SAN DIEGO – After implementation of a new chest pain protocol in the emergency department, a greater proportion of patients with low-risk chest pain were discharged, yet a higher rate of ED recidivism was observed, results from a single-center study in Detroit showed.
Eric M. Blake
While the precise cause of this finding is unclear, it may stem from factors affecting socioeconomically disadvantaged populations, Eric M. Blake, one of the study authors, said at the annual meeting of the American College of Emergency Physicians. “Recurrent ED visits are associated with social determinants of health, including race and economic status,” said Mr. Blake, a second-year student at Wayne State University School of Medicine, Detroit. “Socioeconomically disadvantaged patients often lack the transportation and monetary resources to follow up at an outpatient clinic. Detroit is an example of this type of a community; 83% of our population is African American, 36% of people live below the poverty line, and Detroit has an illiteracy rate of 47% in its adult population.”
He and his colleagues hypothesized that implementation of a standardized chest pain protocol in Detroit Receiving Hospital would safely reduce the number of hospital inpatient admissions and ED recidivism rates. Implemented on Nov. 1, 2012, the protocol uses the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography, and contemporary sensitivity troponin I to triage patients into low-, intermediate-, and high-risk categories. Low-risk patients were discharged and asked to follow up with a cardiologist within 48 hours. For the current study, the researchers retrospectively analyzed patients older than age 18 who presented with low-risk chest pain in the six months before the protocol was implemented and six months after.
A total of 3,613 patients were studied: 1,837 in the pre-protocol group and 1,776 in the post-protocol group. Their mean age was 47 years, 82% were African American, and 53% were male. No differences were observed between the pre- and post-protocol groups in terms of race (P = .280) or sex (P = .497). There was no statistical difference in the proportion of patients deemed at low risk in the pre- vs. post-protocol periods (P = .167). Significantly more low-risk patients were discharged in the post-protocol group, , compared with the pre-protocol group (55% vs. 44%; P less than .001), however. ED recidivism was also significantly greater in the post-protocol vs. pre-protocol group (3% vs. 1.6%; P = .0035).
“These findings may reflect an embedded racial mistrust of the medical system by certain minority groups,” Mr. Blake said. “Due to an extensive history of racism and segregation, a community like Detroit may have reservations when it comes to medical follow-up at outpatient clinics. Difficulty assessing outpatient follow-up for a variety of logistical and monetary reasons common among underprivileged communities may also be reflected in the increased recidivism rates.”
He concluded that administrators and clinicians in EDs nationwide “need to better understand the needs of underprivileged patients. A reduction in resource expenditures when a patient is discharged must be balanced with the cost of a recidivism in vulnerable populations like Detroit.”
To address poor cardiac outpatient follow-up rates, he and his colleagues are conducting a prospective randomized controlled trial investigating the use of motivational interviewing techniques with these patients.
The study’s senior author was Vijaya “Arun” Kumar, MD of Wayne State University School of Medicine. Mr. Blake reported having no financial disclosures.
SOURCE: Kumar VA et al. Ann Emerg Med. 2018 Oct;72;4:S117-18. doi. 10.1016/j.annemergmed.2018.08.304.