Control Group: (n = 83, 83 analysed): standard evaluation- 3 sets of cardiac enzymes, 2 ECGs and 24 hours of cardiac and clinical monitoring
Experimental Group: (n = 82, 82 analysed): emergency department based accelerated diagnostic protocol- 12 hours of rhythm monitoring, creatine-kinase-MB levels using monoclonal antibodies performed at 0, 4,48 and 12 hours, ECGs at 0, 6 and 12 hours, clinical examination and review of test results by an attending physician at 0, 6 and 12 hours or for any change in condition, aspirin, 2 L oxygen by nasal cannula and an intravenous line

100% followed for ?
Outcome notes:

The evidence

Myocardial infarction: accelerated diagnostic protocols decreased hospitalisation.

Clinical bottom line (level 1b)

  1. Patients with chest pain who were placed on an accelerated diagnostic protocol were less likely to be hospitalised, than those given a standard evaluation (NNT = 2 at unknown) .
  2. Patients placed on an accelerated diagnostic protocol were more likely to have a shorter length of stay in hospital.
  3. An accelerated diagnostic protocol may be more cost-effective than a standard evaluation.
Roberts et al: Journal of the American Medical Association 1997; 278 (20): 1670-1676
Expires March 2003

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: urban teaching hospital, USA

165 patients (aged mean 48 years, 54% male) patients who needed admission to a monitored bed for possible myocardial infarction/acute cardiac ischaemia
Note:
  • 62% of patients were African American, 11% Hispanic, 5% white and 22% other race.


    • Control Group: (n = 83, 83 analysed): standard evaluation- 3 sets of cardiac enzymes, 2 ECGs and 24 hours of cardiac and clinical monitoring
    Experimental Group: (n = 82, 82 analysed): emergency department based accelerated diagnostic protocol- 12 hours of rhythm monitoring, creatine-kinase-MB levels using monoclonal antibodies performed at 0, 4,48 and 12 hours, ECGs at 0, 6 and 12 hours, clinical examination and review of test results by an attending physician at 0, 6 and 12 hours or for any change in condition, aspirin, 2 L oxygen by nasal cannula and an intravenous line

    100% followed for ?
    Outcome notes:
    • hospitalisation : recurrent ischaemic chest pain or any positive test result during the first 12 hours

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    hospitalisation unknown 83
    (100%)    		 37
    (45.1%)    		 55.0%
    (43.0% to 64.0%)    		 54.9%
    (44.1% to 65.7%)    		 2
    (2 to 2)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    length of stay 44.8
    (31.8)     		33.1
    (28.4)     		11.7
    (2.43 to 21.0)

  • Total cost of treatment in the control group was $2095, and in the accelerated diagnostic protocol was $1528.

    • Comments

    1. Patients were selected consecutively during shifts, but shifts were systematically selected to distribute enrolment evenly throughout the day.
    2. Patients of African and Hispanic descent vary in several cardiological and electrocardiographic aspect from Caucasians.

    Citation

    1. Roberts RR, Zalenski RJ, Mensah EK, et al: Costs of an emergency department-based accelerated diagnostic protocol vs hospitalisation in patients with chest pain: A randomized controlled trial. Journal of the American Medical Association 1997; 278 (20): 1670-1676
    Contributor: Clare Wotton and Musab Hayatli, January 2000
    Reviewer: Dwight Peretz

    Clinical Question.
    Patient chest pain
    Intervention or Exposure accelerated diagnostic protocol
    Comparison standard evaluation
    Outcome hospital admission, total cost and length of stay
Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
hospitalisation unknown 83
(100%)		 37
(45.1%)		 55.0%
(43.0% to 64.0%)		 54.9%
(44.1% to 65.7%)		 2
(2 to 2)

Outcome Control Group
(SD)		 Experimental Group
(SD)		 Mean Difference
(95% CI)
length of stay 44.8
(31.8) 		33.1
(28.4) 		11.7
(2.43 to 21.0)

Total cost of treatment in the control group was $2095, and in the accelerated diagnostic protocol was $1528.

Comments

  1. Patients were selected consecutively during shifts, but shifts were systematically selected to distribute enrolment evenly throughout the day.
  2. Patients of African and Hispanic descent vary in several cardiological and electrocardiographic aspect from Caucasians.

Citation

  1. Roberts RR, Zalenski RJ, Mensah EK, et al: Costs of an emergency department-based accelerated diagnostic protocol vs hospitalisation in patients with chest pain: A randomized controlled trial. Journal of the American Medical Association 1997; 278 (20): 1670-1676
Contributor: Clare Wotton and Musab Hayatli, January 2000
Reviewer: Dwight Peretz

Clinical Question.
Patient chest pain
Intervention or Exposure accelerated diagnostic protocol
Comparison standard evaluation
Outcome hospital admission, total cost and length of stay