Erin N. Harper

Stress Cardiac Magnetic Resonance Imaging With Observation Unit Care Reduces Cost for Patients With Emergent Chest Pain: A Randomized Trial

STUDY OBJECTIVE We determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy. METHODS Emergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups. RESULTS There were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate

Stress CMR Imaging Observation Unit in the Emergency Department Reduces 1-Year Medical Care Costs in Patients With Acute Chest Pain: A Randomized Study for Comparison With Inpatient Care

588; 95% confidence interval

Stress CMR reduces revascularization, hospital readmission, and recurrent cardiac testing in intermediate-risk patients with acute chest pain.

336 to

Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial

811); 79% were managed without hospital admission. CONCLUSION Compared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain.

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OBJECTIVES This study sought to compare the direct cost of medical care and clinical events during the first year after patients with intermediate risk acute chest pain were randomized to stress cardiac magnetic resonance (CMR) observation unit (OU) testing versus inpatient care. BACKGROUND In a recent study, randomization to OU-CMR reduced median index hospitalization cost compared with the cost of inpatient care in patients presenting to the emergency department with intermediate risk acute chest pain. METHODS Emergency department patients with intermediate risk chest pain were randomized to OU-CMR (OU care, cardiac markers, stress CMR) or inpatient care (admission, care per admitting provider). This analysis reports the direct cost of cardiac-related care and clinical outcomes (myocardial infarction, revascularization, cardiovascular death) during the first year of follow-up subsequent to discharge. Consistent with health economics literature, provider cost was calculated from work-related relative value units using the Medicare conversion factor; facility charges were converted to cost using departmental-specific cost-to-charge ratios. Linear models were used to compare cost accumulation among study groups. RESULTS We included 109 randomized subjects in this analysis (52 OU-CMR, 57 inpatient care). The median age was 56 years; baseline characteristics were similar in both groups. At 1 year, 6% of OU-CMR and 9% of inpatient care participants experienced a major cardiac event (p = 0.72) with 1 patient in each group experiencing a cardiac event after discharge. First-year cardiac-related costs were significantly lower for participants randomized to OU-CMR than for participants receiving inpatient care (geometric mean =

Stress CMR Imaging Observation Unit in the Emergency Department Reduces 1-Year Medical Care Costs in Patients With Acute Chest Pain

3,101 vs.

A Multidisciplinary Self-Directed Learning Module Improves Knowledge of a Quality Improvement Instrument: The HEART Pathway.

4,742 including the index visit [p = 0.004] and

In Emergency Department Patients with Acute Chest Pain, Stress Cardiac MRI Observation Unit Care Reduces 1- year Cardiac-Related Health Care Expenditures: A Randomized Trial

29 vs.

Provider-Directed Imaging Stress Testing Reduces Health Care Expenditures in Lower-Risk Chest Pain Patients Presenting to the Emergency Department

152 following discharge [p = 0.012]). During the year following randomization, 6% of OU-CMR and 9% of inpatient care participants experienced a major cardiac event (p = 0.72). CONCLUSIONS An OU-CMR strategy reduces cardiac-related costs of medical care during the index visit and over the first year subsequent to discharge, without an observed increase in major cardiac events. (Cost Comparison of Cardiac Magnetic Resonance Imaging [MRI] Use in Emergency Department [ED] Patients With Chest Pain; NCT00678639).

IN EMERGENCY DEPARTMENT PATIENTS WITH ACUTE CHEST PAIN, STRESS CARDIAC MRI OBSERVATION UNIT CARE REDUCES 1-YEAR CARDIAC-RELATED HEALTH CARE EXPENDITURES: A RANDOMIZED TRIAL

OBJECTIVES The aim of this study was to determine the effect of stress cardiac magnetic resonance (CMR) imaging in an observation unit (OU) on revascularization, hospital readmission, and recurrent cardiac testing in intermediate-risk patients with possible acute coronary syndromes (ACS). BACKGROUND Intermediate-risk patients commonly undergo hospital admission with high rates of coronary revascularization. It is unknown whether OU-based care with CMR is a more efficient alternative. METHODS A total of 105 intermediate-risk participants with symptoms of ACS but without definite ACS on the basis of the first electrocardiogram and troponin were randomized to usual care provided by cardiologists and internists (n = 53) or to OU care with stress CMR (n = 52). The primary composite endpoint of coronary artery revascularization, hospital readmission, and recurrent cardiac testing at 90 days was determined. The secondary endpoint was length of stay from randomization to index visit discharge; safety was measured as ACS after discharge. RESULTS The median age of participants was 56 years (range 35 to 91 years), 54% were men, and 20% had pre-existing coronary disease. Index hospital admission was avoided in 85% of the OU CMR participants. The primary outcome occurred in 20 usual care participants (38%) versus 7 OU CMR participants (13%) (hazard ratio: 3.4; 95% confidence interval: 1.4 to 8.0, p = 0.006). The OU CMR group experienced significant reductions in all components: revascularizations (15% vs. 2%, p = 0.03), hospital readmissions (23% vs. 8%, p = 0.03), and recurrent cardiac testing (17% vs. 4%, p = 0.03). Median length of stay was 26 h (interquartile range: 23 to 45 h) in the usual care group and 21 h (interquartile range: 15 to 25 h) in the OU CMR group (p < 0.001). ACS after discharge occurred in 3 usual care participants (6%) and no OU CMR participants. CONCLUSIONS In this single-center trial, management of intermediate-risk patients with possible ACS in an OU with stress CMR reduced coronary artery revascularization, hospital readmissions, and recurrent cardiac testing, without an increase in post-discharge ACS at 90 days. (Randomized Investigation of Chest Pain Diagnostic Strategies; NCT01035047).