Incorporation of the HEART Score Into a Low-risk Chest Pain Pathway to Safely Decrease Admissions.

Chest pain can be a challenging complaint to manage in the emergency department. A missed diagnosis can result in significant morbidity or mortality, whereas avoidable testing and hospitalizations can lead to increased health care costs, contribute to hospital crowding, and increase risks to patients. The HEART score is a validated decision aid to identify patients at low risk for acute coronary syndrome who can be safely discharged without admission or objective cardiac testing. In the largest and one of the longest studies to date (N = 31,060; 30 months), we included the HEART score into a larger, newly developed low-risk chest pain decision pathway, using a retrospective observational pre/post study design with the objective of safely lowering admissions. The modified HEART score calculation tool was incorporated in our electronic medical record. A significant increase in discharges of low-risk chest pain patients (relative increase of 21%; p < 0.0001) in the postimplementation period was observed with no significant difference in the rates of major adverse cardiac events between the pre and post periods. There was a decrease in the amount of return admissions for 30 days (4.65% fewer; p = 0.009) and 60 days (3.78% fewer; p = 0.020). No significant difference in length of stay was observed for patients who were ultimately discharged. A 64% decrease in monthly coronary computed tomography angiograms was observed in the post period (p < 0.0001). These findings support the growing consensus in the literature that the adoption of the HEART pathway or similar protocols in emergency departments, including at large and high-volume medical institutions, can substantially benefit patient care and reduce associated health care costs.

Variation in outpatient emergency department utilization in Texas Medicaid: a state-level framework for finding "superutilizers".

BACKGROUND: Very frequent outpatient emergency department (ED) use-so called "superutilization"-at the state level is not well-studied. To address this gap, we examined frequent ED utilization in the largest state Medicaid population to date. METHODS: Using Texas Medicaid (the third largest in the USA) claims data, we examined the variability in expenditures, sociodemographics, comorbidities, and persistence across seven levels of ED utilization/year (i.e., 1, 2, 3-4, 5-6, 7-9, 10-14, and ≥ 15 visits). We classified visits into emergent and non-emergent categories using the most recent New York University algorithm. RESULTS: Thirty-one percent (n = 346,651) of Texas Medicaid adult enrollees visited the ED at least once in 2014. Enrollees with ≥ 3 ED visits accounted for 8.5% of all adult patients, 60.4% of the total ED visits, and 62.1% of the total ED expenditures. Extremely frequent ED users (≥ 10 ED visits) represented < 1% of all users but accounted for 15.5% of all ED visits and 17.4% of the total ED costs. The proportions of ED visits classified as non-emergent or emergent, but primary care treatable varied little as ED visits increased. Overall, approximately 13% of ED visits were considered not preventable or avoidable. CONCLUSIONS: The Texas Medicaid population has a substantial burden of chronic disease with only modest increases in substance use and mental health diagnoses as annual visits increase. Understanding the characteristics that lead to frequent ED use is vital to developing strategies and Medicaid policy to reduce high utilization.