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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
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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
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Michael Adelberg, MA, MPP; Austin Frakt, PhD; Daniel Polsky, PhD; and Michelle Kitchman Strollo, DrPH, MHS
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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
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Leah L. Zullig, PhD; Bradi B. Granger, PhD; Helene Vilme, DrPH; Megan M. Oakes, MPA; and Hayden B. Bosworth, PhD
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Maria de Jesus Diaz-Perez, PhD; Rita Hanover, PhD; Emilie Sites, MPH; Doug Rupp, BS; Jim Courtemanche, MS; and Emily Levi, MPH
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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
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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.
DISCUSSION

We performed a retrospective analysis of a pilot UCC outpatient protocol for the unmonitored evaluation of patients presenting with potential ACS. To our knowledge, this represents the first formal review of such a protocol. Triage protocols for point-of-care or protocolized testing of patients presenting with potential ACS are common as interventions targeting patient throughput, but any unmonitored waiting room time is not by explicit design.13,14 This unmonitored empiric testing occurs as a pragmatic response to inadequate resource availability. Similar logistics are encountered at our institution, and our novel intervention aims to relieve crowding burdens on our EDs while retaining standards of quality and safety. This also has secondary effects on avoidable resource utilization for the health system and of both timeliness and out-of-pocket costs for patients.

No serious events were detected or reported upon review. This is not unexpected, however, considering that the rate of serious events in low-risk patients hospitalized for the evaluation of chest pain has been reported to be as low as 0.18% by Weinstock et al.8 In their study, of the cases reviewed, none of 7266 patients with normal ECGs and normal vital signs sustained cardiac AEs unless triggered by iatrogenic intervention. This study was not powered or intended to validate the prognostic value of the HEART score, but our observed 1.5% prevalence of ACS within 30 days is similar to that expected for those in a chest pain cohort at low risk for ACS.15

In the 10 patients with ACS whose evaluation was initiated at the UCC, all had NSTEMI and underwent early invasive strategies for management. An initial evaluation in UCC introduces delays to definitive diagnosis, including potential harms. No specific harms were identified in our limited cohort.

Continuous quality improvement review for protocol violations was part of this effort, as evaluation of non–low-risk patients increases the likelihood of AEs. For example, if a patient with active chest pain were incorrectly referred to the UCC, this could result in clinically important delays in care if the patient in question were suffering a STEMI. Although this did not occur during our pilot, we did incidentally encounter protocol violations during medical record review, most involving troponin testing in patients with HEART scores greater than 3. These findings inform future individual provider education and quality improvement efforts.

Overall, 673 of 802 (83.9%) patients were successfully managed in the UCC setting with point-of-care troponin testing without ED referral or 30-day recidivism. Prior to implementation of this protocol, all patients in the UCC who were judged to require evaluation for potential ACS would have been transferred via emergency medical services to the ED for evaluation. No reliable data quantifying the cost reduction of this initiative could be obtained, but it is reasonable to suggest that redirecting even a small portion of our national ED burden to outpatient settings might represent a significant reduction in healthcare expenditures.

Limitations

Our study has many limitations. Although the roll-out of this protocol was closely followed by key administrative leaders, no formal process for submitting safety events or concerns was present. Our integrated health system and EHR typically capture documentation relating to serious events and emergency response to UCCs, but it is still possible that an undocumented safety event was missed. Although 90% of our study population were members of our health plan with reliable 30-day follow-up data, undetected events may have occurred in the remaining 10% whose insurance status was out-of-network or unknown. Given the frequency of expected events overall, the risk of missed adverse outcomes is likely low.

Clinicians had complete individual discretion to include patients in the protocol or to refer them directly to the ED, and this subjectivity at entry introduces a selection bias. HEART score elements abstracted from the medical record may be imprecise due to their dependence on the accuracy of the problem list in structured data. Additional study is necessary to fully quantify a reduction in ED evaluations, as some of the UCC troponin testing may represent “indication creep” resulting from its availability, rather than actual avoided ED referrals. Furthermore, this indication creep may also contribute to the apparent safety profile of this protocol, as the availability of the test may encourage an excess of evaluations in a very low-risk population. Many cases individually reviewed were referred to the ED for further evaluation of other diagnoses, as evidenced by the diversity of final diagnoses in Table 3, suggesting that ACS was not always the most relevant concern. Finally, our results are not generalizable to a setting in which patients with chest pain are not routinely discharged from the ED, as this would likely preclude patients being discharged directly from an UCC setting. Furthermore, it is unclear how these protocols would integrate into a setting in which routine cardiac stress, functional, or anatomic testing occurs in low-risk patients presenting with potential ACS. In our health system, urgent follow-up for stress testing is rare and typically left to the discretion of our primary care providers per routine.

Qualitatively, the implementation of this protocol has been acceptable to clinicians practicing in the UCCs. Initial concerns regarding its roll-out stemmed primarily from concerns regarding lack of monitoring and clinical supervision of patients undergoing evaluation. These were addressed initially with education and subsequently by feedback regarding the ongoing safety monitoring relating to this pilot. Future steps include roll-out to additional primary care locations, along with potentially raising the HEART score threshold for UCC to 5.12

CONCLUSIONS

We successfully implemented a pilot protocol for UCC evaluation of ACS. Our early results do not refute the underlying premise of safety. Substantial potential healthcare system cost savings may result from moving the evaluation of patients at low risk for ACS to an outpatient, nonhospital venue.

Author Affiliations: Kaiser Permanente Northwest (RPR, KFF, TSE, CPH, TEG, HMP, AJM, NRH, BLE-B), Portland, OR.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RPR, KFF, CPH, HMP, AJM, NRH, BLE-B); acquisition of data (KFF, TSE, TEG, HMP, BLE-B); analysis and interpretation of data (RPR, TEG, AJM, NRH, BLE-B); drafting of the manuscript (RPR, KFF); critical revision of the manuscript for important intellectual content (RPR, BLE-B); statistical analysis (RPR, KFF, CPH, TEG); provision of patients or study materials (TSE); administrative, technical, or logistic support (TSE, CPH, HMP, AJM, NRH, BLE-B); project management support (NRH); and supervision (TSE, CPH, HMP, BLE-B).

Address Correspondence to: Ryan P. Radecki, MD, MS, Kaiser Permanente Northwest, 500 N Multnomah Ave, Portland, OR 97232. Email: ryan.p.radecki@kp.org.
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