The changing reimbursement pathways in emergency department chest pain centers for patients with acute coronary syndrome
Sandra Sieck, R.N., BBA

Ms. Sieck is director of cardiovascular development, Providence Hospital, Mobile, Alabama.

Integrating the goals of health care organizations and providers

Although chest pain units and emergency departments (EDs) have elements in common for evaluation and treatment of patients with suspected acute coronary syndromes (ACS), there are no universally accepted treatment or diagnostic algorithms. The recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines provide detailed recommendations regarding diagnostic and treatment approaches in patients with ACS,1 but these guidelines have not yet been translated into algorithms. This is partly because few therapeutic areas are as dynamic as cardiology. An equally important factor is that numerous regulatory and professional organizations have become more involved in all aspects of patient care. In addition, hospital staff must strive for a delicate balance between complying with specific orders, standing orders, and critical pathways, while staying within the bounds of evidence-based medicine. One of the goals of establishing a specialized chest pain unit is to facilitate this process and establish a partnership between ED physicians and cardiologists. Until recently, the importance of this partnership was under appreciated. Now, with the bewildering array of diagnostic tools and treatment options for patients with ACS, this partnership has become crucial.

The goals of health care organizations and providers include improving the quality of care, reducing lengths of hospital stay and cost of care, and increasing revenue. While attempting to meet these goals, health care providers must strive to satisfy the often-competing demands of health care regulatory agencies, which may have different priorities. The Health Care Financing Administration (HCFA), one of five major health care regulatory agencies in the United States, administers Medicare, Medicaid, and the State Children's Health Insurance Program and also regulates laboratory testing, develops coverage policies, and maintains oversight of the survey and certification of nursing homes and continuing care providers. HCFA is primarily interested in the financial aspects of health care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an independent, nonprofit organization, accredits, sets standards for and evaluates compliance with established benchmarks for health care organizations. Its primary concern is monitoring and maintaining acceptable clinical outcomes within health care organizations. The Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), is involved in developing treatment standards that are consistent with evidence-based medicine. The National Committee for Quality Assurance (NCQA) is an independent, nonprofit organization that evaluates and reports on the quality of managed care organizations. One of its primary focuses is to insure medications are being used within their approved indications and in coh (NIH) consists of 25 separate institutes and centers that conduct, fund, and monitor publicly funded biomedical research in the United States. Despite a billion dollar budget for research, the NIH has not had the effect on health care delivery it had expected. For example, whereas mortality rates in well-controlled clinical trials of acute myocardial infarction (AMI) have been reduced approximately 30%, mortality in clinical practice remains unacceptably high.

Formerly, ED physicians focused on managing the acute disease state. Now they must focus on implementing guidelines that include detailed recommendations on diagnosis and treatment. Indeed, in today's environment of integrated care, all clinicians involved in treating patients with chest pain need to be aware of these guidelines. With this paradigm shift in health care delivery, we must explore ways to implement these guidelines starting at the "front door," that is, in the ED, and continuing through to cardiology and primary care. Although there is no single solution to ensuring a seamless transition from the ED to cardiology, specialized chest pain centers appear to be uniquely positioned to facilitate this process.

References

1. Braunwald E, Antman EM, Beasley JW et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2000;36:970-1062.