% (685); p<0.001) and less likely to have severe stenosis (7% (169) vs 13% (307); p<0.001). FI was used less for 4% (93) women, 5% (108) men; ICA was also used less for women (8% (182) vs 14% (321)), as was revascularisation (4% (83) vs 8% (177), p<0.001 for all), including those with ≥moderate CTCA stenosis undergoing ICA (53% (79) vs 61% (166); p<0.001). CONCLUSIONS: Women referred for a NICE CG95 (2016) CTCA are more likely to have normal coronary arteries and men more likely to have CAD. More men than women will then undergo ICA and revascularisation even after adjustments for CTCA disease severity. Raised awareness of these inequalities may improve contemporary chest pain care.


Assuntos
Dor no Peito/terapia , Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Hospitais , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/epidemiologia , Dor no Peito/etiologia , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reino Unido/epidemiologia , Adulto Jovem
8.
Crit Pathw Cardiol ; 20(3): 143-148, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33958520

RESUMO

Chest pain is one of the most common reasons for patients to present to healthcare professionals. One of the main challenges with the management of chest pain is the wide differential diagnosis, ranging from minor chest trauma to potentially life-threatening acute myocardial infarction. In a patient-centered health service pathway, the aim is to assess, investigate, diagnose, and treat patients in the safest and most accurate, time, and cost-efficient manner. This report describes the concept of clinical pathways and their importance. It iterates different perspectives of the investigation of chest pain and the barriers to understanding the clinical sequence of events. By considering the patient, clinician, and healthcare service perspective, it is possible to critically evaluate the current stable chest pain pathway. This exercise gives consideration into the way in which patient care could be improved.


Assuntos
Dor no Peito , Infarto do Miocárdio , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Dor no Peito/terapia , Atenção à Saúde , Diagnóstico Diferencial , Serviço Hospitalar de Emergência , Humanos , Infarto do Miocárdio/diagnóstico
9.
Emerg Med J ; 38(11): 808-813, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33837120

RESUMO

BACKGROUND/AIM: In ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP). METHODS: This was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI). RESULTS: A total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively. CONCLUSION: The combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.


Assuntos
Dor no Peito/terapia , Protocolos Clínicos/normas , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Adulto , Idoso , Biomarcadores/análise , Biomarcadores/sangue , Dor no Peito/diagnóstico , Dor no Peito/epidemiologia , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Estudos Prospectivos , Fatores de Risco , Sensibilidade e Especificidade , Suécia/epidemiologia , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Troponina T/análise , Troponina T/sangue
10.
Rev Bras Enferm ; 74(2): e20190849, 2021.
Artigo em Inglês, Português | MEDLINE | ID: mdl-33886832

RESUMO

OBJECTIVE: to analyze the facilities and difficulties in the use by nurses of the care flow for patients with chest pain. METHODS: descriptive analytical study, with a qualitative approach, conducted with 17 nurses from an emergency care unit in a municipality of the State of Ceara, in 2018. Data collected through documents and interviews, analyzed in a descriptive manner, in absolute and relative frequencies and through content analysis thematic. RESULTS: the use of assistance flow streamlines the process of transferring to referral units, reducing serious and lethal complications in the patient. It considers teamwork and communication as facilitating points in the care of patients with chest pain. The lack of permanent education, physical structure, equipment, transport delay and patient regulation as factors that hamper. FINAL CONSIDERATIONS: investments in physical structure and equipment, in the reorganization of the care network and in permanent education to enable benefits to the service of excellence in health care.


Assuntos
Serviços Médicos de Emergência , Enfermeiras e Enfermeiros , Brasil , Dor no Peito/terapia , Serviço Hospitalar de Emergência , Humanos , Pesquisa Qualitativa
11.
Curr Sports Med Rep ; 20(3): 164-168, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33655998

RESUMO

ABSTRACT: Slipping rib syndrome is pain created at the lower, anterior border of the rib cage when performing upper-extremity activities, coughing, laughing, or leaning over. Defects in the costal cartilage of ribs 8 to 10 result in increased movement of the ribs, impinging soft tissue and intercostal nerves. Advancements have been made in the diagnosis of slipping rib syndrome by dynamic ultrasound. Ultrasound can identify abnormalities in the rib and cartilage anatomy, as well as soft tissue swelling. Although the mainstays of treatment continue to be reassurance, nonsteroidal anti-inflammatory drugs, physical therapy, intercostal nerve injections, osteopathic manipulative treatment, surgery for refractory pain, and botulinum toxin injections have been attempted, and there may be a role for prolotherapy in treatment. Surgical techniques are being examined secondary to recurrence of pain following resection. The hooking maneuver and surgery remain important for identification and treatment, respectively.


Assuntos
Costelas/diagnóstico por imagem , Costelas/fisiopatologia , Doenças Torácicas/diagnóstico por imagem , Dor no Peito/diagnóstico por imagem , Dor no Peito/etiologia , Dor no Peito/cirurgia , Dor no Peito/terapia , Tratamento Conservador , Humanos , Dor Intratável/diagnóstico por imagem , Dor Intratável/etiologia , Dor Intratável/cirurgia , Dor Intratável/terapia , Recidiva , Síndrome , Doenças Torácicas/etiologia , Doenças Torácicas/terapia , Ultrassonografia
13.
Med Decis Making ; 41(5): 559-572, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33655790

RESUMO

OBJECTIVE: To decrease referrals to cardiology of patients ages 7 to 21 years with low-probability cardiac pathology who presented to primary care with chest pain by 50% within 24 months. STUDY DESIGN: A multidisciplinary team designed and implemented an initiative consisting of 1) a decision support tool (DST), 2) educational sessions, 3) routine feedback to improve use of referral criteria, and 4) patient family education. Four pediatric practices, comprising 34 pediatricians and 7 nurse practitioners, were included in this study. We tracked progress via statistical process control charts. RESULTS: A total of 421 patients ages 7 to 21 years presented with chest pain to their pediatrician. The utilization of the DST increased from baseline of 16% to 68%. Concurrently, the percentage of low-probability cardiology referrals in pediatric patients ages 7 to 21 years who presented with chest pain decreased from 17% to 5% after our interventions. At a median follow-up time of 0.9 years (interquartile range, 0.3-1.6 years), no patient had a life-threatening cardiac event. CONCLUSION: Our health care improvement initiative to reduce low-probability cardiology referrals for children presenting to primary care practices with chest pain was feasible, effective, and safe.


Assuntos
Cardiologia , Melhoria de Qualidade , Adolescente , Adulto , Dor no Peito/terapia , Criança , Humanos , Atenção Primária à Saúde , Encaminhamento e Consulta , Adulto Jovem
14.
Emerg Med J ; 38(11): 851-854, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33687992

RESUMO

Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Serviço Hospitalar de Emergência/ética , Síndrome Coronariana Aguda/complicações , Dor no Peito/etiologia , Dor no Peito/terapia , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência/organização & administração , Humanos , Autonomia Pessoal , Fatores de Risco , Justiça Social
15.
Int J Clin Pract ; 75(6): e14133, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33683805

RESUMO

OBJECTIVE: Early diagnosis or rule-out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE-ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high-sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule-out and prolonged observation with repeated hsTnt testing at a high-volume tertiary care emergency department. PATIENTS AND METHODS: We conducted a pre- and post-changeover analysis 3 months before and 3 months after transition from less (hsTnt cut-off 30 ng/L, 3-hour rule-out) to more conservative (hsTnt cut-off 14 ng/L, 1-hour rule-out) guidelines in 2015, comparing proportions of patients requiring repeated testing. RESULTS: We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early-rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision. CONCLUSION: The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.


Assuntos
Síndrome Coronariana Aguda , Cardiologia , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Adulto , Idoso , Biomarcadores , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Dor no Peito/terapia , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Troponina T
16.
Int J Qual Stud Health Well-being ; 16(1): 1901449, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33779530

RESUMO

Purpose: Encountering patients with chest pain iscommon for Registered Nurses (RNs) in Emergency Medical Services (EMS) who are responsible for the patient's medical and nursing care . From a lifeworld perspective, bodily illness is related to existential suffering, requiring knowledge to asses the situation from a holistic perspective . The aim of this study is to describe the caring approach when RNs encounter patients with chest pain.Methods: A phenomenological methodology to capture RNs' lived experiences was chosen. Seven qualitative in-depth interviews were conducted at three ambulance stations in Sweden.Results: The essence of the caring approach while encountering patients with chest pain comprises two constituents; "trust based on confidence and competence" and "the collegial striving towards the best possible care". Trust is two-parted; trust in oneself, and striving towards gaining the patient's trust . Competence and experience when combined, develop into confidence especially in stressful situations. The caring approach is nurtured in a well-functioning collegial team.Conclusions: This study contributes to understanding the caring approach based on the specific patient's lifeworld in holistic EMS care. By trusting oneself, the patient, and one's colleague, RNs in EMS shift focus from medical-orientated care to a holistic lifeworld caring approach. . More research is needed on trust as a phenomenon in EMS, both from caregivers' and patients' perspectives.


Assuntos
Serviços Médicos de Emergência , Enfermeiras e Enfermeiros , Ambulâncias , Dor no Peito/terapia , Humanos , Pesquisa Qualitativa , Suécia
18.
Chest ; 159(1): e35-e38, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33422238

RESUMO

CASE PRESENTATION: A 28-year-old man presented with shortness of breath, chest pain, and scant hemoptysis. Three weeks previously, he was admitted for coronavirus disease 2019 pneumonia that had been diagnosed by nasal swab polymerase chain reaction. Chest CT imaging demonstrated bilateral ground-glass opacities without evidence of VTE. He was treated with hydroxychloroquine, up to 7 L/min oxygen, and self-proning. After 8 days of hospitalization, he was discharged on 4 L/min oxygen. After discharge, his symptoms and hypoxia resolved.


Assuntos
COVID-19/complicações , Dor no Peito/etiologia , Dispneia/etiologia , Hemoptise/etiologia , Adulto , Dor no Peito/terapia , Dispneia/terapia , Hemoptise/terapia , Humanos , Masculino
19.
Circ Cardiovasc Qual Outcomes ; 14(1): e006297, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33430609

RESUMO

BACKGROUND: Wide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events. METHODS: We conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction. RESULTS: Thirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%). CONCLUSIONS: Wide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.


Assuntos
Dor no Peito , Síndrome Coronariana Aguda , Adolescente , Adulto , Idoso , Dor no Peito/diagnóstico , Dor no Peito/epidemiologia , Dor no Peito/terapia , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Médicos , Estudos Retrospectivos , Adulto Jovem
20.
Acad Emerg Med ; 28(1): 36-45, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33107088

RESUMO

OBJECTIVE: We compare utilization of diagnostic resources and admissions in emergency department (ED) patients with chest pain and abdominal pain when managed by advanced practice providers (APPs) and physicians. METHODS: We used 2016 to 2019 data from a national emergency medicine group. We compared visits managed by physicians and APPs based on demographics and observed resource utilization (labs, radiography, computed tomography) use and hospital admission/transfer, stratified by patient age. To reduce selection bias, we created inverse propensity score weights (IPWs). To estimate the average treatment effect for APP visits for each outcome, we included IPWs in a multivariable linear probability model with a dummy variable indicating treatment by an APP and used a facility fixed effect. We then estimated the average treatment effect comparing physician to APP visit for all visits and for discharged visits separately, stratified by the study outcomes. Sensitivity analyses were performed using different cohort definitions and adjusting for past medical history. RESULTS: In chest pain, we included 77,568 visits seen by 1,011 APPs and 586,031 visits seen by 1,588 physicians. In abdominal pain, we included 184,812 ED visits seen by 1,080 APPs and 761,230 visits seen by 1,689 physicians. For both chest pain and abdominal pain visits, physicians saw more older adult patients (55+ years) and admitted a higher percentage of visits than APPs. For chest pain, physicians saw more circulatory system diseases (70.7% vs. 58.6%); APPs saw more respiratory system diseases (17.1% vs. 9.8%). In abdominal pain, emergency physicians saw more digestive system diseases (28.5% vs. 23.3%); APPs saw more genitourinary system diseases. After matching with IPW, predicted probabilities of laboratory, radiology, and admissions either did not vary or were slightly lower for APPs compared to physicians for all outcomes. Sensitivity analyses showed similar results, including controlling for past medical history. CONCLUSION: Diagnostic testing and hospitalization rates for chest pain and abdominal pain between APPs and physicians is largely similar after matching for severity and complexity. This suggests that APPs do not have observably higher use of ED and hospital resources in these conditions in this national group.


Assuntos
Dor Abdominal , Dor no Peito , Serviço Hospitalar de Emergência , Médicos , Dor Abdominal/diagnóstico , Dor Abdominal/terapia , Idoso , Dor no Peito/diagnóstico , Dor no Peito/terapia , Hospitalização , Humanos , Pessoa de Meia-Idade
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