Can Risk Score Alerts Improve Office Care for Chest Pain?

The evaluation of ambulatory patients with chest pain is a challenging and serious problem, accounting for a significant proportion of all outpatient visits. High risk patients may go undetected, resulting in missed diagnoses of acute myocardial ischemia, while low risk patients may be subject to unnecessary evaluations. To substantially improve the evaluation and treatment of outpatients with acute chest pain syndromes, new strategies need to be developed in the primary care setting to risk stratify symptomatic patients and guide appropriate care. With a randomized controlled study design, this project implemented and evaluated an intervention to improve the treatment of primary care patients with acute chest pain in a large integrated health care delivery system. The project team studied primary care patients with chest pain within a multispecialty integrated group practice consisting of 15 health centers with 300 primary care clinicians caring for approximately 300,000 patients.

The main objectives of this study were to:

1. Identify predictors of risk-appropriate evaluation and treatment of patients presenting to primary care offices with acute chest pain, including race, sex, and other clinical factors.
2. Determine whether rates of appropriate evaluation and treatment of patients with acute chest pain can be improved through the use of point-of-care electronic risk alerts that provide individual patient cardiac risk profiles and tailored evaluation and treatment recommendations to primary care clinicians.
3. Perform a cost analysis for evaluation of patients with acute chest pain.

The study team found that over one-third of diagnoses of acute myocardial infarction were missed and not directly referred to the emergency department. In addition, while only six percent of patients were evaluated in the emergency department, these patients resulted in significant health care costs. While the alerts were generally well received by clinicians, the intervention did not alter care patterns among either high risk or low risk patients.