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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2721_Библиотеки_им_академика_М_И_Перельмана
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a CPOU in 9 area
hospitals
hospitals to
successfully
implement a CPOU;
range of admission
rates for CP
16–54% preimplementation;
lack of financial
hospital support in
participating
hospitals
contributed to
inability to
implement a CPOU
Kirk et al.
25
1998
Prospective case series
of low-risk CP patients
to assess safety and
utility of immediate
stress testing in a chest
pain unit (N=212)
Low-risk CP patients
undergoing
immediate stress
testing after ED
evaluation without
biomarkers 50%;
Immediate stress
test results 64%
negative 25%
indeterminate 11%
positive; PPV of
immediate stress
test 57%; MACE of
discharged patients
with negative
immediate stress
test at 30-day f/u
0%
Convenience
study – stress
test available
only 14h/day;
incomplete
patient f/u
III
Goodacre
et al.
26
2001
Prospective case series
of CPOU patients
measuring
psychological
Rate of CPOU
patients with
moderate anxiety at
baseline and at
Brief f/u period,
no control
group,
individual
III
441
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
morbidity and healthrelated QOL using
3 questionnaires
(N=192)
1 month 19%, 19%
vs. moderate
depression 13%,
12%; health utility
and all dimensions of
quality of life scores
substantially below
age-adjusted normal
values at baseline,
improvement of pain
score and
deterioration of
physical role and
mental health
dimensions score at
1-month f/u; rate of
CPOU patients
reassured after
evaluation 86%
patient baselines
unknown
Weber
et al.
27
2003
Prospective case series
of CPOU patients with
CP and reported or test
positive cocaine use
(N=302)
Rate of MACE at
30-day f/u after
CPOU d/c for
cocaine-associated
CP cohort 1.6% (all
non-fatal MI in
patients that
continued to use
cocaine)
F/u not available
for all cohort
patients (2
patients not in
National Death
Index and
detailed f/u
available for 256
patients)
III
Goodacre
et al.
28
2005
Extrapolation study of
data from a
prospective
Mean ED costs
£116 CPU care vs.
£73 routine care,
QALYs 0.3936 CPU
vs. 0.3799 routine
care (=2.7%
ESCAPE trial
limitations, use
III
085
21:45:54
randomized controlled
trial (ESCAPE) to create
a model that compares
cost-effectiveness of
protocol-directed CPU
care (N=479) with
nonprotocol- directed
routine care (N=493)
mean cost of
inpatient hospital
stay £312; mean
cost per patient
for CP-related care
over 6 months
£478 CPU vs. £556
routine care
2013 USD $225
CPU vs. $142
routine care, mean
inpatient stay
$605, CP-related
care over
6 months $927
CPU vs. $1,080
routine care
improvement in
quality of life over 6
months). Discharge
to home rate 63%
for CPU vs. 46% for
routine care
of model
assumptions
Madsen
et al.
29
2009
Retrospective case
series of chest pain
patients managed in
an ED OU to determine
baseline rate of positive
stress test and CTA
findings (N=353)
11% of stress tests
were positive;
assuming only 70%
of patients referred
to outpatient
testing actually f/u,
one could
extrapolate that
about 3.3% of
positive stress tests
are missed because
patients are sent
home without one
Single-center,
rate of missed
positive stress
test extrapolated
from mix of case
series data and
assumption
III
Madsen
et al.
30
2010
Retrospective chart
review of OU CP
patients comparing
outcomes of those
with a CAD history
Discharge to home
rate 74% of OU
patients with CAD
history vs. 91.4% OU
patients without
CAD history;
Study type; not
all patients
underwent
stress test or
CTA; possible
selection bias
III
443
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
(N=125) vs. no CAD
history (N=406)
positive stress test
or CTA 32.3% if CAD
history vs. 6.9% no
CAD history; rate of
cardiac cath,
revascularization
12%, 7.2% CAD
history vs. 5.9%,
2.2% no CAD history
Pines et al.
31
2010
Prospective study
surveying ED physician
(N=31) risk tolerance in
patients presenting
with CP syndrome and
effect of opening an
ED OU (N=2872)
Association between
risk tolerance and
decision to admit ED
CP patients to
inpatient or OU/use
CTA and order
biomarkers 78%,
83% most risk-averse
quartile of the risk–
taking scale vs. 68%,
78% least risk-averse
quartile; no diff in CP
admission rate
before and after OU
implementation for
entire cohort 73%
vs. 73% and with
TIMI 0–1 62% vs. 62%
Study limited to
one physician
group at one
institution; CP
admission rate
higher than
benchmarks
III
085
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Asthma exacerbation
Mcdermott
et al.
32
1997
Randomized study of
adult ED patients with
asthma sent to EDTU or
inpatient (N=222)
Inpatient control
subgroup LOS
39h vs. d/c from
EDTU 8.8h
Mean EDTU $1,202
(± $1,343)
Inpatient $2,247
(± $1,110)
P<0.001 2013 USD
EDTU $2,125
(± $2,374)
Inpatient $3,973
(± $2,374)
EDTU was higher on 4 of 7
global satisfaction criteria
p<0.05
8 week relapse rate
EDTU 40%,
Inpatient 42%
P=0.74 NS QOL
EDTU higher in 5 of
8 domains (p≤0.02)
F/u appts 1, 8
weeks;
Telephone
interviews 3, 5, 7
weeks; Equivalent
baseline clinical
and historical
measures
2 groups similar
acuity
I
Rydman
et al.
33
1998
Randomized study of
adult ED patients with
asthma sent to EDTU
vs. inpatient (N=113)
EDTU $1,202
Inpatient $2,247
(p<0.001)
2013 USD EDTU
$2,059 Inpatient
$3,849
Significantly higher
QOL in 5 of 8
domains (p≤0.02).
No diff in relapse,
peak flows, 1 week
health comparisons
Used
standardized
Medical
Outcomes Study
SF 36, equivalent
baseline
measures
I
Rydman
et al.
34
1999
Randomized study of
adult ED patients with
asthma sent to AOU vs.
inpatient (N=163)
Global satisfaction better for
AOU than inpatient in 6 of 7
categories (p<0.05) 1 category
(p=.09, NS)
For problems with
care processes: AOU
better in
4 categories (p≤
0.03); no diff in 4
(NS), 1 category
(financial info)
worse (p=.02)
Patients “more
satisfied, fewer
problems with
OU than
(inpatient
admission)”
I
Zwicke
et al.
35
1982
Cohort study of adult
ED patients with
asthma (N=46) d/c
home =12, admit from
ED =7 HOSTT =27 (18
discharged +
9 admitted to hospital)
LOS 20h on
HOSTT Inpatient
3.3 days
HOSTT $459
Inpatient $1,347
HOSTT =34% of
inpatient cost
2013 USD HOSTT
$2,057 Inpatient
$6,037
Clinical variables
have little predictive
value. Historical data
(symptoms >24h,
prior HOSTT or
hospital admission)
predicted disposition
(need hospital
admission)
Equivalent
baseline criteria
Downgrade for
small N (only
27 HOSTT
patients) and
HOSTT patients
included holding
patients not just
observation
patients
III
445
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
Brillman
et al.
36
1994
Case series of ED
patients with asthma
(mainly adults) before
and after opening OU
(N=1224). Used
historical controls preobservation 834 postobservation 390
Median admission
charge $2,968.
Savings $57,705/
year for 2.7% # in
hospital admission
rate. OU charge
$210 for 12h x 48.3
patients/year =
$10,143; net
savings of
$47,542/year
2013 USD Median
admission charge
$8,240. Savings
$160,199/year for
2.7% # in hospital
admission rate. OU
charge $583 for
12h x 48.3 pts/year
=$28,159; net
savings of
$132,040/year
Hospital admission
rate preobservation 16.1%,
post-observation
13.4% (p=0.25, NS).
Discharged from ED
pre-observation
83.9%, postobservation 77.2%
(p=0.01)
Did not include
charges for OU
patients
discharged
home so
downgraded
since difficult to
compare preobservation and
postobservation
III
Mace et al.
37
2001
7 studies (3 pediatric, 4
adult) of OU treatment
of asthma reviewed
LOS in OU <
inpatient when
compared (2
peds, 2 adult
studies). Short
LOS for OU in
2 other peds
studies but not
compared with
inpatient
Inpatient costs >
than OU in all
studies that
evaluated cost
(2 peds, 4 adult
studies)
Patient satisfaction for OU >
inpatient when compared (2
adult studies)
Better QOL/
decreased
problems with care
(2 adult studies).
Readmission rate
no diff in 1 adult
and 1 peds study
(OU vs. inpatients)
Includes OU
protocol on
asthma
III
Asthma exacerbation
085
21:45:54
Syncope
Shen et al.
38
2004
Patients with
intermediate risk for
serious disease as
cause of syncope
randomized to special
“syncope unit” care or
standard care (N=103)
Diagnostic yield
67% in ED OU
patients and 10% in
standard care
patients. Hospital
admission rate 43%
for ED OU patients,
98% for standard
care patients
Small numbers
and
sophisticated
evaluation
protocol limit
use in other
hospitals
I
Stockley
et al.
39
2009
Survey of 177 EDs in UK
and Ireland on
approach to syncope
18% of EDs had
syncope guidelines,
55% had an ED OU
III
Transient ischemic attack
Ross et al.
40
2007
Randomized trial of
ADP in ED OU or
admitted to standard
care (N=149)
ADP 25.6h;
Admit 61.2h
ADP $844; Admit
$1,529 2013 USD
ADP $998; Admit
$1,807
Stroke within 90
days=3.3% in both
groups. Compliance
with protocol, e.g.,
carotid imaging
ADP=97%
Admit=91%
Small numbers
limit power
I
Brown
et al.
41
2007
Prospective cohort
study of patients to
assess the impact of a
TIA protocol in ED
(N=75)
46.7% of patients
discharged home
after TIA protocol.
Compliance with
recommendation
for antithrombotic
and carotid
imaging was 85.3%
Convenience
sample;
Hawthorne
effect
II
Stead et al.
45
2009
Case series of patients
who underwent a TIA
protocol in an ED OU
(N=418)
30.4% of patients
discharged home
from ED OU; risk of
stroke after ED OU
stay at 2 days was
0.96%, at 7 days
1.2%, at 30 days
III
447
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
1.9%, and 2.4% at 90
days
Deep vein thrombosis
Koopman
et al.
46
1996
Randomized trial of
LMWH vs. UF heparin
(N=400)
LOS for UF
heparin 8.1 days;
LMWH 50% not
admitted and
25% of rest sent
home in <48h
No decrement in
QOL with LMWH
No mention of
ED OU, though
concept is
apparent
I
Atrial fibrillation
Decker
et al.
52
2008
Prospective
randomized trial of
patients for an ED OU
pathway for
cardioversion vs.
traditional admission
(N=153)
Median LOS ED
OU 10.1h
Inpatient 25.2h
ED OU "12%
patients in NSR at
discharge
No diff in tests/
procedures/
adverse events,
or rehosp at 6month f/u
1
Cristoni
et al.
53
2011
Prospective
comparison of two
cohorts at two different
hospitals, comparing a
chemical protocol vs.
an electrical protocol
for cardioversion, using
a “short observation
unit” (N=322)
LOS same in
patients who
converted within
6h but many
more chemical
pathway patients
admitted (44%
vs. 6%)
93% of electrical
protocol sent home
in NSR within 24h
vs. 51% for chemical
protocol
Patients not
randomized;
electrical
cardioversion
protocol mixed
chemical and
electrical Rx
I
Transient ischemic attack
085
21:45:54
Conti et al.
55
2012
Observational study of
patients before and
after the
implementation of an
observation protocol
and outpatient clinic
(N=3,475)
Before OU 50%
admitted,
decreasing to 38%
and eventually to
24%, with the
addition of a
specific f/u clinic.
Patients not
randomized,
single institution
II
Koenig
et al.
56
2002
Case series of patients
in an ED OU protocol
for atrial fibrillation
(N=67)
LOS in ED 4.7h;
LOS in ED OU
11.8h for those
who convert
and 17h for
those admitted
While in ED OU 83%
converted to NSR.
Complications –
none; positive
diagnostic
outcomes -2 AMI, 2
fever, and 1 VT
No comparison
group
III
Ross et al.
57
2004
Case series of patients
with an ED OU
protocol for atrial
fibrillation (N=74)
Mean ED OU
LOS was 14.9h
81% of patients sent
home after ED OU
stay; 73% converted
with chemical
treatment; 6%
needed electrical
cardioversion
III
Stiell et al.
58
2008
Case series patients
managed with an EDbased atrial fibrillation
protocol involving
chemical cardioversion
and if unsuccessful,
followed by electrical
cardioversion (N=660)
ED LOS 4.9h
(3.9h for
successful
chemical and
6.5h if electrical
cardioversion
required)
95% discharged
home; 90% in
NSR. 7.6% adverse
events mostly
transient
hypotension; 3%
admission rate, no
death or stroke in
7 days
Retrospective
and
observational;
All in ED
III
Abdominal pain
Graff et al.
62
1991
Retrospective cohort
study of patients who
underwent a period of
Mean ED OU
LOS 10.4h
True and false
positives and
negatives
Retrospective;
antedates
II
449
085
21:45:54
Table 80.1 (cont.)
Author/
Year
Design Outcomes Limitations/
Comments
Class
Length of Stay
(LOS)
Cost Patient Satisfaction Other Metrics
Chest pain
observation in an ED
OU increased
diagnostic accuracy;
used Alvarado
appendicitis score
(N=252)
(regarding the
presence of
appendicitis at
surgery)
widespread use
of CT
Graff et al.
63
2000
Retrospective two-arm
cohort study at
12 acute care hospitals
examining consecutive
appendectomy
patients and
consecutive ED
patients with
abdominal pain
(N=1,026)
Subset of patients
who were observed
had 18% false
negative rate with
marked inter
institution
variability; presence
of OU improved
processes of care
but did not affect
other outcomes
Retrospective;
antedates
widespread use
of CT
II
Saunders
et al.
65
1988
Retrospective cohort
study of patients with
recurrent alcoholic
pancreatitis managed
under an ED OU
protocol (N=27)
Mean LOS of ED
OU patients sent
home was 14.4h;
mean LOS of
directly
admitted
patients was 5.8
days
52% of ED OU
patients sent home
within 24h
Downgraded for
small number of
patients
III
Head injury
Fabbri
et al.
66
2004
Prospective cohort
study of patients with
“high-risk” mild head
Median obs LOS
96h
No diff in
intracranial injuries
between groups, no
Uncontrolled
patient
selection;
I
Abdominal pain
085
21:45:54
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