Howard Blumstein

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

Teaching Emergency Medicine Residents Evidence-Based Critical Appraisal Skills: A Controlled Trial

588; 95% confidence interval

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

336 to

Performance of the maximum modified early warning score to predict the need for higher care utilization among admitted emergency department patients

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.

Utility of Radiography in Suspected Ventricular Shunt Malfunction

STUDY OBJECTIVES To compare the performance of an evidence-based medicine (EBM) approach and a traditional approach to teaching critical appraisal skills to emergency medicine residents. METHODS This was a prospective, case-controlled trial of 32 emergency medicine residents (16 control and 16 intervention). Intervention residents were exposed to a monthly, 1-hour journal club using an EBM approach to critical appraisal over the course of 1 year. Control residents were exposed to a traditional, unstructured journal club, also monthly. Both groups were given a factitious article to evaluate in an essay format before and after the 12-month study period. The Wilcoxon rank sum test was used to compare mean improvement in test scores for each group. RESULTS The mean improvement in test scores was 1.80 for the control group and 1.53 for the intervention group; these values were not significantly different (P =.90). The difference in mean change in test score between the 2 groups was.27 points. CONCLUSION Compared with a traditional approach, an EBM approach to teaching critical appraisal did not appear to improve the critical appraisal skills of emergency medicine residents. However, because of the small number of subjects studied, small differences in critical appraisal skill improvement cannot be ruled out.

Gender differences in testing for syphilis in emergency department patients diagnosed with sexually transmitted diseases.

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 =

Weekday Psychiatry Faculty Rounds on Emergency Department Psychiatric Patients Reduces Length of Stay

3,101 vs.

A SURVEY OF EMERGENCY PHYSICIANS REGARDING DUE PROCESS, FINANCIAL PRESSURES, AND THE ABILITY TO ADVOCATE FOR PATIENTS

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

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

29 vs.

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

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).