Is Coronary Computed Tomography Angiography a Resource Sparing Strategy in the Risk Stratification and Evaluation of Acute Chest Pain? Results of a Randomized Controlled Trial

Authors

  • Adam H. Miller MD, MSMM, MSCS,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Paul E. Pepe MD, MPH,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Ron Peshock MD,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Rafia Bhore PhD,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Clyde C. Yancy MD,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Lei Xuan PhD,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Margarita M. Miller MD,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Gisselle R. Huet MA,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Clayton Trimmer DO,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Rene Davis RN,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Rebecca Chason,

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Micheal T. Kashner PhD, JD

    1. From the University of Texas Southwestern Medical Center, Department of Surgery, Division of Emergency Medicine (AHM, PEP); the Department of Internal Medicine, Division of Cardiology (RP); the Department of Radiology, Division of Interventional Radiology (CT); the Department of Clinical Sciences (AHM, MK, GRH, RD); the Division of Biostatistics (RB, LX, RC); and the Children’s Medical Center (MMM), Parkland Health & Hospital System, Dallas, TX; and Department of Cardiology (CY), Baylor University Medical Center, Dallas, TX.
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  • Support grants: grant number 5 UL1 RR024982-03; principal investigator Packer, Milton; project title North and Central Texas Clinical and Translational Science Initiative (UL1);award dates 9/17/07–5/31/12. KL2 Grant Information (replaces the K12):grant number 5 KL2 RR024983-03;principal investigator Packer, Milton; project title North and Central Texas Clinical and Translational Science Initiative (KL2);award dates 09/17/07–5/31/12. Information on NCRR is available at http://www.ncrr.nih.gov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp. These support grants did not influence the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

  • Clinicaltrials.gov NCT00825435.

  • UTSWMC IRB #032007-067.

  • Supervising Editor: Stephen W. Smith, MD.

Address for correspondence and reprints: Adam H. Miller, MD, MSMM, MSCS; e-mail: adam.miller@utsouthwestern.edu.

Abstract

ACADEMIC EMERGENCY MEDICINE 2011; 18:458–467 © 2011 by the Society for Academic Emergency Medicine

Abstract

Objectives:  Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD.

Methods:  Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs.

Results:  The mean (± standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group ($10,134; SD ±$14,239) versus the SC-only group ($16,579; SD ±$19,148; p = 0.144), as was the median for the SC + CCTA ($4,288) versus SC only ($12,148; p = 0.652; median difference = –$1,291; 95% confidence interval [CI] = –$12,219 to $1,100; p = 0.652). Among the 60 total study patients, only 19 had an established diagnosis of CAD at 90 days. However, 18 (95%) of these diagnosed participants were in the SC + CCTA group. In addition, there were fewer hospital readmissions in the SC + CCTA group (6 of 30 [20%] vs. 16 of 30 [53%]; difference in proportions = –33%; 95% CI = –56% to –10%; p = 0.007).

Conclusions:  Adding CCTA to the current ED risk stratification of ACPSs resulted in no difference in the quantity of resources utilized, but an increased diagnosis of CAD, and significantly less recidivism and rehospitalization over a 90-day follow-up period.

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