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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.
Selection of Participants

Patients entering this protocol at a UCC in our system were retrospectively identified via electronic health record (EHR) search. All patients for whom a UCC troponin measurement was collected and successfully evaluated were included in our review.

Data Collection and Processing

Information systems analysts provided authors with EHR data based on the defined selection criteria. Authors were provided with medical record numbers of patients, as well as the date and time of any subsequent ED visits. Authors were also provided with cardiology staff interpretations of the ECGs, which were then classified by 1 author (R.P.R.) as “normal,” “nonspecific repolarization disturbance,” or “significant ST deviation” per HEART score definitions. Aggregate data on the presence of specific comorbid disease were collated from the structured problem list data recorded in the EHR, which was further used to determine HEART score contributions. One author (B.L.E.-B.) performed individual review of all patients with subsequent ED visits in structured format. These subsequent ED presentations were identified either (1) by encounters at 1 of the 2 acute care hospitals in our integrated health system or (2) via the regional Emergency Department Information Exchange (Collective Medical Technologies, Inc; Draper, Utah). Information collated from individual review included ED chief complaint, primary discharge diagnoses, results of troponin testing, and whether the diagnoses constituted ACS.

Outcome Measures

The primary outcome of interest was reduction in ED utilization, measured as any visit to an ED within 30 days of the index visit. These visits were stratified as being within 6 hours of or greater than 6 hours since presentation for the index visit. This dichotomy was created with the intention of capturing transfers directly from the UCC at the index visit in the former, separately from independent presentations in the latter. Secondary outcome measures included cardiac and noncardiac diagnoses assigned at subsequent ED visits or hospitalization. The primary safety outcome of interest was any reported serious event during UCC evaluation of potential ACS. This safety end point was defined as clinical deterioration while present in the UCC, including worsening chest pain symptoms, development of malignant cardiac arrhythmia, receipt of advanced cardiac life support, defibrillation, or death.


During the review period between July 5, 2017, and November 20, 2017, 802 patients were evaluated at a UCC for possible ACS and received point-of-care troponin testing. All patients were included in our analysis. The median age of patients tested was 55 years, with an interquartile range of 45 to 66 years. The gender distribution was 58% female. By race, our population was 68% white, 8% Hispanic, 6% black, 5% Pacific Islander, 1% Asian, and 12% multiple races or unknown. Members of the Kaiser Permanente health plan made up 90% of our sample, with 66% commercial insurance purchasers and 24% Medicare product purchasers. The remaining 10% held out-of-network health insurance or were documented as having an unknown insurance status. No Medicaid patients were included in our study population to our knowledge.

The most common comorbidities in our population were obesity, smoking, and hypertension. The distribution of these features in our population is shown in Table 1. Most patients had normal or nonspecific ECG findings. Individual HEART scores for each patient could not be calculated retrospectively, specifically due to inability to score the History element. An overview of the remainder of the elements of HEART score available at presentation are shown in Table 2.

Of these 802 patients, 73 (9.1%) were referred to or evaluated in the ED within 6 hours of the index visit. Of these, 24 had positive iStat troponin tests in the UCC and 10 ultimately received a diagnosis of ACS following further evaluation. All cases of ACS were type 1 non–ST-segment elevation myocardial infarction (NSTEMI). Examples of non-ACS causes for elevated troponin included tachycardia-related demand ischemia, congestive heart failure, sepsis, and pulmonary embolism. These subsequent primary diagnoses are included in Table 3. The 1 inpatient death in this population resulted from complications following coronary artery bypass grafting (CABG).

Of the remaining 729 patients, 56 (7.6%) were evaluated in the ED within 30 days of a negative UCC evaluation, including assessment for ACS. Two (0.2%) of these patients subsequently had ACS diagnosed. One patient was a 71-year-old male who was evaluated for atypical chest pain and had a negative initial evaluation in the UCC. Thirteen days later, the patient was evaluated for chest pain in the ED, and a quantitative troponin level measured 0.07 ng/mL. He subsequently underwent diagnostic coronary angiography and was referred for CABG. The second patient was a 68-year-old female with chest tightness and body aches who received a negative UCC evaluation and a diagnosis of acute bronchospasm. Two days later, the patient was admitted to the hospital for febrile respiratory illness and contemporaneously found to have a troponin level of 1.83 ng/mL. A nuclear stress test was abnormal, and the patient opted for medical management of presumed ACS. The other primary diagnoses from the subsequent encounters are included in Table 4. No deaths occurred from any cause. No safety events were reported or identified on review.

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