Stress Cardiac Magnetic Resonance Imaging With Observation Unit Care Reduces Cost for Patients With Emergent Chest Pain: A Randomized Trial
Study objective
We determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy.
Methods
Emergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups.
Results
There were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate $588; 95% confidence interval $336 to $811); 79% were managed without hospital admission.
Conclusion
Compared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain.
Provide feedback on this article at the journal's Web site, www.annemergmed.com.
Please see page 210 for the Editor's Capsule Summary of this article.
Dr. Hwang is now affiliated with Penn State Hershey College of Medicine, Hershey, PA.
Supervising editor: Judd E. Hollander, MD
Author contributions: CDM, WH, JWH, DC, CAH, and WGH were responsible for conceiving and designing the study. CDM and WGH obtained research funding. CDM supervised the conduct of the trial. HB was the study safety monitor and analyzed and interpreted events. Data acquisition was performed by CDM, JWH, CL, and ENH. Data analysis was performed by CDM and DC. Data interpretation was performed by all authors. BH and DBD analyzed, interpreted, and adjudicated clinical endpoints. CDM drafted the article. All authors revised it critically for important intellectual content and granted final approval of the article. CDM takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Funded by the Translational Science Institute of Wake Forest University School of Medicine. Dr. Miller has received research support from Biosite, Schering-Plough, Siemens, and Heartscape Technologies Inc; has been a consultant for Molecular Insight and the Medicines Co; and has been a speaker for Sanofi-Aventis (indirect sponsor of a CME event). Dr. Lefebvre has received research support from Heartscape Technologies Inc.
Reprints not available from the authors.
Publication date: Available online May 31, 2010.
PII: S0196-0644(10)00375-6
doi:10.1016/j.annemergmed.2010.04.009
© 2010 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
