Is coronary computed tomography angiography a resource sparing strategy in the risk stratification and evaluation of acute chest pain? Results of a randomized controlled trial

Adam H. Miller, Paul E Pepe, Ronald M Peshock, Rafia Bhore, Clyde C. Yancy, Lei Xuan, Margarita M. Miller, Gisselle R. Huet, Clayton K Trimmer, Rene Davis, Rebecca Chason, Micheal T. Kashner

Research output: Contribution to journalArticle

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Abstract

Objectives: Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD. Methods: Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs. Results: The mean (± standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group ($10,134; SD ±$14,239) versus the SC-only group ($16,579; SD ±$19,148; p = 0.144), as was the median for the SC + CCTA ($4,288) versus SC only ($12,148; p = 0.652; median difference = -$1,291; 95% confidence interval [CI] = -$12,219 to $1,100; p = 0.652). Among the 60 total study patients, only 19 had an established diagnosis of CAD at 90 days. However, 18 (95%) of these diagnosed participants were in the SC + CCTA group. In addition, there were fewer hospital readmissions in the SC + CCTA group (6 of 30 [20%] vs. 16 of 30 [53%]; difference in proportions = -33%; 95% CI = -56% to -10%; p = 0.007). Conclusions: Adding CCTA to the current ED risk stratification of ACPSs resulted in no difference in the quantity of resources utilized, but an increased diagnosis of CAD, and significantly less recidivism and rehospitalization over a 90-day follow-up period.

Original languageEnglish (US)
Pages (from-to)458-467
Number of pages10
JournalAcademic Emergency Medicine
Volume18
Issue number5
DOIs
StatePublished - May 2011

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Acute Pain
Chest Pain
Randomized Controlled Trials
Angiography
Acute Chest Syndrome
Tomography
Coronary Artery Disease
Hospital Emergency Service
Confidence Intervals
Computed Tomography Angiography
Patient Readmission
Standard of Care
Hospitalization
Demography
Delivery of Health Care

ASJC Scopus subject areas

  • Emergency Medicine

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Is coronary computed tomography angiography a resource sparing strategy in the risk stratification and evaluation of acute chest pain? Results of a randomized controlled trial. / Miller, Adam H.; Pepe, Paul E; Peshock, Ronald M; Bhore, Rafia; Yancy, Clyde C.; Xuan, Lei; Miller, Margarita M.; Huet, Gisselle R.; Trimmer, Clayton K; Davis, Rene; Chason, Rebecca; Kashner, Micheal T.

In: Academic Emergency Medicine, Vol. 18, No. 5, 05.2011, p. 458-467.

Research output: Contribution to journalArticle

Miller, Adam H. ; Pepe, Paul E ; Peshock, Ronald M ; Bhore, Rafia ; Yancy, Clyde C. ; Xuan, Lei ; Miller, Margarita M. ; Huet, Gisselle R. ; Trimmer, Clayton K ; Davis, Rene ; Chason, Rebecca ; Kashner, Micheal T. / Is coronary computed tomography angiography a resource sparing strategy in the risk stratification and evaluation of acute chest pain? Results of a randomized controlled trial. In: Academic Emergency Medicine. 2011 ; Vol. 18, No. 5. pp. 458-467.
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AU - Bhore, Rafia

AU - Yancy, Clyde C.

AU - Xuan, Lei

AU - Miller, Margarita M.

AU - Huet, Gisselle R.

AU - Trimmer, Clayton K

AU - Davis, Rene

AU - Chason, Rebecca

AU - Kashner, Micheal T.

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N2 - Objectives: Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD. Methods: Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs. Results: The mean (± standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group ($10,134; SD ±$14,239) versus the SC-only group ($16,579; SD ±$19,148; p = 0.144), as was the median for the SC + CCTA ($4,288) versus SC only ($12,148; p = 0.652; median difference = -$1,291; 95% confidence interval [CI] = -$12,219 to $1,100; p = 0.652). Among the 60 total study patients, only 19 had an established diagnosis of CAD at 90 days. However, 18 (95%) of these diagnosed participants were in the SC + CCTA group. In addition, there were fewer hospital readmissions in the SC + CCTA group (6 of 30 [20%] vs. 16 of 30 [53%]; difference in proportions = -33%; 95% CI = -56% to -10%; p = 0.007). Conclusions: Adding CCTA to the current ED risk stratification of ACPSs resulted in no difference in the quantity of resources utilized, but an increased diagnosis of CAD, and significantly less recidivism and rehospitalization over a 90-day follow-up period.

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