COST-EFFECTIVENESS OF MANDATORY STRESS-TESTING IN CHEST PAIN CENTER PATIENTS

Study objective: To determine whether emergency patients with acute ch est pain and low suspicion of acute myocardial infarction (AMI) can be managed cost-effectively and safely in a dedicated chest pain center (CPC) that incorporates mandatory stress testing. Methods: We assemble d a prospective observational case series of consecutive adult patient s transferred from the emergency department to a nine-bed, 23-hour CPC in a 564-bed community hospital from January 13 through May 31, 1994. In our institution, all emergency patients with acute nontraumatic ch est pain of unclear origin, suggestive of myocardial ischemia but with a low probability of AMI, are transferred to the CPC for further eval uation. All patients in whom AMI is ruled out undergo individually app ropriate cardiac diagnostic testing in accordance with CPC clinical gu idelines. Patients with end-stage coronary artery disease transferred to the CPC for a ''rule-out'' protocol only did not undergo further di agnostic testing. Admitted and discharged patients were followed throu gh chart review and telephone survey, respectively. Results: Of the 50 2 patients transferred to the CPC, 477 (95%) completed follow-up at 14 days. Four hundred ten (86%) were discharged home. Those discharged a fter diagnostic evaluation yielded negative findings had 100% survival and zero diagnosis of AMI at 5-month follow-up. Overall mortality and incidence of AMI on long-term follow-up for all patients transferred to the CPC were .4% and .2%, respectively. Sixty-seven patients (13%) were admitted from the CPC, of whom 44 (66%) had a final diagnosis of ischemic heart disease (IHD) or AMI. Twenty-four patients with IHD (55 %; 6% of stress-tested group) were identified only on further stress t esting. Of these patients, seven underwent percutaneous transluminal c oronary angioplasty or coronary artery bypass grafting during hospital ization. All were discharged home without major morbidity. Four hundre d twenty-four patients (84%) underwent stress testing. The cost of man datory stress testing to identify one patient with IHD after AMI was r uled out was $3,125. An average cost-per-case savings of 62% was achie ved for each patient transferred to the CPC who would have been hospit alized before the inception of the CPC. Conclusion: Mandatory stress t esting is a safe, cost-effective, and valuable diagnostic and prognost ic tool in CPC patients.