The HAS-Choice study: Utilizing the HEART score, an ADP, and shared decision-making to decrease admissions in chest pain patients

Gafni-Pappas, Gregory; DeMeester, Susanne; Boyd, Michael; Ganti, Arun; Nicholson, Adam M.; Albright, Jeremy J.; Wu, Juan

doi:10.1016/j.ajem.2018.02.005

Cited by 9 publications

(22 citation statements)

References 24 publications

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“…Although the HEART Pathway recommends that most older adults be admitted, shared decision making can still play an important role in guiding disposition. [41][42][43] Among older adults in the post-implementation cohort, less than 2.5% experienced non-index death or MI during the 30-day follow-up period. While this is above the 1% miss rate that most emergency providers accept, some older adults may find this level of risk acceptable and prefer discharge with outpatient management.…”

Section: Discussionmentioning

confidence: 99%

Age differences in the safety and effectiveness of the HEART Pathway accelerated diagnostic protocol for acute chest pain

Ashburn

Snavely

Paradee

et al. 2022

J American Geriatrics Society

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Background: The HEART Pathway is a validated protocol for risk stratifying emergency department (ED) patients with possible acute coronary syndrome (ACS). Its performance in different age groups is unknown. The objective of this study is to evaluate its safety and effectiveness among older adults. Methods: A pre-planned subgroup analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time series accrued adult ED patients with possible ACS who were without ST-elevation across three US sites from 11/2013–01/2016. After implementation, providers prospectively used the HEART Pathway to stratify patients as low-risk or non-low-risk. Patients were classified as older adults (≥65 years), middle-aged (46–64 years), and young (21–45 years). Primary safety and effectiveness outcomes were 30-day death or MI and hospitalization at 30 days, determined from health records, insurance claims, and death index data. Fisher’s exact test compared low-risk proportions between groups. Sensitivity for 30-day death or MI and adjusted odds ratios (aORs) for hospitalization and objective cardiac testing were calculated. Results: The HEART Pathway implementation study accrued 8474 patients, of which 26.9% (2281/8474) were older adults, 45.5% (3862/8474) middle-aged, and 27.5% (2331/8474) were young. The HEART Pathway identified 7.4% (97/1303) of older adults, 32.0% (683/2131) of middle-aged, and 51.4% (681/1326) of young patients as low-risk ( p < 0.001). The HEART Pathway was 98.8% (95% CI 97.1–100) sensitive for 30-day death or MI among older adults. Following implementation, the rate of 30-day hospitalization was similar among older adults (aOR 1.25, 95% CI 1.00–1.55) and cardiac testing increased (aOR 1.25, 95% CI 1.04–1.51). Conclusion: The HEART Pathway identified fewer older adults as low-risk and did not decrease hospitalizations in this age group.

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Section: Discussionmentioning

confidence: 99%

Age differences in the safety and effectiveness of the HEART Pathway accelerated diagnostic protocol for acute chest pain

Ashburn

Snavely

Paradee

et al. 2022

J American Geriatrics Society

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“…The development of a shared decision-making tool to facilitate patient-provider communication, such as has been demonstrated effective in reducing low value workups for low-risk chest pain in the ED, could enable clarification of the patient's actual expectations (if any) while educating them about their individual risk and the providers level of diagnostic certainty (or lack thereof). 37,38 Barriers related to the external environment need to be addressed at a healthcare-system level. For instance, providers often 'lower the bar' to treat patients who have known difficulties with access to follow-up care.…”

Section: Discussionmentioning

confidence: 99%

Characterizing barriers to antibiotic stewardship for skin and soft-tissue infections in the emergency department using a systems engineering framework

Pulia

Schwei

Hesse

et al. 2022

ASHE

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Objective: Skin and soft-tissue infections (SSTIs) account for 3% of all emergency department (ED) encounters and are frequently associated with inappropriate antibiotic prescribing. We characterized barriers and facilitators to optimal antibiotic use for SSTIs in the ED using a systems engineering framework and matched them with targeted stewardship interventions. Design and participants: We conducted semistructured interviews with a purposefully selected sample of emergency physicians. Methods: An interview guide was developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Interviews were recorded, transcribed, and analyzed iteratively until conceptual saturation was achieved. Themes were identified using deductive directed content analysis guided by the SEIPS model. Results: We conducted 20 interviews with physicians of varying experience and from different practice settings. Identified barriers to optimal antibiotic prescribing for SSTIs included poor access to follow-up (organization), need for definitive diagnostic tools (tools and technology) and fear over adverse outcomes related to missed infections (person). Identified potential interventions included programs to enhance follow-up care; diagnostic aides (eg, rapid MRSA assays for purulent infections and surface thermal imaging for cellulitis); and shared decision-making tools. Conclusions: Using a systems engineering informed qualitative approach, we successfully characterized barriers and developed targeted antibiotic stewardship interventions for SSTIs managed in the ED work system. The interventions span multiple components of the ED work system and should inform future efforts to improve antibiotic stewardship for SSTIs in this challenging care setting.

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“…Therefore, it is recommended that such patients can be safely discharged from ED. Previous studies found that hospital admissions have been reduced by greater than 15% using the HEART score without increasing MACE among ED chest pain patients [ 6 , 7 ]. On the other hand, chest pain patients who were considered high-risk ACS due to higher HEART scores were admitted to the hospitals.…”

Section: Introductionmentioning

confidence: 99%

Using HEART2 score to risk stratify chest pain patients in the Emergency Department: an observational study

Schrader

Kumar

Zhou

et al. 2022

BMC Cardiovasc Disord

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Background A significant number of chest pain patients had previous cardiac imaging tests (CIT) performed before being presented to the Emergency Department (ED). The HEART (history, electrocardiogram, age, risk factors, and troponin) score has been used to risk-stratify chest pain patients in the ED, but not particularly for patients with CIT performed. We aim to modify the current HEART score with the addition of most recent CIT findings (referred to as HEART2 score), to predict a 30-day major adverse cardiac event (MACE) among ED chest pain patients, compare the performance accuracy of using HEART versus HEART2 score for 30-day MACE outcome predictions, and further determine the value of HEART2 in a subset group of ED chest pain patients (i.e., ones with previous CIT). Methods This is a single-center observational study. We included chest pain patients with HEART scores calculated during their index ED visits. A modified HEART2 score was developed with the addition of CIT findings as one of the HEART2 components. Patients were divided into three groups, including low (≤ 3), moderate (4–6), and high-risk HEART/HEART2 scores (≥ 7). MACE occurrence of a patient with different risks of HEART and HEART2 scores and overall performance accuracy of HEART versus HEART2 score predicting MACE outcomes were compared. Results We included a total of 9419 chest pain patients at ED, among which one out of five patients (1874/9419) had previous CIT performed. Fewer (38.2%) of such patients had low-risk HEART scores in comparison to 55.5% of low-risk HEART2 scores (p < 0.001). The MACE outcomes were similar in low-risk HEART patients compared with low-risk HEART2 patients (2.2% versus 3.1%, p = 0.3021). The overall performance accuracy of using the HEART2 score to stratify chest pain patients with previous CIT was better than using the HEART score’s (AUC 0.74 versus 0.71, p = 0.0082). Conclusions Using the HEART2 score might be suitable to stratify low-to-moderate risk chest pain patients at ED with a similar 30-days MACE occurrence compared to the HEART score. More importantly, with the use of similar low-risk criteria (HEART2 ≤ 3), over 45% more chest pain patients with previous CIT performed could be discharged directly from ED.

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The HAS-Choice study: Utilizing the HEART score, an ADP, and shared decision-making to decrease admissions in chest pain patients

Cited by 9 publications

References 24 publications

Age differences in the safety and effectiveness of the HEART Pathway accelerated diagnostic protocol for acute chest pain

Age differences in the safety and effectiveness of the HEART Pathway accelerated diagnostic protocol for acute chest pain

Characterizing barriers to antibiotic stewardship for skin and soft-tissue infections in the emergency department using a systems engineering framework

Using HEART2 score to risk stratify chest pain patients in the Emergency Department: an observational study

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