scholarly journals Cost conscious care: preoperative evaluation by a cardiologist prior to low-risk procedures

2019 ◽  
Vol 8 (2) ◽  
pp. e000481 ◽  
Author(s):  
Joseph Coffman ◽  
Thanh Tran ◽  
Troy Quast ◽  
Michael S Berlowitz ◽  
Sanders H Chae
Keyword(s):  
Length Of Stay ◽  
Statistical Significance ◽  
Preoperative Evaluation ◽  
Low Risk ◽  
Linear Regression Models ◽  
Cardiac Events ◽  
Preoperative Testing ◽  
Statistical Significance Testing ◽  
Adverse Cardiac Events ◽  
And Gender

BackgroundPreoperative testing before low-risk procedures remains overutilised. Few studies have looked at factors leading to increased testing. We hypothesised that consultation to a cardiologist prior to a low-risk procedure leads to increased cardiac testing.Methods and results907 consecutive patients who underwent inpatient endoscopy/colonoscopy at a single academic centre were identified. Of those patients, 79 patients (8.7%) received preoperative consultation from a board certified cardiologist. 158 control patients who did not receive consultation from a cardiologist were matched by age and gender. Clinical and financial data were obtained from chart review and hospital billing. Logistic and linear regression models were constructed to compare the groups. Patients evaluated by a cardiologist were more likely to receive preoperative testing than patients who did not undergo evaluation with a cardiologist (OR 47.5, (95% CI 6.49 to 347.65). Specifically, patients seen by a cardiologist received more echocardiograms (60.8% vs 22.2%, p<0.0001) and 12-lead electrocardiograms (98.7% vs 54.4%, p<0.0001). There was a higher rate of ischaemic evaluations in the group evaluated by a cardiologist, but those differences did not achieve statistical significance. Testing led to longer length of stay (4.35 vs 3.46 days, p=0.0032) in the cohort evaluated by a cardiologist driven primarily by delay to procedure of 0.76 days (3.14 vs 2.38 days, p=0.001). Estimated costs resulting from the longer length of stay and increased testing was $10 624 per patient. There were zero major adverse cardiac events in either group.ConclusionPreoperative consultation to a cardiologist before a low-risk procedure is associated with more preoperative testing. This preoperative testing increases length of stay and cost without affecting outcomes.

scholarly journals Development of an ensemble machine learning prognostic model to predict 60-day risk of major adverse cardiac events in adults with chest pain

2021 ◽  
Author(s):  
Chris J. Kennedy ◽  
Dustin G. Mark ◽  
Jie Huang ◽  
Mark J. van der Laan ◽  
Alan E. Hubbard ◽  
...  
Keyword(s):  
Machine Learning ◽  
Logistic Regression ◽  
Chest Pain ◽  
Random Forest ◽  
Decision Trees ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Risk Scores ◽  
Cardiac Events ◽  
Adverse Cardiac Events

Background: Chest pain is the second leading reason for emergency department (ED) visits and is commonly identified as a leading driver of low-value health care. Accurate identification of patients at low risk of major adverse cardiac events (MACE) is important to improve resource allocation and reduce over-treatment. Objectives: We sought to assess machine learning (ML) methods and electronic health record (EHR) covariate collection for MACE prediction. We aimed to maximize the pool of low-risk patients that are accurately predicted to have less than 0.5% MACE risk and may be eligible for reduced testing. Population Studied: 116,764 adult patients presenting with chest pain in the ED and evaluated for potential acute coronary syndrome (ACS). 60-day MACE rate was 1.9%. Methods: We evaluated ML algorithms (lasso, splines, random forest, extreme gradient boosting, Bayesian additive regression trees) and SuperLearner stacked ensembling. We tuned ML hyperparameters through nested ensembling, and imputed missing values with generalized low-rank models (GLRM). We benchmarked performance to key biomarkers, validated clinical risk scores, decision trees, and logistic regression. We explained the models through variable importance ranking and accumulated local effect visualization. Results: The best discrimination (area under the precision-recall [PR-AUC] and receiver operating characteristic [ROC-AUC] curves) was provided by SuperLearner ensembling (0.148, 0.867), followed by random forest (0.146, 0.862). Logistic regression (0.120, 0.842) and decision trees (0.094, 0.805) exhibited worse discrimination, as did risk scores [HEART (0.064, 0.765), EDACS (0.046, 0.733)] and biomarkers [serum troponin level (0.064, 0.708), electrocardiography (0.047, 0.686)]. The ensemble's risk estimates were miscalibrated by 0.2 percentage points. The ensemble accurately identified 50% of patients to be below a 0.5% 60-day MACE risk threshold. The most important predictors were age, peak troponin, HEART score, EDACS score, and electrocardiogram. GLRM imputation achieved 90% reduction in root mean-squared error compared to median-mode imputation. Conclusion: Use of ML algorithms, combined with broad predictor sets, improved MACE risk prediction compared to simpler alternatives, while providing calibrated predictions and interpretability. Standard risk scores may neglect important health information available in other characteristics and combined in nuanced ways via ML.

Identifying low-risk chest pain in the emergency department without troponin testing: a validation study of the HE-MACS and HEAR risk scores

2021 ◽  
pp. emermed-2021-211669
Author(s):  
Fraser Todd ◽  
James Duff ◽  
Edward Carlton
Keyword(s):  
Risk Factors ◽  
Chest Pain ◽  
Limit Of Detection ◽  
Controlled Trial ◽  
Statistical Significance ◽  
Low Risk ◽  
Risk Scores ◽  
Cardiac Events ◽  
Presenting Symptoms ◽  
Randomised Controlled

IntroductionPatients presenting to EDs with chest pain of possible cardiac origin represent a substantial and challenging cohort to risk stratify. Scores such as HE-MACS (History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid) and HEAR (History, ECG, Age, Risk factors) have been developed to stratify risk without the need for troponin testing. Validation of these scores remains limited.MethodsWe performed a post hoc analysis of the Limit of Detection and ECG discharge strategy randomised-controlled trial dataset (n=629; June 2018 to March 2019; 8 UK hospitals) to calculate HEAR and HE-MACS scores. A <4% risk of major adverse cardiac events (MACE) at 30 days using HE-MACS and a score of <2 calculated using HEAR defined ‘very low risk’ patients suitable for discharge. The primary outcome of MACE at 30 days was used to assess diagnostic accuracy.ResultsMACE within 30 days occurred in 42/629 (7%) of the cohort. HE-MACS and HEAR scores identified 85/629 and 181/629 patients as ‘very low risk’, with MACE occurring in 0/85 and 1/181 patients, respectively. The sensitivities of each score for ruling out MACE were 100% (95% CI: 91.6% to 100%) for HE-MACS and 97.6% (95% CI: 87.7% to 99.9%) for HEAR. Presenting symptoms within these scores were poorly predictive, with only diaphoresis reaching statistical significance (OR: 4.99 (2.33 to 10.67)). Conventional cardiovascular risk factors and clinician suspicion were related to the presence of MACE at 30 days.ConclusionHEAR and HE-MACS show potential as rule out tools for acute myocardial infarction without the need for troponin testing. However, prospective studies are required to further validate these scores.

scholarly journals Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events

2018 ◽  
Vol 33 (1) ◽  
pp. 58-62 ◽  
Author(s):  
Jason P. Stopyra ◽  
William S. Harper ◽  
Tyson J. Higgins ◽  
Julia V. Prokesova ◽  
James E. Winslow ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Chest Pain ◽  
Decision Aid ◽  
Care Center ◽  
Tertiary Care ◽  
Low Risk ◽  
Cardiac Events ◽  
Predictive Values ◽  
Heart Score ◽  
Adverse Cardiac Events

AbstractIntroductionThe History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.HypothesisA prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.MethodsA retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.ResultsOver the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.ConclusionsPrehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.StopyraJP, HarperWS, HigginsTJ, ProkesovaJV, WinslowJE, NelsonRD, AlsonRL, DavisCA, RussellGB, MillerCD, MahlerSA. Prehospital modified HEART score predictive of 30-day adverse cardiac events. Prehosp Disaster Med. 2018;33(1):58–62.

scholarly journals The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis

2017 ◽  
Vol 7 (2) ◽  
pp. 111-119 ◽  
Author(s):  
Patricia Van Den Berg ◽  
Richard Body
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Diagnostic Accuracy ◽  
Meta Analysis ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Current Evidence ◽  
Cardiac Events ◽  
Heart Score ◽  
Adverse Cardiac Events

Aims: The objective of this systematic review was to summarise the current evidence on the diagnostic accuracy of the HEART score for predicting major adverse cardiac events in patients presenting with undifferentiated chest pain to the emergency department. Methods and results: Two investigators independently searched Medline, Embase and Cochrane databases between 2008 and May 2016 identifying eligible studies providing diagnostic accuracy data on the HEART score for predicting major adverse cardiac events as the primary outcome. For the 12 studies meeting inclusion criteria, study characteristics and diagnostic accuracy measures were systematically extracted and study quality assessed using the QUADAS-2 tool. After quality assessment, nine studies including data from 11,217 patients were combined in the meta-analysis applying a generalised linear mixed model approach with random effects assumption (Stata 13.1). In total, 15.4% of patients (range 7.3–29.1%) developed major adverse cardiac events after a mean of 6 weeks’ follow-up. Among patients categorised as ‘low risk’ and suitable for early discharge (HEART score 0–3), the pooled incidence of ‘missed’ major adverse cardiac events was 1.6%. The pooled sensitivity and specificity of the HEART score for predicting major adverse cardiac events were 96.7% (95% confidence interval (CI) 94.0–98.2%) and 47.0% (95% CI 41.0–53.5%), respectively. Conclusions: Patients with a HEART score of 0–3 are at low risk of incident major adverse cardiac events. As 3.3% of patients with major adverse cardiac events are ‘missed’ by the HEART score, clinicians must ask whether this risk is acceptably low for clinical implementation.

scholarly journals Can the HEART Score Safely Reduce Stress Testing and Cardiac Imaging in Patients at Low Risk for Major Adverse Cardiac Events?

2011 ◽  
Vol 10 (3) ◽  
pp. 128-133 ◽  
Author(s):  
Simon A. Mahler ◽  
Brian C. Hiestand ◽  
David C. Goff ◽  
James W. Hoekstra ◽  
Chadwick D. Miller
Keyword(s):  
Cardiac Imaging ◽  
Stress Testing ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Cardiac Events ◽  
Heart Score ◽  
Adverse Cardiac Events

scholarly journals The barts heart attack centre early discharge pathway:- a novel protocol for next day discharge after primary pci for ST-elevation myocardiai infarction

2021 ◽  
Vol 20 (Supplement_1) ◽  
Author(s):  
K Comer ◽  
O Casey-Gillman ◽  
E Moore ◽  
S Adey ◽  
S Mower
Keyword(s):  
Length Of Stay ◽  
Early Discharge ◽  
Low Risk ◽  
Successful Implementation ◽  
Primary Pci ◽  
Cardiac Events ◽  
Median Length ◽  
Post Discharge ◽  
Group 5

Abstract Funding Acknowledgements Type of funding sources: None. Introduction To respond to the challenges of COVID-19 and based on evidence confirming low rates of Major Adverse Cardiac Events (MACE) occurring between 24- and 48-hours post AMI (Acute Myocardial Infarction), we sought to design and implement a novel Early Hospital Discharge (EHD) pathway Aim The goal of the EHD protocol is to accurately and efficiently identify low-risk AMI patients who can be safely discharged between 24 and 48 hours after successful primary PCI, aiming to provide a  safe discharge for low risk patients, reduce length of stay  enhance the follow up of patients post AMI Methodology : Project was designed a QI project and patients were discharged with a structured follow up at 48 hours , 2 weeks and 8 weeks and with a interventional cardiologist at 3 months  Virtual follow up was conducted using a bespoke application enable a 2 way messaging and video consultation Patients with AMI are taken for primary PCI in an unselected manner which includes post cardiac arrest, intubated and ventilated patients Results :The median follow-up was 201 days (OQR: 98-268 days). In the early discharge group, there were 2 deaths (0.5%), both due to COVID-19 (both &gt;30 days after d/c) with 0% cardiovascular mortality (comparator group 5% mortality, 2.5% cardiovascular  Overall, this resulted in a significant reduction in the overall length of stay for all patients presenting with STEMI undergoing primary PCI over the time period. The median length of stay was 3 days (IQR 2-5 days) from October 2019 to March 2020 before the pathway was introduced. Following the pathway introduction, from April 2020 to February 2021 the median length of stay was 2 days (1-4 days) (p &lt; 0.0001), significantly reduced from pre pathway introduction Conclusion :Driven by the necessity to adapt to the pandemic, we report the safe and successful implementation of an early post MI discharge pathway with an integrated and structural multidisciplinary virtual follow up schedule.  This has shortened hospital admission times, decreasing the risk of nosocomial infections and optimised resource utilization, while at the same time enhancing the quality of post discharge care with high levels of patient satisfaction.

Abstract 13935: Steroids Wean Failures After Heart Transplantation - Does It Lead to Mortality?

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Rafael Skorka ◽  
Keith Nishihara ◽  
Adriana Shen ◽  
Jignesh K Patel ◽  
David H Chang ◽  
...  
Keyword(s):  
Acute Cellular Rejection ◽  
Low Risk ◽  
Cardiac Events ◽  
Lower Survival Rate ◽  
Post Transplant ◽  
Antibody Mediated Rejection ◽  
Corticosteroid Withdrawal ◽  
Adverse Cardiac Events ◽  
Significant Difference ◽  
Cellular Rejection

Introduction: It is estimated that approximately 90% of heart transplant (HTx) patients who are low risk can be weaned off steroids after 6 months post-transplant. However, for those 10% who fail weaning subsequent outcome is not known. There is concern that failure to wean off steroids may lead to subsequent greater morbidity/mortality. Methods: Between 2010 and 2014, 178 HTx patients at low rejection risk were initiated to be weaned off steroids after 6 months post-transplant. Our protocol includes decreasing prednisone by 1mg per month from a baseline of 5mg daily. Monthly heart biopsy or use of Allomap are used to exclude rejection during weaning. 15 patients failed the corticosteroid wean due to either rejection (n=8), abnormal echocardiogram (n=2) or severe corticosteroid withdrawal symptoms (n=5). Study endpoints include subsequent 5-year survival, freedom from cardiac allograft vasculopathy (CAV) and non-fatal major adverse cardiac events (NF-MACE); and 1-year freedom from any treated rejection (ATR), antibody-mediated rejection (AMR), acute cellular rejection (ACR). Results: The failed wean group compared to the successful wean group had a trend for lower subsequent 5-year survival. There was no significant difference between the two groups in subsequent 5-year freedom from CAV or NF-MACE. Subsequent 1 Year freedom all rejection (ATR, ACR, AMR) were significantly lower in the failed steroid wean group compared to the successfully weaned group. Conclusions: HTx patients who are deemed low risk who failed corticosteroid weaning may be at risk to develop more rejection with compromised 5-year outcome, including a possible lower survival rate. It is unclear whether the act of corticosteroid weaning activated a deleterious response in these patients. Caution must be given to those patients who fail corticosteroid weaning.

scholarly journals Determinants of Hospital Costs for Management of Chronic-Disease Patients in Southern Thailand

2021 ◽  
Author(s):  
Wichayaporn Thongpeth ◽  
Apiradee Lim ◽  
Sunee Kraonual ◽  
Akemat Wongpairin ◽  
Thaworn Thongpeth
Keyword(s):  
Chronic Disease ◽  
Length Of Stay ◽  
Diagnosis Related Groups ◽  
Hospital Costs ◽  
Disease Patient ◽  
Tertiary Hospital ◽  
Primary Diagnosis ◽  
Linear Regression Models ◽  
Health Security ◽  
And Gender

Objective: Diagnosis-related groups (DRGs) are the main mechanism for assessing payments for medical treatment. This study aimed to analyze the determinants of costs for chronic-disease patient visits in a major public hospital.Material and Methods: Hospital cost data available from the hospital database relating to claims made to the Thailand Health Security Office were obtained from a major tertiary hospital for all such patients admitted and discharged in 2016. Linear regression models were created to predict the cost based on several determinants including age and gender, primary diagnosis, number of diagnoses, length of stay, number of procedures, and discharge status.Results: Only length of stay in hospital and number of procedures were significant predictors of the total hospital costs.Conclusion: It thus appears that just a combination of these two factors might be a better measure of the true hospital visit costs for patients with chronic disease than DRGs.

scholarly journals Is hydroxychloroquine with macrolide a good combination in COVID-19 compared to hydroxychloroquine alone from cardiac perspective? A systematic review and meta-analysis

2020 ◽  
Author(s):  
Sitaram Khadka ◽  
Pravash Budhathoki ◽  
Dhan Bahadur Shrestha ◽  
Era Rawal
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Statistical Significance ◽  
Cochrane Library ◽  
Cardiac Events ◽  
Level Of Evidence ◽  
Risk Of Mortality ◽  
Adverse Cardiac Events ◽  
Fixed And Random Effects ◽  
Quantitative Synthesis

Abstract Background: The global spread of COVID-19 and the lack of definite treatment has caused an alarming crisis in the world. Hydroxychloroquine (HCQ) and azithromycin (AZT) are considered a possible treatment option. We aimed to evaluate the outcome and potential harmful cardiac effects of AZT+HCQ compared to HCQ alone for COVID-19 treatment.Methods: Pubmed, Medline, Google Scholar, Cochrane Library, and clinicaltrials.gov were searched using appropriate keywords and identified six studies using PRISMA guidelines. The quantitative synthesis was performed using fixed and random effects for the pooling of studies. Result: In this systematic review and meta-analysis, the risk of mortality (RR 1.16; 0.92-1.46) and adverse cardiac events (OR 1.06; 0.82-1.37) demonstrated a small increment though of no significance. There are no increased odds of mechanical ventilation (OR 0.84; 0.33-2.15) and significant QTc prolongation (OR 0.84, 0.59-1.21). Neither the critical QTc threshold (OR 1.92, CI 0.81-4.56) nor absolute ΔQTc ≥60ms (OR 1.95, CI 0.55-6.96) is increased to the level of statistical significance among HCQ+AZT arm compared to HCQ alone; but its slightly increased odds need to be considered in clinical practice. Conclusion: The combination of AZT+HCQ leads to small increased odds of mortality and cardiac events compared to HCQ alone. It is of no statistical significance for the critical QTc threshold and absolute ΔQTc ≥60ms, but increased odds with HCQ+AZT arm need to be considered in clinical relevance. Our result does not guide against the use of combination or HCQ alone based on the present level of evidence.

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