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E-Journal of the Society of Chest Pain Centers

Spring 2003, Volume II, Number I

REVIEW

Steve Goodacre, MD
Medical Care Research Unit
University of Sheffield
Regent Court, 30 Regent Street
Sheffield, S1 4DA
Email: s.goodacre@sheffield.ac.uk
Telephone: 0114 222 0842
Fax: 0114 222 0749

Development of Chest Pain Centers in the United Kingdom

Chest Pain Centers (CPCs) initially developed in the United States (US) in the 1980's and 1990's. The factors that led to the development of CPCs in the US also exist in the United Kingdom (UK), where interest in CPC care is rapidly growing. However, international differences in routine clinical practice and health care funding have created important differences in the development and evaluation of CPC care in the UK. This article describes the development of CPC care in the UK and highlights some key issues in international CPC development.

Background: the problem and the challenge of developing CPC care

The development of CPC care in the UK has been prompted by recognition that patients attending hospital with symptoms suggestive of an acute coronary syndrome (ACS) receive variable, and often sub-optimal care. Audits have revealed evidence of inappropriate discharge in patients with ACS1,2 and it has recently been estimated that 7% of a cohort of patients discharged after emergency department (ED) assessment had evidence of significant myocardial damage.3 A national survey of chest pain care in the ED4 revealed widespread variation in practice with little use of short-stay observation facilities or provocative cardiac testing.

These data clearly show that there is scope for CPCs to improve care, but also show reasons why published data from the US, supporting CPC development, cannot automatically be applied to the UK. Recorded admission rates for patients with chest pain were low, varying from 29 to 43%,1,2,5,6 while estimated admission rates for patients with undifferentiated chest pain varied from below 20% to above 80%.4 Meanwhile, review of routine inpatient care for patients with undifferentiated chest pain at a typical UK hospital7 found that only two patients out of 106 were managed on the coronary care unit and only three underwent cardiac catheterisation at any stage over the following six months. Health service costs in this study were $1332 per patient over six months compared to values varying from $1826 to $6565 for comparable groups in the US8-14 (all figures have been up-rated to 2001 prices). Hence it appears that routine care in the UK is very cheap, although its effectiveness is highly questionable.

This creates a problem for CPC development in the UK. Evidence from controlled trials of cost-savings associated with CPC care12-14 created a powerful rationale for hospitals to develop CPC care in the US, yet similar savings are unlikely to be reproduced in comparison to routine care the UK. Furthermore, health care in the UK is overwhelmingly centrally funded (through general taxation) and administered. Economic evaluation is thus more likely to influence policy if it takes a health service, rather than an institutional perspective, and allows comparison of CPC care to a wide range of potential health care interventions. This is crucial if we suspect that CPC care may improve care but will cost more - additional expenditure must be justified. Pioneers of CPC care in the UK thus face two challenges: to develop models of CPC care that can compete economically with routine care, and to undertake evaluation that compares both the costs and the outcomes of CPC care and allows comparison to other health care interventions.

Models of CPC care in the UK

To date, CPCs in the UK have focussed on the specific role of providing diagnostic evaluation for patients with a low to moderate risk of ACS, although concurrent developments, such as specialist "chest pain nurses" have addressed issues of thrombolytic therapy and community outreach.15 Data have been published from centres in Manchester, Bath and Sheffield.16-18

The Chest Pain Assessment Unit at Manchester Royal Infirmary16 uses a protocol consisting of ST segment monitoring and measurement of CK-MB (mass) at presentation and at least three hours later. Exercise treadmill testing is provided for selected patients as an outpatient. The ROMEO pathway at Royal United Hospital in Bath17 provides serial ECG recording and troponin I measurement 12 hours after symptom onset followed by exercise treadmill test. The Chest Pain Observation Unit at the Northern General Hospital in Sheffield18 provides two to six hours of ST segment monitoring, measurement of the CK-MB (mass) gradient and six-hour troponin T, followed by an exercise treadmill test.

Prospective studies have shown that, provided a low risk cohort is selected, these protocols successfully identify patients at low risk of adverse events who can be safely discharged home.16-18 All three protocols are relatively simple. The Manchester protocol in particular requires very little additional funding and is highly likely to be cost saving compared to routine UK practice. The Sheffield protocol is probably the most complex. It is run by specialist chest pain nurses and is unique (to my knowledge) in the UK in providing ED-based exercise treadmill testing. The amount of infrastructure required to support the Sheffield CPC has raised the possibility that this unit may be more expensive than routine care.7,18 Further evaluation is required to accurately measure the costs of CPC versus routine care and to determine whether this approach can improve outcomes.

Evaluating the effectiveness and cost-effectiveness of CPC care

Demonstrating that a CPC can improve outcomes presents a substantial challenge. The CPC aims to reduce inadvertent discharge with ACS and reduce adverse events. Yet these outcomes are rare and measurable differences unlikely except in a huge, multi-centre trial. Process-of-care measures, such as admission rates, length of stay and ED reattendance, are more likely to show significant differences, but are arguably only weakly related to patient preference. However, modeling outcomes from CPC care has shown that health-related quality of life after assessment has a powerful effect upon overall effectiveness.19 This outcome is clearly important to the patient but has only rarely been measured.20 Yet it could be hypothesized that if a CPC provides a rigorous and structured approach to diagnosis and management then quality of life could be improved.

Measurement of quality of life is also crucial to cost-effectiveness analysis. Combination of survival and quality of life data allows outcomes to be measured as quality-adjusted life-years (QALYs).21 Estimation of the additional cost required to gain one additional QALY (the incremental cost per QALY) by using CPC as opposed to routine care provides a powerful way of estimating the cost-effectiveness of CPC care that can be compared to a wide range of other demands for health care resources.

For these reasons the Sheffield CPC has been subject of a recent economic evaluation alongside a randomised controlled trial. Days of the week (442 in total) were randomised to CPC or routine care and 972 patients recruited. Outcomes (including inappropriate discharge with ACS, adverse events, quality of life, ED reattendance and hospital readmission) and health service costs were measured over six months. Results of this study have yet to be published, but preliminary presentation of the data22,23 suggests that the CPC significantly improves outcomes and is associated with a non-significant reduction in health service costs.

Future developments

Because central government in the UK has overall control of most health care funding, this is a highly politicized area in the UK. Emergency care and coronary heart disease are both high priorities for the UK government and are the subject of specific policies to improve care.24,25 Health care providers are being encouraged to develop innovative ways of managing emergency patients, including rapid diagnostic testing, nurse-led care, and care provided at the point of patient contact (usually the ED).

The CPC would seem to fit this policy agenda perfectly. Indeed the National Health Service (NHS) Emergency Care Modernization Program advocates development of CPCs and CPCs have received NHS Modernization Awards for innovative practice. Further evaluation is still required, specifically directed at disseminating CPC care from the small number of centres currently sited in departments with a specialist interest to the majority of hospitals that may have other priorities and competing demands. Refinements and development of the CPC approach is required to ensure that best current CPC practice is brought to the UK. Finally, the role of the CPC in improving care for patients with proven ACS and in undertaking community outreach needs to be developed.

Conclusion

CPC care is developing rapidly in the UK in response to the same problems that have prompted development elsewhere. However, the variable and typically resource-limited nature of routine care, coupled with the highly politicized nature of health care funding in the UK has resulted in specific implications for CPC development. These include simple, cheap, diagnostic protocols, evaluation that measures patient-centered outcomes, and economic evaluation from a health service, rather than an institutional perspective.

References

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  8. Hoekstra JW, Gibler WB, Levy RC, Sayre M, Naber W, Chandra A et al. Emergency-department diagnosis of acute myocardial infarction and ischaemia: a cost analysis of two diagnostic protocols. Acad Emerg Med 1994;1:103-10.
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  25. The National Service Framework for Coronary Heart Disease. 2000. London, UK Department of Health.

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