Faculty Collaboration Database

The impact of unstable angina guidelines in the triage of emergency department patients with possible acute coronary syndrome. Med Decis Making 2006;26(6):606-16

Date

11/14/2006

Pubmed ID

17099199

DOI

10.1177/0272989X06295358

Scopus ID

2-s2.0-33750919753 (requires institutional sign-in at Scopus site)   9 Citations

Abstract

OBJECTIVE: The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain.

METHODS: The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups.

RESULTS: No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS.

CONCLUSION: Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.

Author List

Katz DA, Aufderheide TP, Bogner M, Rahko PR, Brown RL, Brown LM, Prekker ME, Selker HP

Author

Tom P. Aufderheide MD Professor in the Emergency Medicine department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Adult
Aged
Algorithms
Angina, Unstable
Chest Pain
Decision Support Techniques
Diagnosis, Differential
Emergency Service, Hospital
Female
Follow-Up Studies
Humans
Inservice Training
Male
Middle Aged
Myocardial Infarction
Practice Guidelines as Topic
Prospective Studies
Risk Assessment
Triage