Hospital Variation in Noninvasive Cardiac Imaging
expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28(1):25-33. 11. Mudrick DW, Cowper PA, Shah BR, et al. Downstream procedures and outcomes after stress testing for chest pain without known coronary artery disease in the United States. Am Heart J. 2012;163(3):454-461. 12. Wennberg DE, Kellett MA, Dickens JD, Malenka DJ, Keilson LM, Keller RB. The association between local diagnostic testing intensity and invasive cardiac procedures. JAMA. 1996;275(15):1161-1164. 13. Lucas FL, Siewers AE, Malenka DJ, Wennberg DE. Diagnostic-therapeutic cascade revisited: coronary angiography, coronary artery bypass graft surgery, and percutaneous coronary intervention in the modern era. Circulation. 2008;118(25): 2797-2802.
Original Investigation Research
14. Mission and Vision. Premier Inc website. https://www.premierinc.com/wps/portal /premierinc/public/aboutpremier/missionvision. Accessed December 19, 2013. 15. Kim AS, Sidney S, Klingman JG, Johnston SC. Practice variation in neuroimaging to evaluate dizziness in the ED. Am J Emerg Med. 2012;30(5):665-672. 16. Raja AS, Andruchow J, Zane R, Khorasani R, Schuur JD. Use of neuroimaging in US emergency departments. Arch Intern Med. 2011;171(3):260-262. 17. Coco AS, O’Gurek DT. Increased emergency department computed tomography use for common chest symptoms without clear patient benefits. J Am Board Fam Med. 2012;25(1):33-41. 18. Penumetsa SC, Mallidi J, Friderici JL, Hiser W, Rothberg MB. Outcomes of patients admitted for
observation of chest pain. Arch Intern Med. 2012;172(11):873-877. 19. Beller GA, Watson DD. Risk stratification using stress myocardial perfusion imaging: don’t neglect the value of clinical variables. J Am Coll Cardiol. 2004;43(2):209-212. 20. Rozanski A, Gransar H, Hayes SW, et al. Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009. J Am Coll Cardiol. 2013;61(10):1054-1065. 21. Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362(10):886-895. 22. Baker LC. Acquisition of MRI equipment by doctors drives up imaging use and spending. Health Aff (Millwood). 2010;29(12):2252-2259.
Invited Commentary
The Patient With Chest Pain Low Risk, High Stakes Ezra A. Amsterdam, MD; Edris Aman, MD
The etiology of chest pain is serious in only a distinct minority of the multitude of patients who visit the emergency department (ED) with this symptom each year, but the consequences of missing acute coronary syndrome or other Related article page 546 life-threatening conditions can include grave clinical sequelae and major liability. Thus, the dilemma of low risk but high stakes in this patient population continues to spur efforts to optimally serve both groups by rapid identification of those requiring urgent treatment and safe, cost-effective, and early discharge in the large majority with a benign condition. The contemporary approach to this challenge in many centers has evolved into accelerated diagnostic protocols (ADPs) that entail initial recognition of low risk based on clinical stability, normal electrocardiogram, and negative results for cardiac injury markers followed by a predischarge test to evaluate suitability for early discharge.1 Predischarge tests vary from exercise treadmill to stress imaging or computed tomographic coronary angiography (CTA), depending on institutional resources, expertise, and physician preference. Negative results allow discharge with outpatient follow-up while abnormal findings mandate admission. During more than 2 decades, this strategy has averted unnecessary admissions, reduced length of stay (LOS), and resulted in safe clinical outcomes.1 Indeed, ADPs have been associated with a greater than 99% negative predictive value for adverse cardiac events at 30 days or longer1 and have reduced the classic “rule out myocardial infarction [MI]” process from days to hours. However, despite these estimable results, the logic of routine cardiac testing for these low-risk patients has recently been sharply challenged on the grounds of clinical rationale,2 resource utilization, and cost—ironically, the same bases on which the case for cardiac testing was formulated. jamainternalmedicine.com
The report by Safavi et al3 in this issue of JAMA Internal Medicine is germane to this question. In their study of hospital use of noninvasive cardiac imaging (NICI) methods in a very large patient population evaluated for chest pain suspicious for myocardial ischemia, they found that (1) hospital use of NICI in these patients varied widely, (2) hospitals with higher NICI rates more frequently admitted patients for angiography, but (3) increased NICI rates were not associated with substantial differences in revascularization rates or readmission for MI. It might be concluded from these findings that the NICI did not provide any clinical advantage in the management of these patients and that the authors identified high utilization of an expensive resource that was not associated with substantial clinical gain. However, potential benefits resulting from the evaluation sequence but not assessed in this study could have included improved medical therapy for patients with cardiac disease who did not require revascularization and also reduced ED visits for chest pain in those shown to have no clinically significant disease. Thus, further study of outcomes in this population would be useful. The results of the study by Safavi et al3 offer a strikingly different perspective than that presented earlier in this commentary on the utility of cardiac testing, including NICI, in achieving salutary outcomes of ADPs in patients presenting with chest pain without MI. Their study is one of an increasing number of reports asserting that routine cardiac testing of low-risk patients presenting to the ED with chest pain is neither necessary nor cost-effective. Prasad et al2 cogently reviewed the evidence against routine testing of low-risk patients presenting with chest pain in terms of absence of improved clinical outcomes, increased costs, and obsolete rationale. Furthermore, the utility of excluding MI with a recently developed 2-hour diagnostic protocol using highsensitivity troponin in patients with a normal result from an electrocardiogram and a thrombolysis in myocardial infarcJAMA Internal Medicine April 2014 Volume 174, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Nanyang Technological University User on 05/26/2015
553
Research Original Investigation
Hospital Variation in Noninvasive Cardiac Imaging
tion (TIMI) score of 0 holds promise to further advance our management of low-risk patients.4 In the current state of our knowledge, it is reasonable to call for a halt to routine cardiac testing in favor of physician discretion in selection of patients for predischarge testing. Routine use of CTA in low-risk patients with chest pain is questionable and warrants specific attention. Despite a negative predictive value of more than 99%, decreased LOS, and lower upfront ED costs in fully capable units, this method has considerable drawbacks.5 These include ionizing radiation with its potential for future risk of cancer and a suboptimal positive predictive value that can promote follow-up invasive coronary angiography, additional radiation exposure, and use of nephrotoxic radiographic contrast medium, plus allergic reactions. Of importance, CTA is associated with elevated rates of invasive angiography and subsequent increases in revascularization, with the potential for increased downstream costs and no evidence of clinical benefit compared with usual care.6,7 In this regard, it is important to appreciate that even when testing does reveal coronary artery disease, a causal relationship ARTICLE INFORMATION Author Affiliations: University of California School of Medicine, Davis, Sacramento (Amsterdam, Aman); Division of Cardiovascular Medicine, Lawrence J. Ellison Ambulatory Care Center, Sacramento, California (Amsterdam). Corresponding Author: Ezra A. Amsterdam, MD, Division of Cardiovascular Medicine, Lawrence J. Ellison Ambulatory Care Center, University of California, Davis, 4860 Y St, Ste 2820, Sacramento, CA 95817 ([email protected]).
cannot be inferred between symptom and disease. Computed tomographic coronary angiography is a remarkable tool, but clearly it should be reserved for selected patients among the low-risk group presenting to the ED with chest pain. At the University of California, Davis, Medical Center in Sacramento, we practice physician discretion in selecting patients for predischarge testing. In more than 500 patients discharged directly from the unit after evaluation consisting of normal results of electrocardiograms and cardiac troponin tests, there has been only 1 adverse cardiac event (0.2%) at the 30-day follow-up. Thus, low risk is not no risk, and the crucial aspects of this strategy remain meticulous clinical history and examination, accurate electrocardiographic interpretation, and reliable and contemporary assay for cardiac troponin. The extent to which this concept will reduce the burden of unnecessary testing of low-risk patients will depend on each institution’s patient mix, the readiness of clinicians steeped in the hazards of missed acute coronary syndromes to adopt new and reasonable algorithms, and the interests and influences on clinical care at their institutions.
Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756-1776. 2. Prasad V, Cheung M, Cifu A. Chest pain in the emergency department: the case against our current practice of routine noninvasive testing. Arch Intern Med. 2012;172(19):1506-1509.
REFERENCES
3. Safavi KC, Li S-X, Dharmarajan K, et al. Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes [published online February 10, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2013.14407.
1. Amsterdam EA, Kirk JD, Bluemke DA, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the
4. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized
Published Online: February 10, 2014. doi:10.1001/jamainternmed.2013.13415. Conflict of Interest Disclosures: None reported.
clinical trial [published online October 7, 2013]. JAMA Intern Med. doi:10.1001/ jamainternmed.2013.11362. 5. Karakas M, Koenig W. Coronary CT angiography for acute chest pain. N Engl J Med. 2012;367(17):1664-1665. 6. Gibbons RJ. Chest pain triage in the ED: is CT coronary angiography the answer? J Nucl Cardiol. 2012;19(3):404-406. 7. Hulten E, Pickett C, Bittencourt MS, et al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 2013;61(8):880-892.
Editor's Note
Priorities in the Evaluation of Patients With Chest Pain Rita F. Redberg, MD, MSc
The excellent article by Safavi et al and commentary by Amsterdam and Aman remind us that the first question in evaluation of patients with chest pain who are at low risk for myocardial infarction is not “What test should I order?” Related article page 546 but rather “Does this patient need any further testing?” Many patients can be safely discharged from the emergency department to outpatient follow-up without any stress test or imaging such as cardiac com-
554
puted tomography. Certainly, no one wants to miss a myocardial infarction, but we also do not want to keep people for hours and days to perform additional imaging tests that are not associated with better outcomes but may lead to increased radiation exposure. More time spent talking with patients about their symptoms and their functional status, as well as the risks and benefits of immediate vs deferred testing, is likely to result in shorter emergency department stays and fewer unnecessary tests.
JAMA Internal Medicine April 2014 Volume 174, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Nanyang Technological University User on 05/26/2015
jamainternalmedicine.com
expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28(1):25-33. 11. Mudrick DW, Cowper PA, Shah BR, et al. Downstream procedures and outcomes after stress testing for chest pain without known coronary artery disease in the United States. Am Heart J. 2012;163(3):454-461. 12. Wennberg DE, Kellett MA, Dickens JD, Malenka DJ, Keilson LM, Keller RB. The association between local diagnostic testing intensity and invasive cardiac procedures. JAMA. 1996;275(15):1161-1164. 13. Lucas FL, Siewers AE, Malenka DJ, Wennberg DE. Diagnostic-therapeutic cascade revisited: coronary angiography, coronary artery bypass graft surgery, and percutaneous coronary intervention in the modern era. Circulation. 2008;118(25): 2797-2802.
Original Investigation Research
14. Mission and Vision. Premier Inc website. https://www.premierinc.com/wps/portal /premierinc/public/aboutpremier/missionvision. Accessed December 19, 2013. 15. Kim AS, Sidney S, Klingman JG, Johnston SC. Practice variation in neuroimaging to evaluate dizziness in the ED. Am J Emerg Med. 2012;30(5):665-672. 16. Raja AS, Andruchow J, Zane R, Khorasani R, Schuur JD. Use of neuroimaging in US emergency departments. Arch Intern Med. 2011;171(3):260-262. 17. Coco AS, O’Gurek DT. Increased emergency department computed tomography use for common chest symptoms without clear patient benefits. J Am Board Fam Med. 2012;25(1):33-41. 18. Penumetsa SC, Mallidi J, Friderici JL, Hiser W, Rothberg MB. Outcomes of patients admitted for
observation of chest pain. Arch Intern Med. 2012;172(11):873-877. 19. Beller GA, Watson DD. Risk stratification using stress myocardial perfusion imaging: don’t neglect the value of clinical variables. J Am Coll Cardiol. 2004;43(2):209-212. 20. Rozanski A, Gransar H, Hayes SW, et al. Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009. J Am Coll Cardiol. 2013;61(10):1054-1065. 21. Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362(10):886-895. 22. Baker LC. Acquisition of MRI equipment by doctors drives up imaging use and spending. Health Aff (Millwood). 2010;29(12):2252-2259.
Invited Commentary
The Patient With Chest Pain Low Risk, High Stakes Ezra A. Amsterdam, MD; Edris Aman, MD
The etiology of chest pain is serious in only a distinct minority of the multitude of patients who visit the emergency department (ED) with this symptom each year, but the consequences of missing acute coronary syndrome or other Related article page 546 life-threatening conditions can include grave clinical sequelae and major liability. Thus, the dilemma of low risk but high stakes in this patient population continues to spur efforts to optimally serve both groups by rapid identification of those requiring urgent treatment and safe, cost-effective, and early discharge in the large majority with a benign condition. The contemporary approach to this challenge in many centers has evolved into accelerated diagnostic protocols (ADPs) that entail initial recognition of low risk based on clinical stability, normal electrocardiogram, and negative results for cardiac injury markers followed by a predischarge test to evaluate suitability for early discharge.1 Predischarge tests vary from exercise treadmill to stress imaging or computed tomographic coronary angiography (CTA), depending on institutional resources, expertise, and physician preference. Negative results allow discharge with outpatient follow-up while abnormal findings mandate admission. During more than 2 decades, this strategy has averted unnecessary admissions, reduced length of stay (LOS), and resulted in safe clinical outcomes.1 Indeed, ADPs have been associated with a greater than 99% negative predictive value for adverse cardiac events at 30 days or longer1 and have reduced the classic “rule out myocardial infarction [MI]” process from days to hours. However, despite these estimable results, the logic of routine cardiac testing for these low-risk patients has recently been sharply challenged on the grounds of clinical rationale,2 resource utilization, and cost—ironically, the same bases on which the case for cardiac testing was formulated. jamainternalmedicine.com
The report by Safavi et al3 in this issue of JAMA Internal Medicine is germane to this question. In their study of hospital use of noninvasive cardiac imaging (NICI) methods in a very large patient population evaluated for chest pain suspicious for myocardial ischemia, they found that (1) hospital use of NICI in these patients varied widely, (2) hospitals with higher NICI rates more frequently admitted patients for angiography, but (3) increased NICI rates were not associated with substantial differences in revascularization rates or readmission for MI. It might be concluded from these findings that the NICI did not provide any clinical advantage in the management of these patients and that the authors identified high utilization of an expensive resource that was not associated with substantial clinical gain. However, potential benefits resulting from the evaluation sequence but not assessed in this study could have included improved medical therapy for patients with cardiac disease who did not require revascularization and also reduced ED visits for chest pain in those shown to have no clinically significant disease. Thus, further study of outcomes in this population would be useful. The results of the study by Safavi et al3 offer a strikingly different perspective than that presented earlier in this commentary on the utility of cardiac testing, including NICI, in achieving salutary outcomes of ADPs in patients presenting with chest pain without MI. Their study is one of an increasing number of reports asserting that routine cardiac testing of low-risk patients presenting to the ED with chest pain is neither necessary nor cost-effective. Prasad et al2 cogently reviewed the evidence against routine testing of low-risk patients presenting with chest pain in terms of absence of improved clinical outcomes, increased costs, and obsolete rationale. Furthermore, the utility of excluding MI with a recently developed 2-hour diagnostic protocol using highsensitivity troponin in patients with a normal result from an electrocardiogram and a thrombolysis in myocardial infarcJAMA Internal Medicine April 2014 Volume 174, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Nanyang Technological University User on 05/26/2015
553
Research Original Investigation
Hospital Variation in Noninvasive Cardiac Imaging
tion (TIMI) score of 0 holds promise to further advance our management of low-risk patients.4 In the current state of our knowledge, it is reasonable to call for a halt to routine cardiac testing in favor of physician discretion in selection of patients for predischarge testing. Routine use of CTA in low-risk patients with chest pain is questionable and warrants specific attention. Despite a negative predictive value of more than 99%, decreased LOS, and lower upfront ED costs in fully capable units, this method has considerable drawbacks.5 These include ionizing radiation with its potential for future risk of cancer and a suboptimal positive predictive value that can promote follow-up invasive coronary angiography, additional radiation exposure, and use of nephrotoxic radiographic contrast medium, plus allergic reactions. Of importance, CTA is associated with elevated rates of invasive angiography and subsequent increases in revascularization, with the potential for increased downstream costs and no evidence of clinical benefit compared with usual care.6,7 In this regard, it is important to appreciate that even when testing does reveal coronary artery disease, a causal relationship ARTICLE INFORMATION Author Affiliations: University of California School of Medicine, Davis, Sacramento (Amsterdam, Aman); Division of Cardiovascular Medicine, Lawrence J. Ellison Ambulatory Care Center, Sacramento, California (Amsterdam). Corresponding Author: Ezra A. Amsterdam, MD, Division of Cardiovascular Medicine, Lawrence J. Ellison Ambulatory Care Center, University of California, Davis, 4860 Y St, Ste 2820, Sacramento, CA 95817 ([email protected]).
cannot be inferred between symptom and disease. Computed tomographic coronary angiography is a remarkable tool, but clearly it should be reserved for selected patients among the low-risk group presenting to the ED with chest pain. At the University of California, Davis, Medical Center in Sacramento, we practice physician discretion in selecting patients for predischarge testing. In more than 500 patients discharged directly from the unit after evaluation consisting of normal results of electrocardiograms and cardiac troponin tests, there has been only 1 adverse cardiac event (0.2%) at the 30-day follow-up. Thus, low risk is not no risk, and the crucial aspects of this strategy remain meticulous clinical history and examination, accurate electrocardiographic interpretation, and reliable and contemporary assay for cardiac troponin. The extent to which this concept will reduce the burden of unnecessary testing of low-risk patients will depend on each institution’s patient mix, the readiness of clinicians steeped in the hazards of missed acute coronary syndromes to adopt new and reasonable algorithms, and the interests and influences on clinical care at their institutions.
Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756-1776. 2. Prasad V, Cheung M, Cifu A. Chest pain in the emergency department: the case against our current practice of routine noninvasive testing. Arch Intern Med. 2012;172(19):1506-1509.
REFERENCES
3. Safavi KC, Li S-X, Dharmarajan K, et al. Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes [published online February 10, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2013.14407.
1. Amsterdam EA, Kirk JD, Bluemke DA, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the
4. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized
Published Online: February 10, 2014. doi:10.1001/jamainternmed.2013.13415. Conflict of Interest Disclosures: None reported.
clinical trial [published online October 7, 2013]. JAMA Intern Med. doi:10.1001/ jamainternmed.2013.11362. 5. Karakas M, Koenig W. Coronary CT angiography for acute chest pain. N Engl J Med. 2012;367(17):1664-1665. 6. Gibbons RJ. Chest pain triage in the ED: is CT coronary angiography the answer? J Nucl Cardiol. 2012;19(3):404-406. 7. Hulten E, Pickett C, Bittencourt MS, et al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 2013;61(8):880-892.
Editor's Note
Priorities in the Evaluation of Patients With Chest Pain Rita F. Redberg, MD, MSc
The excellent article by Safavi et al and commentary by Amsterdam and Aman remind us that the first question in evaluation of patients with chest pain who are at low risk for myocardial infarction is not “What test should I order?” Related article page 546 but rather “Does this patient need any further testing?” Many patients can be safely discharged from the emergency department to outpatient follow-up without any stress test or imaging such as cardiac com-
554
puted tomography. Certainly, no one wants to miss a myocardial infarction, but we also do not want to keep people for hours and days to perform additional imaging tests that are not associated with better outcomes but may lead to increased radiation exposure. More time spent talking with patients about their symptoms and their functional status, as well as the risks and benefits of immediate vs deferred testing, is likely to result in shorter emergency department stays and fewer unnecessary tests.
JAMA Internal Medicine April 2014 Volume 174, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Nanyang Technological University User on 05/26/2015
jamainternalmedicine.com
