Rationale and design of a cohort study evaluating triage of acute chest pain in out-of-hours primary care in the Netherlands (TRACE)

Abstract

The aims of this study are (1) to evaluate the performance of current triage for chest pain; (2) to describe the case mix of patients undergoing triage for chest pain; and (3) to identify opportunities to improve performance of current Dutch triage system for chest pain. Chest pain is a common symptom, and identifying patients with chest pain that require urgent care can be quite challenging. Making the correct assessment is even harder during telephone triage. Temporal trends show that the referral threshold has lowered over time, resulting in overcrowding of first responders and emergency services. While various stakeholders advocate for a more efficient triage system, careful evaluation of the performance of the current triage in primary care is lacking. TRiage of Acute Chest pain Evaluation in primary care (TRACE) is a large cohort study designed to describe the current Dutch triage system for chest pain and subsequently evaluate triage performance in regard to clinical outcomes. The study consists of consecutive patients who contacted the out-of-hours primary care facility with chest pain in the region of Alkmaar, the Netherlands, in 2017, with follow-up for clinical outcomes out to August 2019. The primary outcome of interest is ‘major event’, which is defined as the occurrence of death from any cause, acute coronary syndrome, urgent coronary revascularization, or other high-risk diagnoses in which delay is inadmissible and hospitalization is necessary. We will evaluate the performance of the triage system by assessing the ability of the triage system to correctly classify patients regarding urgency (accuracy), the proportion of safe actions following triage (safety) as well as rightfully deployed ambulances (efficacy). TRACE is designed to describe the current Dutch triage system for chest pain in primary care and to subsequently evaluate triage performance in regard to clinical outcomes.

Evaluation of telephone triage among chest pain patients in out-of-hours primary care in the Netherlands (TRACE)

“… 16 A detailed description of study design and methods was published previously. 17 In short, we performed an observational, retrospective cohort study of consecutive, adult patients with chest pain who contacted the OOH-PC facility in Alkmaar, the Netherlands, between 1 January and 31 December 2017. At the outset of the TRACE study, eligible patients received information by mail and were provided the opportunity to opt-out of sharing data.…”

Performance of a simplified HEART score and HEART-GP score for evaluating chest pain in urgent primary care

“…We reported this diagnostic accuracy study in accordance with the Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015 statement [ 15 ]. This study protocol was evaluated by our institution’s Medical Ethical Review Committee (TRACE) [ 16 ]. All patients were informed by mail of the conduct of this study and were provided with the opportunity to opt out of sharing data for this study [ 16 ].…”

“…This study protocol was evaluated by our institution’s Medical Ethical Review Committee (TRACE) [ 16 ]. All patients were informed by mail of the conduct of this study and were provided with the opportunity to opt out of sharing data for this study [ 16 ].…”

“…Data were collected and processed using a secure, web-based, electronic data capture platform (Castor EDC, Amsterdam, The Netherlands). Further information on the methodology used for data collection can be found in a methodology paper published previously by our group [ 16 ].…”

Performance of risk scores for coronary artery disease: a retrospective cohort study of patients with chest pain in urgent primary care

“… 6 The study protocol was evaluated by our institution’s Medical Ethical Review Committee, and was granted a waiver because of its observational nature. 7 …”