MedicalResearch.com Interview with:
Philip G. Cotterill PhD
Centers for Medicare & Medicaid Services
Medical Research: What is the background for this study? What are the main findings?
Dr. Cotterill: Chest pain is one of those elusive complaints where patients can seem initially low-risk based on symptoms or risk factors, and subsequently have an acute myocardial infarction (AMI) or die in a short period of time. Using combinations of history and physical examination findings to discriminate patients with serious causes of chest pain is often not possible. In our study, we demonstrated wide variation in the decision to hospitalize Medicare beneficiaries with chest pain – nearly two fold between the lowest (38%) and highest (81%) quintile of hospitals – and that patients treated in hospitals with higher admission rates for chest pain are less likely to have an acute myocardial infarction within 30-days of the index event and less likely to die.
While the findings were statistically significant – differences in outcomes were small: 4 fewer AMIs and 3 fewer deaths per 1,000 patients comparing the highest and lowest admission quintiles. Stated differently, these numbers suggest that if low admitting hospitals were to behave more like high admitting hospitals, 250 patients would need to be admitted to prevent one AMI and 333 cases to prevent one death.
Medical Research: What should clinicians and patients take away from your report?
Dr. Cotterill: A main reason for hospital admission of patients with a symptom of chest pain, but who do not have an objective diagnosis during the first few hours of emergency department (ED) care, is to assess the presence of serious causes that are not initially detected – such as acute coronary syndrome and other conditions. Factors such as risk tolerance and malpractice fear have been identified as important explanatory factors associated with the wide variation in admission rates among emergency physicians. Patients who are treated and released, but subsequently return with serious causes for chest pain, are a particular concern because patients with “missed” acute myocardial infarction (AMI) have worse outcomes. The rate of “missed” AMI has been estimated at around 2% of patients with AMI. Missed acute myocardial infarction is the leading cause for ED medical malpractice litigation. Although there have been attempts to create decision rules for Missed acute myocardial infarction is the leading cause for ED medical malpractice litigation-based chest pain, there are currently no broadly validated or accepted instruments that suitably identify patients as safe for ED discharge.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Cotterill: We did not have detailed information on the specific processes of care that might explain our results; however, we can hypothesize that higher admission rates allow more time for patient evaluation and assessment for serious causes of chest pain. If our findings can be interpreted as meaning that a more intensive approach to risk-stratification and observation for chest pain is more effective, and comparable to other recommended screening interventions in terms of effectiveness, the ultimate clinical question is how we can achieve this goal in the context of national health policy that is pushing toward lower use of expensive resources such as inpatient admissions.
Additional studies will be required to reassess how risk-stratification in the ED is conducted as the diagnostic technology to detect occult coronary syndromes– such as high sensitivity troponins and CT coronary angiograms — and other serious diagnoses evolves. Specifically, future work should focus on how to appropriately exclude serious diagnoses with either advanced technology in the ED, in hospital-based observation units, or alternatively for patients to have short-term follow-up with specialists such as cardiologists for outpatient stress testing. As new payment models emerge, finding cost-effective alternatives to identify occult serious causes for chest pain will be increasingly important in an era with an increasing focus on the value of the healthcare dollar.
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Philip G. Cotterill PhD (2015). Hospitals Vary in Rates of Missed Acute Myocardial Infarction Diagnosis