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

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?

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

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

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

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?

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

FRS Cutoff	Sensitivity	Specificity
≥5%	96	61
≥10%	85	75
≥20%	54	86

Slide 8

Study Questions

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

Slide 9

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

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

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

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

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

Slide 14

High Risk Patient Alert

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

Slide 15

Low Risk Patient Alert

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

Slide 16

SmartLink (.frsdetail)

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

Slide 17

Baseline Patient Characteristics

Characteristics		Intervention (n = 3,634)	Control (n = 3,449)	p value
Mean age, years		49.7	48.6	0.001
Female, %		63	65	0.03
Insurance	Commercial	76	77	0.01
	Medicare	14	11
	Medicaid	8	9
	Uninsured	3	3
Framingham Risk Score	<10%	80	82	0.03
Framingham Risk Score	≥10%	20	18

Slide 18

Clinical Care and Outcomes

		High Risk (n=1327)	Low Risk (n=5756)	p value
Evaluation and treatment	Electrocardiogram	50	43	<0.001
	Aspirin therapy	19	7	<0.001
	Cardiac stress test	17	10	<0.001
Follow up care	Home	91	96	<0.001
Follow up care	Hospitalized	7	3	<0.001
Diagnoses	Acute myocardial infarction*	1.1	0.2	0.01

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

Slide 19

Impact of Electronic Alerts

Image: Bar chart shows the following data:

	High Risk Patients		Low Risk Patients
	EKG Performance	Aspirin Therapy	Cardiac Stress Testing
Intervention	51	20	10
Control	48	18	9

Slide 20

Clinician Views on Intervention

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

Image: Bar chart shows the following data:

	Always	Often	Sometimes	Rarely or Never
Intervention	5	40	47	8

Slide 21

Clinician Views on Intervention

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

Image: Bar graph shows the following data:

	Too high	About right	Too low
Intervention	12	81	7

Slide 22

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

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

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

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

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

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

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?

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

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 October 2014

Internet Citation: Improving Office Care for Chest Pain (Text Version). October 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2011/sequist/index.html