Testing of ER Patients for Heart Attack in Absence of Symptoms Widespread

Press Release:

DALLAS – November 17, 2014 – Emergency rooms are testing many patients for markers of acute coronary syndrome who show no signs of having suffered a heart attack, UT Southwestern Medical Center researchers have found.

Inappropriate testing for heart attacks increases the cost of treatment; increases the number of false positives, which could lead to further testing and unnecessary consultations; and adds to patient anxiety, said Dr. Anil Makam, Assistant Professor of Internal Medicine at UT Southwestern and first author of the study published today in JAMA Internal Medicine.

Using data from the National Hospital Ambulatory Medical Care Surveys, Dr. Makam looked at nearly 45,000 adult emergency room visits across the country during 2009 and 2010, comparing symptoms and tests ordered. The study defined symptoms of heart attack broadly: chest pain, nausea, vomiting, heartburn, upper abdominal pain, palpitations, shortness of breath or other breathing problems, general malaise, fainting or dizziness, sweating, fluid abnormality, edema, jaw pain, neck pain, or arm pain. If a patient exhibited at least one of these symptoms, the patient was counted as having signs of heart attack. Cardiac biomarker tests were creatinine kinase MB, troponin I, and troponin T.

Despite the broad definition of coronary symptoms, 29.7 percent of all patients tested for these cardiac markers exhibited no symptoms of a heart attack. Among patients who were hospitalized following their emergency room visit, 35.4 percent were tested for cardiac markers despite showing no symptoms of a heart attack.

The biggest predictor of whether a patient was tested for cardiac markers was the overall number of procedures and tests ordered. Patients who were admitted to the hospital at the end of their emergency room visit were also more likely to have cardiac tests ordered. But even among patients who were treated and released, 7.5 percent of patients who exhibited no heart attack symptoms were tested for cardiac markers.

“Extrapolating our findings, our extremely conservative estimate is that there were 1.7 million individuals with a false-positive cardiac biomarker test in the U.S. over those two years,” Dr. Makam said.

Dr. Makam said legal concerns, as well as testing practices at institutions, were likely behind the pattern of testing when patients did not exhibit symptoms.

“I would have expected symptoms to be the main driver but it was testing practices that were the strongest predictor of cardiac biomarker testing,” he said.

Dr. Oanh Nguyen, Assistant Professor of Internal Medicine at UT Southwestern and senior author of the study, said there are several reasons why physicians might be ordering tests in the absence of symptoms.

“First, providers who are ordering the tests may be fearful of missing a diagnosis and they are ordering everything but the kitchen sink in terms of tests, ‘just in case,’” said Dr. Nguyen. “Second, providers may be over-ordering tests in situations where they are uncertain of a diagnosis, and are hoping that the tests will help them make a quick diagnosis. Finally, providers may simply be following institutional guidelines,” she said.

About UT Southwestern Medical Center

UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty includes many distinguished members, including six who have been awarded Nobel Prizes since 1985. Numbering approximately 2,800, the faculty is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in 40 specialties to about 92,000 hospitalized patients and oversee approximately 2.1 million outpatient visits a year.

Expanded availability of epinephrine in schools called potential lifesaver

From NJSpotlight:

When Wendy Antosiewicz said she wants every school in New Jersey to have an epinephrine autoinjector to prevent students and staff from going into shock from allergies, she speaks from experience.

She and other parents, along with a company that supplies free autoinjectors to schools, are backing a state bill, S-801 /A-304, that requires public and private schools to have epinephrine that school nurses or trained staff members can give to any student. Under current state law, schools only administer epinephrine to students who have prescriptions. But since many people have undiagnosed allergies, bill advocates say the measure would save lives.

The measure follows the School Access to Emergency Epinephrine Act signed by President Barack Obama last year, which gives preference for federal asthma education grants to states that develop school plans to administer the medication at any time during school hours. Obama noted in signing the law that his daughter Malia has a peanut allergy.

If the bill becomes law, New Jersey would join just six other states — Maryland, Michigan, Nebraska, Nevada, North Carolina and Virginia — that require schools to have autoinjectors.

State Senator Named Legislator Of The Year By Connecticut Emergency Physicians

From the Herald:

State Senator Joe Markley recently received The Connecticut College of Emergency Physicians Legislator of the Year award. Sen. Markley worked to pass a bill allowing Medicaid reimbursement for emergency departments across the state. The bill was passed with bipartisan support. The AAC Medicaid Reimbursement for Emergency Department bill allows emergency department physicians to be reimbursed separately from hospitals for treating Medicaid recipients.

Many of the patients who are seen in the emergency room and don’t have adequate medical insurance fall into the Medicaid category. These patients will never be asked about insurance coverage. They are given care regardless of status.
What is happening however is that hospitals are contracting out to private practices for their emergency room doctors. The doctors are not employees of the hospital. State law did not allow for emergency physicians to bill Medicaid directly for their professional fees but rather bundled the fees into hospital facility charges. This created a system that didn’t ensure these doctors were being paid equitably like their peers in private practice.

Dr. Michael Zanker, the legislative chairman for the Connecticut College of Emergency Physicians testified, “Many studies have shown that the majority of the cost of healthcare today is generated by inpatient care. Emergency care accounts for two percent of our healthcare expenses. Yet our emergency departments are providing care to more patients every year, well over 100 million visits annually. The reasons for this are manifold and are based on the fact that or system is being overstressed. Private physicians are seeing more patients in their offices are more often unable to “fit in a patient during office hours”.

“Our community health centers and clinics are full and cannot take on new patients or unscheduled visits. Patients are referred to the emergency department of simply find the system too confusing to navigate and know the only place they can walk in and see a provider is in the emergency department. To fix our healthcare system will require cultural change, not just in how we deliver and pay for healthcare but in how we as a society expect healthcare. In the meantime, we as emergency physicians welcome the visits to our department and the satisfaction of caring for our fellow citizens.”

A Post ER Follow-Up Could Save Your Life

From the Cleveland Clinic:

Even if Emergency Room doctors say you didn’t actually have a heart attack, that doesn’t mean you have a clean bill of health. You should still follow up with your doctor.

As originally reported by Reuters, recent studies confirm that chest pain patients who followed up with a doctor visit after their ER-release fared better in the next year than those who “swept the worry under the rug.”