Valuation of a simple tool for chest pain patient risk-stratification in North America

摘要(30行) 一种很有前途的新的心脏风险定量计算器，心脏评分(病史，心电图发现， 年龄、危险因素和肌钙蛋白价值)，最近被认为是指导处置的有用辅助手段。 急诊科(ED)评估后潜在心源性胸痛(CP)患者的手术治疗 评估。在荷兰ED患者身上获得并验证，并在亚太地区队列中进行外部验证，这一点 已经证明，简单的结果预测指标可以准确地量化发生重大不良心脏事件的可能性 事件(MACE)，在指数访问后30天内，并且表现优于其他决策辅助以及临床GE 在严格控制的临床试验中停用。我们不知道的是心脏的表现特征 SCORE在美国医疗体系中的应用，研究它的可行性和实用性 繁忙的美国ED的设置，以及它与其他选项相比的相对易用性。目标是 这项试点研究的目的是确定进行一项由R01资助的大型临床试验的可行性和实用性 心功能评分在鉴别ED患者中低危CP中的价值 美国这项先导性研究的基本原理是，一种将指导临床实践并产生影响的工具-- 必须测试定位决策的准确性和方便性，以便在繁忙的ED实践中有效地使用- 蒂斯。我们的中心假设是，心脏评分将是可测试的，将具有可接受的可靠性，并且 卓越的易用性，使其适合作为决策辅助工具，以安全地减少不必要的入院和支持 微尘提供商配置一致性。我们的目的是1)测试进行研究评估的可行性 在忙碌的美国教育部门的练习设置中，使用注册和完成 作为终点进行随访，2)生成心脏评分的初步数据，以区分 一项前瞻性观察研究中的低风险和中等风险心脏ED患者，以及3)测量和比较 提供者自我报告的心跳评分的易用性。当我们实现我们的目标时，我们将提供 我们计划的R01提案的基础是通过生成心脏评分的初步数据来 在美国患者中区分低风险和中等风险的CP和2)验证心脏评分 易于使用。我们的建议是创新的，因为这种研究心脏评分决策辅助的方法 在教育部门的实践设置以前从来没有做过。这项工作意义重大，因为它构成了 在美国ED环境中定义心脏评分的表现特征的第一步，在骗局之外- 在它可以安全地纳入临床路径之前，它已经进行了临床试验。此外，这个问题在中无处不在 急诊医学−对这一主诉的处置决定不一致是导致实践的主要原因- 这个国家的气候变化无常，每年可能会影响数十万美国人。这一行 调查将缩小CP招生差距，优化资源利用，这将改善 卫生保健的质量、安全、效率和有效性。

Abstract (30 lines) A promising, new quantitative cardiac risk-calculator, the HEART score (History, Electrocardiogram findings, Age, Risk factors, and Troponin value), has recently been proposed as a useful aid for guiding disposition de- cisions for patients with potential cardiac chest pain (CP) after inconclusive Emergency Department (ED) eval- uation. Derived and validated on Dutch ED patients and externally validated in an Asian-Pacific cohort, this simple outcome predictor has been shown to accurately quantify the likelihood of a major adverse cardiac event (MACE) within 30 days of an index visit, and has outperformed other decision aids as well as clinical ge- stalt in rigorously controlled clinical trials. What we don't know is the performance characteristics of the HEART score when applied in the context of the U.S. healthcare system, the feasibility and practicality of studying it in the setting of a busy U.S. ED., and what its relative ease of use is compared with other options. The objective of this pilot study is to determine the feasibility and practicality of conducting a large R01-funded clinical trial to determine the value of the HEART score in discriminating low- from moderate-risk CP among ED patients in the U.S. The rationale for this pilot study is that an instrument that will guide clinical practice and impact dispo- sition decisions must be tested for accuracy and convenience in order to be effectively used in a busy ED prac- tice. Our central hypothesis is that the HEART score will be feasible to test, will have acceptable reliability, and superior ease of use, making it suitable as a decision aid to safely reduce unnecessary admissions and pro- mote provider disposition consistency. Our aims are to 1) test the feasibility of conducting a study evaluating the HEART score in real-time within the practice setting of a busy U.S. ED, using enrollment and completion of follow-up as endpoints, 2) to generate preliminary data for the HEART score's ability to discriminate between low- and moderate-risk cardiac ED patients in a prospective observational study, and 3) measure and compare providers' self-reported ease of use for the HEART score. When we accomplish our aims, we will 1) provide the foundation for our planned R01 proposal by generating preliminary data for the HEART score's ability to discriminate between low- and moderate-risk CP among patients in the U.S. and 2) verify the HEART score's ease of use. What we propose is innovative in that this approach to studying the HEART score decision aid within the ED practice setting has never before been done. This work is significant because it constitutes the first step in defining the HEART score's performance characteristics in a U.S. ED setting, outside of a con- trolled clinical trial before it can be safely incorporated into clinical pathways. Further, this issue is ubiquitous in emergency medicine − inconsistent disposition decisions for this chief complaint are the leading cause of prac- tice variability in this country, potentially affecting hundreds of thousands of Americans annually. This line of investigation will decrease CP admission disparities and optimize resource utilization, which will improve the quality, safety, efficiency, and effectiveness of health care.