CPJXXX10.1177/0009922816684605Clinical PediatricsHarahsheh et al 684605research-article2017 Original Article Clinical Pediatrics 1 –8 Pediatric Chest Pain—Low-Probability © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav Referral: A Multi-Institutional Analysis DOI:https://doi.org/10.1177/0009922816684605 10.1177/0009922816684605 From Standardized Clinical Assessment journals.sagepub.com/home/cpj and Management Plans (SCAMPs®), the Pediatric Health Information Systems Database, and the National Ambulatory Medical Care Survey Ashraf S. Harahsheh, MD, FACC, FAAP1,2, Michael L. O’Byrne, MD, MSCE1,2, Bill Pastor, MA, MPH1, Dionne A. Graham, PhD3, and David R. Fulton, MD3 Abstract We conducted a study to assess test characteristics of red-flag criteria for identifying cardiac disease causing chest pain and technical charges of low-probability referrals. Accuracy of red-flag criteria was ascertained through study of chest pain Standardized Clinical Assessment and Management Plans (SCAMPs®) data. Patients were divided into 2 groups: Group1 (concerning clinical elements) and Group2 (without). We compared incidence of cardiac disease causing chest pain between these 2 groups. Technical charges of Group 2 were analyzed using the Pediatric Health Information System database. Potential savings for the US population was estimated using National Ambulatory Medical Care Survey data. Fifty-two percent of subjects formed Group 1. Cardiac disease causing chest pain was identified in 8/1656 (0.48%). No heart disease was identified in patients in Group 2 (P = .03). Applying red-flags in determining need for referral identified patients with cardiac disease causing chest pain with 100% sensitivity. Median technical charges for Group 2, over a 4-year period, were US2014$775 559. Eliminating cardiac testing of low- probability referrals would save US2014$3 775 182 in technical charges annually. Red-flag criteria were an effective screen for children with chest pain. Eliminating cardiac testing in children without red-flags for referral has significant technical charge savings. Keywords quality improvement, pediatric cardiology, subspecialty referral, chest pain Background pediatricians feel pressured to make unwarranted sub- specialty referrals related solely on parent concerns.5,6 In the medical home model, primary pediatricians are We conducted a retrospective study to determine if the first contact for triaging complaints and for identify- clinical indicators (red-flags) identified a subpopulation ing which patients need to be seen by medical special- of children with chest pain in whom cardiac disease ists.1,2 Appropriately triaging emotion-laden complaints, such as chest pain, can be problematic. Chest pain is a common complaint, but it is very infrequently caused by 1Children’s National Health System, Washington, DC, USA 3,4 2George Washington University, Washington, DC, USA a cardiac etiology. To date there have not been effec- 3 tive empirical criteria for identifying which children Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA should be referred for cardiac evaluation. Therefore, referral is at the discretion of the primary care physician Corresponding Author: and thus is prone to practice variation. Previous studies Ashraf Harahsheh, Pediatrics, Division of Cardiology, Children’s National Health System, 111 Michigan Ave, NW Washington, DC have demonstrated that pediatricians feel undereducated 20010, USA. 5 about the issue of subspecialty referral, and some Email: [email protected] 2 Clinical Pediatrics explained their chest pain. We also used data from a Box 1. Items Representing Red-Flag for Referrals. national outpatient survey to measure the incidence of Patient History low-probability referrals, and we combined this with •• Chest pain with exertion administrative data to measure the magnitude of techni- •• Exertional syncope cal charges from resultant cardiac testing of these •• Chest pain that radiates to back, jaw, left arm, or left referrals. shoulder •• Chest pain that increases with supine position •• Chest pain temporally associated with fever (>38.4°C) Methods Past Medical Historya Data Sources •• Hypercoagulable state •• Arthritis/vasculitis Standardized Clinical Assessment and Management •• Immobilization Plans (SCAMPs®) is a quality improvement tool, the Family History goals of which are to reduce practice variation, reduce •• Sudden unexplained death unnecessary utilization of resources, and improve •• Cardiomyopathy patient care and outcomes.7 A SCAMPs® for the evalu- •• Hypercoagulable state ation of chest pain in a pediatric cardiology clinic was Physical Examination designed and first implemented by Boston Children’s •• Respiratory rate >40 Hospital and later expanded to include the New England •• Temperature >38.4°C Congenital Cardiology Association (11 hospitals) as •• Ill-appearing well as Children’s National Health System (1 hospital •• Painful/swollen extremities in metropolitan Washington, DC, area). For each patient •• Non-innocent murmur a SCAMPs® data form (SDF) was completed by the •• Distant heart sounds cardiologist at the time of the first outpatient encounter. •• Gallop Data collected on the SDF included details of the chest •• Pulmonic component of S2 pain, relationship to exercise, associated cardiac symp- •• Pericardial friction rub •• Peripheral edema toms, past medical history, and family history including sudden unexplained death and cardiomyopathy. aChest pain SCAMPs® excluded patients with known cardiac disease Physical examination characteristics were documented which otherwise would have represented a red-flag for referral. as were details of the electrocardiogram (ECG). The SDF highlighted red-flags for the cardiologist based on includes clinical and resource utilization data for 45 not- the patient data with the suggestion that patients meet- for-profit, tertiary care pediatric hospitals in the United ing specific criteria undergo an echocardiogram (Box State.10 These hospitals are affiliated with the Children’s 1). Indications for echocardiography were based on the Hospital Association, Overland Park, KS. The data SCAMPs® methodology as previously described.8 warehouse function for the PHIS database is managed Cardiologists were permitted to diverge from suggested by Truven Health Analytics (Ann Arbor, MI).10 Each next steps and were encouraged to provide the reason. participating hospital submits their charge master with Both the findings of and reasons for ordering the echo- the accompanying charges. The individual charge codes cardiogram (as well as other testing) were documented. are mapped to a common system (Clinical Transaction The final diagnosis as determined by the cardiologist Classification [CTC]) to allow comparative analysis. was captured in the SDF. The accuracy of this has been For example, each hospital’s unique charge code for demonstrated in previous studies.9 The data were sub- ECG is mapped to CTC code 511101, which enables mitted to and analyzed by the Institute for Relevant comparing the charges for ECGs among all participating Clinical Data Analytics in Boston, MA. The institu- hospitals. The population examined included patients tional review board of participating sites reviewed the seen from January 1, 2014, to December 31, 2014. We SCAMPs® and determined that it did not represent arbitrarily choose this interval as representative. human subjects research rather a quality improvement. Therefore, charges are expressed in United States year Subsequently, the current project was reviewed by the 2014 dollars (US2014$). We generated PHIS reports for institutional review board at Children’s National Health selected charge codes (CTC code) at the de-identified System for purpose of publication and was determined patient level to calculate total charges and charge/day to be exempt from review. per charge code. Volume of cases per item ranged from The Pediatric Health Information System (PHIS) 143 (Exercise Stress Test—CTC 511115) to 72 782 database is an administrative pediatric database that (ECG—CTC 511101). Harahsheh et al 3 The National Ambulatory Medical Care Survey Given that these red-flag criteria correctly identified a (NAMCS) is a national probability sample survey of subpopulation with no cardiac disease, we sought to esti- visits to office-based physicians conducted by the mate the economic impact of these low-probability refer- National Center for Health Statistics, Centers for Disease rals. This is the second component of the analysis. Using Control and Prevention.11 To quantify the magnitude of the original cohort of chest pain SCAMPs® cohort, we referrals in children presenting with chest pain, the measured the proportion of patients undergoing ECG, NAMCS organization provided the data set for the year echocardiograms, cardiopulmonary exercise tests, Holter 2012 (most recent data reported) for following diagnosis monitor, event monitor, loop monitors, and cardiac mag- codes that were recorded as 1 of the 3 reasons for the netic resonance imaging in the low-probability SCAMPs® visit: 1050.0 Chest pain and related symptoms; 1050.1 group (negative red-flag criteria; Group 2; between 2010 Chest pain, soreness; 1050.2 Chest discomfort, pressure, and 2014). Dividing the total number for each diagnostic tightness, heaviness; 1050.3 Burning sensation in the test by the total number of patients in the cohort generates chest; 1265.0 Heart pain. From that larger data set, we the probability of