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Does Concordance with Guideline Triage Recommendations Affect Clinical Care of Patients with Possible Acute Coronary Syndrome?

Department of Medicine, University of Iowa Carver College of Medicine, david-katz{at}uiowa.edu

Jeffrey Dawson, ScD

Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa

Joni R. Beshansky, RN, MPH

Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, Massachusetts

Peter S. Rahko, MD

Division of Cardiology

Tom P. Aufderheide, MD

Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee

Mark Bogner, MD

Section of Emergency Medicine at the University of Wisconsin-Madison

Hocine Tighouart, MS

Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, Massachusetts

Harry P. Selker, MD, MSPH

Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, Massachusetts

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.

Key Words: Key words: guidelines • unstable angina • risk assessment • emergency medical services • triage • controlled clinical trials. (Med Decis Making 2007;27:423—437)

This version was published on August 1, 2007

Medical Decision Making, Vol. 27, No. 4, 423-437 (2007)
DOI: 10.1177/0272989X07302557


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