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Chest Pain Admits Drop – Are Dollars Talking?

September 14, 2017

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From 2006 – 2012, admission rates for low-risk chest pain dropped 41%.  This may have been due to decreased reimbursement for such hospital stays.

Why does this matter?
Low risk chest pain doesn’t mean NO risk chest pain.  You have to be very careful which patients you deem safe for outpatient workup.  We have come a long way in chest pain risk stratification, but it seems financial disincentive for admission may have been a contributor to a decrease in admissions as well. I wonder if we have developed better risk stratification tools and a greater acceptance of shared decision making in this same period of time, and the financial part contributed little.  But that’s just speculation.

Are dollars talking?
This was a retrospective review of the National ED Sample (NEDS) (950 hospitals, 30 states, 31 million ED visits per year) that looked at admission rates from 2006 to 2012 for patients ultimately diagnosed with “non-specific chest pain.”  They also compared type of hospital: safety net, trauma level, region of the US, etc.  They found a 41% drop in admission rate for these patients, from 19.2 to 11.3% over this time period.  The authors cite this US government testimony as a summary of the federal changes that may have led to fewer admissions.  Large teaching hospitals tended to have lower admission rates.  Of note, NEDS did not record observation-status admission, only inpatient.  So it may be that more patients were admitted for “observation” during this timeframe and were not captured in this study.  Also, other unrecognized variables could have contributed to fewer admissions, such as an increased willingness to utilize shared decision making with patients about the real risk of major adverse coronary outcome.  We don’t know what caused this reduction in admissions, but financial disincentive could have played a role.

Change in Care Transition Practice for Patients with Non-Specific Chest Pain after ED Evaluation 2006-2012.  Acad Emerg Med. 2017 Aug 18. doi: 10.1111/acem.13279. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

What are your thoughts?