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Electronic Risk Alerts to Improve Primary Care Management of Chest Pain: A Randomized, Controlled Trial

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Abstract

BACKGROUND

The primary care evaluation of chest pain represents a significant diagnostic challenge.

OBJECTIVE

To determine if electronic alerts to physicians can improve the quality and safety of chest pain evaluations.

DESIGN AND PARTICIPANTS

Randomized, controlled trial conducted between November 2008 and January 2010 among 292 primary care clinicians caring for 7,083 adult patients with chest pain and no history of cardiovascular disease.

INTERVENTION

Clinicians received alerts within the electronic health record during office visits for chest pain. One alert recommended performance of an electrocardiogram and administration of aspirin for high risk patients (Framingham Risk Score (FRS) ≥ 10%), and a second alert recommended against performance of cardiac stress testing for low risk patients (FRS < 10%).

MAIN MEASURES

The primary outcomes included performance of an electrocardiogram and administration of aspirin therapy for high risk patients; and avoidance of cardiac stress testing for low risk patients.

KEY RESULTS

The majority (81%) of patients with chest pain were classified as low risk. High risk patients were more likely than low risk patients to be evaluated in the emergency department (11% versus 5%, p < 0.01) and to be hospitalized (7% versus 3%, p < 0.01). Acute myocardial infarction occurred among 26 (0.4%) patients, more commonly among high risk compared to low risk patients (1.1% versus 0.2%, p < 0.01). Among high risk patients, there was no difference between the intervention and control groups in rates of performing electrocardiograms (51% versus 48%, p = 0.33) or administering aspirin (20% versus 18%, p = 0.43). Among low risk patients, there was no difference between intervention and control groups in rates of cardiac stress testing (10% versus 9%, p = 0.40).

CONCLUSIONS

Primary care management of chest pain is suboptimal for both high and low risk patients. Electronic alerts do not increase risk-appropriate care for these patients.

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Acknowledgements

We would like to thank the clinicians and patients of Harvard Vanguard Medical Associates for participating in this study. This project was supported by grant number R18HS017075 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The funding agency played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Dr. Sequist had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest

Dr. Sequist has served as a consultant on the Aetna External Committee on Racial and Ethnic Equality.

Author information

Authors and Affiliations

  1. Division of General Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA, 02120, USA

    Thomas D. Sequist MD, MPH, Shane M. Morong BS, Carol A. Keohane BSN, RN, E. Francis Cook ScD, E. John Orav PhD & Thomas H. Lee MD, MSc

  2. Department of Health Care Policy, Harvard Medical School, Boston, MA, USA

    Thomas D. Sequist MD, MPH

  3. Harvard Vanguard Medical Associates, Boston, MA, USA

    Thomas D. Sequist MD, MPH & Amy Marston BA

  4. Partners Healthcare System, Boston, MA, USA

    Thomas H. Lee MD, MSc

Authors
  1. Thomas D. Sequist MD, MPH
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  2. Shane M. Morong BS
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  3. Amy Marston BA
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  4. Carol A. Keohane BSN, RN
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  5. E. Francis Cook ScD
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  6. E. John Orav PhD
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  7. Thomas H. Lee MD, MSc
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Corresponding author

Correspondence to Thomas D. Sequist MD, MPH.

Additional information

This study was funded by the Agency for Healthcare Research and Quality (R18HS017075). The study protocol was registered at www.ClinicalTrials.gov. (ID number NCT00674375).

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Sequist, T.D., Morong, S.M., Marston, A. et al. Electronic Risk Alerts to Improve Primary Care Management of Chest Pain: A Randomized, Controlled Trial. J GEN INTERN MED 27, 438–444 (2012). https://doi.org/10.1007/s11606-011-1911-6

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  • DOI: https://doi.org/10.1007/s11606-011-1911-6

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