Faculty Collaboration Database

Does concordance with guideline triage recommendations affect clinical care of patients with possible acute coronary syndrome? Med Decis Making 2007;27(4):423-37

Date

07/21/2007

Pubmed ID

17641142

DOI

10.1177/0272989X07302557

Scopus ID

2-s2.0-34547129819 (requires institutional sign-in at Scopus site)   2 Citations

Abstract

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear.

METHODS: This analysis included 7466 adults who presented to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS) and who participated in 3 prospective clinical effectiveness trials during the period 1993 to 2001. The authors used logistic regression to assess the impact of concordance with guideline triage recommendations on subsequent diagnostic testing, follow-up care, and 30-day mortality and applied propensity score methods to adjust for selection bias.

RESULTS: Among low-risk patients (n = 1099), ED discharge was not associated with higher mortality and did not increase the need for emergency care or hospitalization during follow-up (adjusted odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.63-1.6 for ED revisits); however, 1.7% of discharged low-risk patients had confirmed ACS. Among intermediate- to high-risk patients (n = 6367), admission to a monitored bed was not associated with reduction in 30-day mortality but significantly reduced the need for follow-up ED care (adjusted OR = 0.81, 95% CI = 0.69-0.96).

CONCLUSIONS: This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.

Author List

Katz DA, Dawson J, Beshansky JR, Rahko PS, Aufderheide TP, Bogner M, Tighouart H, 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

Acute Disease
Adult
Angina, Unstable
Coronary Disease
Emergency Service, Hospital
Female
Guideline Adherence
Humans
Logistic Models
Male
Middle Aged
Patient Discharge
Practice Guidelines as Topic
Risk Assessment
Syndrome
Treatment Outcome
Triage