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The American Journal of Managed Care May 2019
Evaluation of Value-Based Insurance Design for Primary Care
Qinli Ma, PhD; Gosia Sylwestrzak, MA; Manish Oza, MD; Lorraine Garneau; and Andrea R. DeVries, PhD
The Presurgical Episode: An Untapped Opportunity to Improve Value
Erika D. Sears, MD, MS; Rodney A. Hayward, MD; and Eve A. Kerr, MD, MPH
Clarification of References to Medication Adherence Scale
Open Doors to Primary Care Should Add a “Screen” to Reduce Low-Value Care
Betsy Q. Cliff, MS; and A. Mark Fendrick, MD
From the Editorial Board: Daniel B. Wolfson, MHSA
Daniel B. Wolfson, MHSA
Cost-Effectiveness of DPP-4 Inhibitor and SGLT2 Inhibitor Combination Therapy for Type 2 Diabetes
Manjiri Pawaskar, PhD; S. Pinar Bilir, MS; Stacey Kowal, MS; Claudio Gonzalez, MD; Swapnil Rajpathak, MD; and Glenn Davies, DrPH
Improving Provider Directory Accuracy: Can Machine-Readable Directories Help?
Michael Adelberg, MA, MPP; Austin Frakt, PhD; Daniel Polsky, PhD; and Michelle Kitchman Strollo, DrPH, MHS
Electronic Consults for Improving Specialty Care Access for Veterans
David E. Winchester, MD, MS; Anita Wokhlu, MD; Juan Vilaro, MD; Anthony A. Bavry, MD, MPH; Ki Park, MD; Calvin Choi, MD; Mark Panna, MD; Michael Kaufmann, MD; Matthew McKillop, MD; and Carsten Schmalfuss, MD
Potential Impact of Pharmaceutical Industry Rebates on Medication Adherence
Leah L. Zullig, PhD; Bradi B. Granger, PhD; Helene Vilme, DrPH; Megan M. Oakes, MPA; and Hayden B. Bosworth, PhD
Producing Comparable Cost and Quality Results From All-Payer Claims Databases
Maria de Jesus Diaz-Perez, PhD; Rita Hanover, PhD; Emilie Sites, MPH; Doug Rupp, BS; Jim Courtemanche, MS; and Emily Levi, MPH
Beyond Satisfaction Scores: Exploring Emotionally Adverse Patient Experiences
Laura M. Holdsworth, PhD; Dani L. Zionts, MScPH; Karen Marie De Sola-Smith, PhD; Melissa Valentine, PhD; Marcy D. Winget, PhD; and Steven M. Asch, MD
Patient-Centered Medical Homes and Preventive Service Use
Joel F. Farley, PhD; Arun Kumar, PharmD, MS; Benjamin Y. Urick, PharmD, PhD; and Marisa E. Domino, PhD
Currently Reading
Pilot of Urgent Care Center Evaluation for Acute Coronary Syndrome
Ryan P. Radecki, MD, MS; Kevin F. Foley, PhD; Timothy S. Elzinga, MD; Cynthia P. Horak, MD; Thomas E. Gant, MS; Heather M. Papp, BA; Adam J. Morris, BS; Natalie R. Hauser, BA; and Briar L. Ertz-Berger, MD, MPH

Pilot of Urgent Care Center Evaluation for Acute Coronary Syndrome

Ryan P. Radecki, MD, MS; Kevin F. Foley, PhD; Timothy S. Elzinga, MD; Cynthia P. Horak, MD; Thomas E. Gant, MS; Heather M. Papp, BA; Adam J. Morris, BS; Natalie R. Hauser, BA; and Briar L. Ertz-Berger, MD, MPH
A formal protocol for urgent care center evaluation of potential acute coronary syndrome safely precluded emergency department visits among 84% of those eligible.
ABSTRACT

Objectives: Patients with chest pain and concern for potential coronary ischemia are frequently referred to the emergency department (ED), resulting in substantial resource utilization and cost. The objective of this study was to implement a protocol for urgent care center (UCC) evaluation of potential acute coronary syndrome (ACS) and describe its performance.

Study Design: This is a descriptive, retrospective review of consecutive cases included in a protocol for UCC evaluation of ACS.

Methods: Consecutive patient encounters from 4 urgent care facilities of our regional integrated health system were reviewed from a period spanning 4.5 months of the 2017 calendar year. The primary outcome was avoidance of an ED visit within 30 days of the index visit, and the primary safety outcome was serious adverse events (AEs) occurring in the UCC setting.

Results: There were 802 patients evaluated, with a median age of 55 years, and 58% were female. Seventy-three (9.1%) patients were referred to the ED or hospitalized for any reason at the index visit, 10 (1.2%) of whom were ultimately diagnosed with ACS. Within 30 days, 56 (7.7%) of the remaining 729 patients had ED visits or hospitalization for any reason, 2 (0.2%) of whom received a diagnosis of ACS. Overall, 673 (83.9%) patients were managed without any ED visit. No serious AEs were recorded.

Conclusions: Our initial pilot data demonstrate the feasibility of an outpatient UCC evaluation for ACS without refuting the underlying premise of safety.

Am J Manag Care. 2019;25(5):e160-e164
Takeaway Points

Adverse events (AEs) during emergency department (ED) evaluation for rule-out acute coronary syndrome (ACS) are exceedingly rare, suggesting that the assumed necessity of ED resources may be questioned. We designed and implemented a formal protocol based on the HEART (History, ECG [electrocardiogram], Age, Risk factors, and Troponin) score and point-of-care troponin testing for evaluation of potential ACS in our outpatient urgent care center (UCC) settings. In a pilot evaluation of 802 consecutive low-risk patients, 84% avoided any ED evaluation within 30 days and none suffered serious AEs.
  • Existing evidence suggests that most patients undergoing evaluation for ACS are at low risk for AEs.
  • Risk stratification and point-of-care biomarker testing is feasible in an outpatient UCC setting.
  • Most patients reviewed in this cohort safely avoided evaluation in our EDs, representing savings to our healthcare organization and of patients’ out-of-pocket costs.
Chest pain is among the most common presenting complaints to the emergency department (ED), estimated to account for 5% to 7% of all visits in the United States.1 The total annualized cost of these visits represents a substantial financial burden, approaching $7 billion, the largest cumulative cost of any ED diagnosis.2 However, the benefit and value of routine referral to an ED setting for evaluation of chest pain, along with its associated higher healthcare costs, are unclear. The preponderance of evidence suggests low rates of life-threatening arrhythmia or serious events in most patients being evaluated for chest pain in the ED or during inpatient hospitalization.3-8 In particular, these data support the practice standards in which patients with chest pain who are at low risk for acute coronary syndrome (ACS) do not require continuous telemetry during evaluation.9 The logical extension of these data and recommendations further suggests that the infrastructure associated with an acute care facility is not routinely necessary to evaluate patients at low risk for ACS.

The ED at Kaiser Permanente Northwest (KPNW) currently implements a protocol for the rapid evaluation and discharge of low-risk chest pain based on the History, ECG (electrocardiogram), Age, Risk factors, and Troponin (HEART) score.10,11 Based on positive local and systemwide experience with the HEART score,12 elements of this ED protocol were adapted to our outpatient setting, starting with our urgent care centers (UCCs). Patients meeting low-risk criteria by HEART score were able to receive complete evaluation in the UCC, and health plan members calling the nurse advice line were explicitly directed to UCCs rather than the ED. Implementation of this protocol was followed by ongoing institutional quality assurance evaluation. Our goals for evaluation of our pilot phase were to measure downstream outcomes and resource utilization and detect adverse events (AEs).

METHODS

Study Design

This descriptive study details the results of the pilot phase of our UCC protocol. We conducted a retrospective cohort review of patients captured by our UCC testing protocol during a 4.5-month period between July 2017 and November 2017. This study was reviewed by the KPNW Institutional Review Board and determined to be exempt from oversight as relating to continuous quality improvement.

Study Setting

Our regional integrated health system has 2 inpatient hospital acute care facilities, 4 urgent care facilities, and approximately 600,000 members. This pilot phase involved implementation of the outpatient protocol at our UCCs. These facilities lack telemetry monitoring and are staffed by primary and urgent care physicians, physician assistants, and nurse practitioners. Each facility is capable of recording and interpreting an ECG, is equipped with a small laboratory, and transfers patients to a higher level of care when deemed medically necessary.

Study Procedures

Patients presenting with symptoms attributable to potential ACS were deemed appropriate for entry into the UCC protocol at one of our urgent care facilities if they met the following criteria: (1) clinically well on subjective assessment, (2) onset of most recent episode of symptoms associated with potential ACS greater than 4 hours prior to presentation, (3) absence of acute ischemia on ECG, and (4) a HEART score prior to obtaining a troponin test result of 3 or lower. Typical patients who would not be considered “clinically well,” and thus would be referred immediately to the ED, included those with active chest pain, hypoxia, clinically important arrhythmias, or dyspnea at rest. A pretroponin HEART score was used under the assumption that a patient with a score of 0 for their troponin would then be eligible for discharge directly from the UCC setting. Patients not meeting these criteria were to be referred to the ED.

When it was necessary to perform a troponin test, the UCC staff utilized the local laboratory’s iStat device with a cTnI (cardiac troponin I) cartridge (Abbott Diagnostics; Abbott Park, Illinois); this assay is not considered to be highly sensitive. The threshold for a clinically positive result was considered to be greater than or equal to 0.033 ng/mL.

All other contemporaneous testing was ordered at the discretion of the treating provider, as was subsequent referral to the ED.


 
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