Improving Office Care for Chest Pain (Text Version)

Slide presentation from the AHRQ 2011 conference.

On September 19, 2011, Thomas Sequist made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (660 KB). Plugin Software Help.


Slide 1

Improving Office Care for Chest Pain

Improving Office Care for Chest Pain

Thomas D. Sequist, MD MPH

Associate Professor of Medicine and Health Care Policy
Brigham and Woman's Hospital, Division of General Medicine
Harvard Medical School, Department of Health Care Policy
Harvard Vanguard Medical Associates

Slide 2

Why Chest Pain?

Why Chest Pain?

  • Chest pain is a common symptom:
    • Increasing burden in primary care.
  • Frequent missed diagnosis of acute myocardial infarction (MI).
  • Excess utilization of resources.

Slide 3

Patient Care Model

Patient Care Model

Image: A flowchart of the Patient Care Model is shown:

  • Primary care visit:
    • Home without further testing.
    • Home with further testing.
    • Emergency Department:
      • Discharged.
      • Chest Pain Unit.
      • Inpatient.
      • Intensive Care Unit (ICU).

Slide 4

Patient Care Model

Patient Care Model

Image: A flowchart of the Patient Care Model is shown:

  • Primary care visit:
    • Home without further testing.
    • Home with further testing.
    • Emergency Department:
      • Discharged.
      • Chest Pain Unit.
      • Inpatient.
      • ICU.

Dotted lines now connect "Home without further testing" and "Home with further testing" to the items under "Emergency Department."

Slide 5

Primary Care Challenges

Primary Care Challenges

  • Low risk population:
    • Limit excess resource utilization.
    • Avoid missed diagnoses.
  • Time-limited care:
    • Cannot usually observe over several hours.
  • No immediate cardiac stress testing.
  • No immediate cardiac enzymes.

Slide 6

Can the Framingham Score Help?

Can the Framingham Score Help?

  • Main utility is to raise awareness.
  • Framingham risk score (FRS) variables are generally available.
  • FRS compares favorably with exercise stress testing.

Slide 7

Defining High Risk Patients

Defining High Risk Patients

FRS CutoffSensitivitySpecificity
≥5%9661
≥10%8575
≥20%5486

Slide 8

Study Questions

Study Questions

  1. Can risk score alerts within an electronic health record (EHR) improve risk-appropriate care for patients with chest pain?
  2. What are the additional opportunities to improve the efficiency of chest pain care?

Slide 9

Harvard Vanguard Medical Associates

Harvard Vanguard Medical Associates

  • Multi-specialty group practice.
  • Integrated electronic health record.
  • 15 ambulatory health centers.
  • 175 primary care physicians.
  • 300,000 adult patients.

Image: A map of eastern Massachusetts shows the locations of Harvard Vanguard Medical Associates offices.

Slide 10

Randomization Scheme

Randomization Scheme

Image: A flowchart of the Randomization Scheme is shown:

292 Primary Care Clinicians
7,083 patients (≥30 years old)

  • Intervention Group: 149 clinicians, 3,634 patients:
    • High Risk, 717 patients.
    • Low Risk, 2917 patients.
  • Control Group: 143 clinicians, 3,449 patients:
    • High Risk, 610 patients.
    • Low Risk, 2839 patients.

Slide 11

Intervention Design

Intervention Design

  • Identification of patients with chest pain:
    • Medical assistant training.
  • Automated calculation of Framingham Risk Score.
  • Delivery of risk-appropriate recommendations via electronic alerts.

Slide 12

Risk Appropriate Recommendations

Risk Appropriate Recommendations

  • High risk patients (FRS = 10%):
    • Electrocardiogram performance.
    • Aspirin therapy.
  • Low risk patients (FRS <10%):
    • Avoidance of cardiac stress testing.

Slide 13

Entry of Chest Pain Complaint

Entry of Chest Pain Complaint

Image: A screenshot shows "Chest Pain" being selected as Chief Complaint.

Slide 14

High Risk Patient Alert

High Risk Patient Alert

Image: A screenshot shows a sample High Risk Patient Alert.

Slide 15

Low Risk Patient Alert

Low Risk Patient Alert

Image: A screenshot shows a sample Low Risk Patient Alert.

Slide 16

SmartLink (.frsdetail)

SmartLink (.frsdetail)

Image: A screenshot of SmartLink is shown with patient details entered under "Notes."

Slide 17

Baseline Patient Characteristics

Baseline Patient Characteristics

CharacteristicsIntervention
(n = 3,634)
Control
(n = 3,449)
p value
Mean age, years49.748.60.001
Female, %63650.03
InsuranceCommercial76770.01
Medicare1411 
Medicaid89 
Uninsured33 
Framingham Risk Score<10%80820.03
≥10%2018 

Slide 18

Clinical Care and Outcomes

Clinical Care and Outcomes

 High Risk
(n=1327)
Low Risk
(n=5756)
p value
Evaluation and treatmentElectrocardiogram5043<0.001
Aspirin therapy197<0.001
Cardiac stress test1710<0.001
Follow up careHome9196<0.001
Hospitalized73<0.001
DiagnosesAcute myocardial infarction*1.10.20.01

* Among 26 cases of AMI, 10 (36%) represented missed diagnoses.

Slide 19

Impact of Electronic Alerts  

Impact of Electronic Alerts

Image: Bar chart shows the following data:

 High Risk PatientsLow Risk Patients
EKG PerformanceAspirin Therapy  Cardiac Stress
Testing
Intervention512010
Control48189

Slide 20

Clinician Views on Intervention  

Clinician Views on Intervention

Is the Framingham Risk Score a valid tool for evaluating chest pain?

Image: Bar chart shows the following data:

 AlwaysOftenSometimesRarely or
Never
Intervention540478

Slide 21

 Clinician Views on Intervention

Clinician Views on Intervention

Is a Risk Score Cutoff of 10% to identify high risk patients...

Image: Bar graph shows the following data:

 Too highAbout rightToo low
Intervention12817

Slide 22

 Conclusions

Conclusions

  • Acute MI is uncommon among primary care patients with chest pain.
  • Missed diagnosis of acute MI is common, while many low risk patients undergo cardiac stress testing.
  • Electronic risk alerts do not change care patterns.

Slide 23

 Implications

Implications

  • Failure to change care patterns:
    • Is it lack of belief in the risk assessment tool?
    • Is it failure to deliver information effectively?
    • Do we need more comprehensive efforts?
  • Electronic health records represent one piece of a multi-component program.

Slide 24

Improving Efficiency of Chest Pain Care  

Improving Efficiency of Chest Pain Care

  • Map flow of patients from primary care.
  • Evaluate cost implications for varied evaluation and management strategies.
  • Analyze variation in care patterns.

Slide 25

 Patient Care Model

Patient Care Model

Image: A flowchart of the Patient Care Model is shown:

  • Primary care visit:
    • Home without further testing.
    • Home with further testing.
    • Emergency Department:
      • Discharged.
      • Chest Pain Unit.
      • Inpatient.
      • ICU.

Slide 26

 Estimated Average Costs Per Patient

Estimated Average Costs Per Patient

Image: A flowchart of the Patient Care Model is shown with the data added:

  • Primary care visit:
    • Home without further testing (55%, $293).
    • Home with further testing (40%, $442).
    • Emergency Department (5%):
      • Discharged (37%, $1,087).
      • Chest Pain Unit (47%, $3,192).
      • Inpatient (13%, $17,562).
      • ICU (3%, $47,575).

Slide 27

 Estimated Average Costs Per Patient

Estimated Average Costs Per Patient

Image: A flowchart of the Patient Care Model is shown with the data added. The bolded sections are highlighted in yellow:

  • Primary care visit:
    • Home without further testing (55%, $293).
    • Home with further testing (40%, $442).
    • Emergency Department (5%):
      • Discharged (37%, $1,087).
      • Chest Pain Unit (47%, $3,192).
      • Inpatient (13%, $17,562).
      • ICU (3%, $47,575).

Slide 28

 Physician Level Clinical Variation

Physician Level Clinical Variation

Image: A bar graph shows the following data for percentage of patients referred for care within physician practices:

Cardiac Stress Testing*:

  • 95% Lower CI: 3.8%.
  • Average: 10.8%.
  • 95% Upper CI: 26.7%.

Emergency Department Triage*

  • 95% Lower CI: 1.3%.
  • Average: 4.7%.
  • 95% Upper CI: 14.9%.

* p<0.01 for random effects of physician level variation.

Slide 29

How Can the EHR Improve Efficiency?  

How Can the EHR Improve Efficiency?

  • Increasing awareness of pre-test probability:
    • All variation is within low risk patients.
  • Focus on low value emergency department referrals.
  • Peer to peer education.

Slide 30

 Clinical Process Flow

Clinical Process Flow

Image: A flowchart of the Patient Care Model is shown:

  • Primary care visit → (Triage) →
    • EKG.
    • ETT.
    • Stress ECHO.
    • Stress Nuclear.
    • Cardiology.
    → (Triage) →
    • Emergency Department → (Triage) →
      • Home.
      • Chest Pain Unit.
      • Inpatient.
      • ICU.
    • Home.
Page last reviewed March 2012
Internet Citation: Improving Office Care for Chest Pain (Text Version). March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/sequist/index.html