Modified Risk Score for ED Chest Pain Patients Reduces Hospital Stays, Lowers Costs

Low-risk patients with chest pain identified by a modified risk score in the emergency department (ED) can be safely discharged home without cardiac stress testing, resulting in significantly less time spent in the hospital and more than $6,500 saved per patient, a new study suggests.

Additionally, for patients discharged without stress testing, there were no differences in mortality, acute MI, and coronary revascularization at 30 days when compared with patients sent to the observation unit for further diagnostic testing, although investigators admit the study is not designed to assess differences in clinical outcomes.

The goal of the prospective, randomized study, lead investigator Tiberio Frisoli, MD (Henry Ford Hospital, Detroit, MI), told TCTMD, was to identify truly low-risk patients and to quantify the cost savings that could be achieved with a risk-stratification tool such as the modified HEART score, which they developed at their hospital.

“The first thing anybody thinks about when they feel chest pain is a heart attack, and it really does scare patients,” said Frisoli. “On the flip side, it is a symptom with so many potential causes, the majority of which can be relatively benign.” Despite the odds, no physician wants to miss anything “potentially life-threatening,” such as ACS or pulmonary embolism, he added.

At Henry Ford Hospital, the modified HEART score accounts for the patient’s family history, ECG changes, age, and cardiovascular risk factors. Using the scoring system, the researchers identified 105 individuals with chest pain who had scores of 3 or less on the score and had acute MI excluded on the basis of two negative cardiac troponin tests. These low-risk patients were then randomized to early discharge (without cardiac testing) or management in the observation unit with cardiac testing. The study was published September 27, 2017, in Circulation: Cardiovascular Quality and Outcomes.

More Than $6,500 per Patient Saved

For those discharged without stress testing, hospital length of stay was a median 6.3 hours compared with 25.9 hours for those admitted for observation and stress testing. Similarly, the median total hospital charges were $2,953 for those discharged early and $9,616 for those admitted for further observation and testing.

Frisoli hopes the study spurs conversations about how much chest pain is contributing to the “out-of-control healthcare” expenditures in the United States. Many physicians at Henry Ford Hospital are starting to use the HEART score, he added, coding the score on patient charts when discharging individuals home without stress testing.

One or two physicians did ask, ‘What if they don’t follow-up? Am I sending these patients to the wolves?’ Tiberio Frisoli

“The toughest buy-in was getting the emergency physicians [on board], especially in an inner-city, indigent population where there is the perception these patients won’t follow-up with the primary care physician,” said Frisoli. “We had to get them to buy into the safety of this. One or two physicians did ask, ‘What if they don’t follow-up? Am I sending these patients to the wolves?’”

In response, Frisoli said clinical trials have shown that event rates at 30 days in these low-risk patients are extremely low at less than 1%. Secondly, even though the guidelines state it is reasonable to admit and send these patients for stress testing (class IIa recommendation), there has never been a study showing that stress testing improves clinical outcomes. He added that admitting patients needlessly carries its own burdens, with false positives, radiation exposure, excessive downstream testing, and so on.

“It’s not benign to admit patients,” said Frisoli, noting that he was eventually able to get their ED physicians to participate in the study. As for whether he believes the HEART score can be implemented in other hospitals, he said, “Absolutely.”

In the US, the second most common reason for ED visits is for the evaluation of chest pain, accounting for more than 8 million visits annually. In identifying truly low-risk patients highly unlikely to derive any benefit from cardiac stress testing, Frisoli said, there is the potential to save billions of dollars in healthcare costs.

Consequences on Both Sides of Ledger

In an editorial, Keith Kocher, MD (University of Michigan, Ann Arbor), writes that physicians and researchers “have been hacking away at chest pain for more than 3 decades.” The search is for a “single tool or combination of tools that perfectly sorts” chest pain patients into two groups—those in whom ACS is a consideration and requires further diagnostic work and those at low enough risk to go home.

“The consequences on both sides of the ledger are substantial,” he writes, referring to missed diagnoses on the one side and unnecessary treatment on the other.

Regarding the modified HEART score protocol, Kocher says it’s promising but requires additional evidence before it can be fully endorsed, noting that any adopted approach has to satisfy physicians, patients, and society at large.  

“But the prize is worth the effort,” he writes. “Arriving at a strategy that fully addresses each stakeholder concern, maximizes health outcomes with accompanying cost efficiency while setting up for a potentially smooth translation into widespread routine clinical practice in the ED, will achieve substantial gains for what is a common and costly patient experience.”

Given the low 30-day event rates among these low-risk patients, Frisoli said a clinical trial with hard clinical endpoints, such as mortality, rehospitalizations, MI, and coronary revascularizations, would be a massive undertaking. Still, they have approached the National Institutes of Health about funding such a trial, a study that would involve many thousands of patients and multiple institutions. While nothing is finalized, Frisoli said, a safety study is “in the works.”