Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.
Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.
J Am Heart Assoc. 2021 Nov 16;10(22):e022539. doi: 10.1161/JAHA.121.022539. Epub 2021 Nov 6.
Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, <0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, =0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, =0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
急诊科（ED）疑似冠心病胸痛患者的资源利用情况差异很大。
这是一项在一个综合性医疗系统的 21 个 ED 中进行的对照队列研究，研究了分级冠状动脉风险分层算法（RISTRA-ACS[急性冠状动脉综合征风险分层]）的实施情况。在 48 个月的研究期间（2016 年 1 月至 2019 年 12 月），24 个月后，有 13 个 ED 可以在电子健康记录（RISTRA 站点）中使用 RISTRA-ACS；其余 8 个 ED 作为同期对照。研究参与者的主要抱怨是胸痛和在 ED 中进行血清肌钙蛋白测量。主要结果是就诊时的资源利用情况（观察单元或住院，或 7 天的客观心脏检查）。次要结果是 30 天的客观心脏检查、60 天的主要不良心脏事件（MACE）和 60 天的 MACE-CR（不包括冠状动脉血运重建的 MACE）。差异-差异分析通过分层估计风险和调整危险因素、ED 医生和设施，控制了季节性趋势。共纳入 154914 次就诊。与对照组相比，RISTRA 站点中低（≤2%）估计 60 天 MACE 风险的患者 30 天客观心脏检查减少（-2.5%，95%CI-3.7 至-1.2%，<0.001），而非低（>2%）估计风险的患者增加（+2.8%，95%CI+0.6 至+4.9%，=0.014），但总体变化无统计学意义（-1.0%，95%CI-2.1 至 0.1%，=0.079）。就诊时的资源利用情况、60 天 MACE 或 60 天 MACE-CR 无统计学差异。
RISTRA-ACS 的实施与更好地分配 30 天客观心脏检查以及就诊时资源利用情况或 60 天 MACE 无变化相关。
