RL Jesse, VAMC Richmond; CC Murphy, VAMC Richmond; MJ Michael, VAMC Richmond

Objectives: To reduce the resource intensive evaluation for low-risk chest pain patients through early implementation of prognostic testing.

Methods: Patients presenting to the Emergency Department (ED) with chest pain during nuclear medicine operating hours who were triaged to the low-risk level of a systematic chest pain protocol were injected with Tc-99-m-sestamibi and taken to Nuclear Medicine for a rest myocardial perfusion imaging (MPI) study. Patients with a negative scan were eligible for discharge at the discretion of the ED physician. They were given an appointment for a follow up stress imaging study on the next working day. Resource utilization for these patients were determined, and compared to that for similar risk standard of care cohort of patients who were admitted directly to the Coronary Intensive Care Unit (CCU) for conventional rule out. The study period reported is from 4/1/96 through 8/30/99.

Results: There were 135 patients triaged to early rest MPI from 4/1/96 through 8/30/97. Of these, 42 were admitted and 88 were discharged from the ED. There were no cardiac admissions over the subsequent 12 months among the group discharged following a negative rest MPI study. The estimated cost savings for the non-admitted rest MPI group versus standard admission practices was $523,200.

Conclusions: The high cost of evaluating the chest pain is driven by diagnostic uncertainty and the litigation risk. The ability to provide prognostic information rapidly can prevent admissions, reduce costs, and improve patient outcomes. The VAMC Richmond has an average of 145 chest pain visits per month. Approximately 40-45% meet low risk criteria and would be eligible for acute MPI studies. The question for those at low-risk is how to expediently determine whether it is safe to discharge the patients until the definitive exam can be performed: it is a quesiton of prognosis rather than diagnosis. In the absence of a simple laboratory test to provide this information, rest MPI can provide the prognostic guidance needed to discharge safely, while expediting the definitive evaluation.

Impact: It is reported that up to 5% of patients who present to EDs with myocardial infarctions are inadvertently sent home. This leads to high morbidity and mortality, and in addition accounts for over 20% of the malpractice dollars paid out on behalf of ED physicians. On the other hand, this has led to the widespread practice of routine admission for even low-risk chest pain patients at an estimated cost of over $5 billion per year. Full implementation of this early prognostic algorithm has the potential to provide significant cost reductions in the current climate of limited resources