Sherry Boschert

SAN FRANCISCO – Many patients who come to emergency departments complaining of pain remain in pain after being sent home, even if they're discharged with pain medications, according to two prospective studies.

Either pain management plans are inadequate, or patients aren't using the medications properly–or both–the investigators suggested.

In one study, 326 adults rated their pain levels when leaving the emergency department and were contacted by phone 1 week after discharge. Average pain intensity ratings on an 11-point scale were 5.1 at the time of discharge and 4.5 at the 1-week follow-up for the 67% of patients who used prescribed pain medication after discharge.

Patients who did not use prescribed pain medication after discharge rated their pain intensity as an average of 4.1 at the time of discharge and 3.3 a week later, reported Matthew J. Larsen of the University of Utah, Salt Lake City.

Both groups reported experiencing some pain since discharge that was worse than the pain level at discharge. At the 1-week follow-up, patients rated their worst pain since discharge at 6.6 in the prescription pain medication group and 5.6 in the group that did not use prescription pain medication, he said at the annual meeting of the American College of Emergency Physicians.

“Patients continue to have high levels of average and worst pain 1 week after discharge from the emergency department. The use of prescription pain medication did not provide pain relief,” said Mr. Larsen, a medical student who worked on the study with David E. Fosnocht, M.D., and Eric R. Swanson, M.D., both of the university.

Preliminary results from a separate, ongoing study provided some clues to improving pain management, Knox H. Todd, M.D., said at a meeting of the American Society of Law, Medicine, and Ethics.

The study included 304 patients (mostly adults) seen in 13 U.S. and Canadian emergency departments for moderate to severe pain. The investigators reviewed patient charts and conducted phone interviews with patients a median of 6 days after discharge.

Only 36% of patients were pain free at the follow-up, and more than 30% were still in severe pain. Of the 196 patients who still suffered pain, 70% said that it interfered with their general activities, said Dr. Todd, who led the study while at Emory University, Atlanta, and who is currently at Beth Israel Medical Center, New York.

During their ED visits, which lasted a mean of 192 minutes, 110 minutes elapsed before patients received their first analgesic. “That's the same data we found 6-7 years ago when we studied emergency departments in Atlanta and Chicago. This is something structural that we can deal with,” Dr. Todd said.

Overall, 79% of patients received an initial pain assessment in the emergency department, but follow-up was poor, with only 17% receiving more than one pain assessment in the ED.

Communication problems were common and contributed to poor pain management. In the follow-up phone interviews, 72% of patients said they felt they had needed pain medication while in the ER, and 63% received analgesics; but only 26% said they had asked for pain relief. “Patients don't tend to ask,” Dr. Todd said. “This is an area ripe for education–teaching people how to talk to doctors about pain.”

Patients with chronic pain composed 44% of the cohort, with a median 2-year duration of pain. They used the emergency department much more often (a mean of four visits in the past year), compared with patients without chronic pain (one visit in the past year).

Approximately 60%-70% of people who come to emergency departments do so because of pain, he said, making pain the top reason for ED visits.

SAN FRANCISCO – Many patients who come to emergency departments complaining of pain remain in pain after being sent home, even if they're discharged with pain medications, according to two prospective studies.

Either pain management plans are inadequate, or patients aren't using the medications properly–or both–the investigators suggested.

In one study, 326 adults rated their pain levels when leaving the emergency department and were contacted by phone 1 week after discharge. Average pain intensity ratings on an 11-point scale were 5.1 at the time of discharge and 4.5 at the 1-week follow-up for the 67% of patients who used prescribed pain medication after discharge.

Patients who did not use prescribed pain medication after discharge rated their pain intensity as an average of 4.1 at the time of discharge and 3.3 a week later, reported Matthew J. Larsen of the University of Utah, Salt Lake City.

Both groups reported experiencing some pain since discharge that was worse than the pain level at discharge. At the 1-week follow-up, patients rated their worst pain since discharge at 6.6 in the prescription pain medication group and 5.6 in the group that did not use prescription pain medication, he said at the annual meeting of the American College of Emergency Physicians.

“Patients continue to have high levels of average and worst pain 1 week after discharge from the emergency department. The use of prescription pain medication did not provide pain relief,” said Mr. Larsen, a medical student who worked on the study with David E. Fosnocht, M.D., and Eric R. Swanson, M.D., both of the university.

Preliminary results from a separate, ongoing study provided some clues to improving pain management, Knox H. Todd, M.D., said at a meeting of the American Society of Law, Medicine, and Ethics.

The study included 304 patients (mostly adults) seen in 13 U.S. and Canadian emergency departments for moderate to severe pain. The investigators reviewed patient charts and conducted phone interviews with patients a median of 6 days after discharge.

Only 36% of patients were pain free at the follow-up, and more than 30% were still in severe pain. Of the 196 patients who still suffered pain, 70% said that it interfered with their general activities, said Dr. Todd, who led the study while at Emory University, Atlanta, and who is currently at Beth Israel Medical Center, New York.

During their ED visits, which lasted a mean of 192 minutes, 110 minutes elapsed before patients received their first analgesic. “That's the same data we found 6-7 years ago when we studied emergency departments in Atlanta and Chicago. This is something structural that we can deal with,” Dr. Todd said.

Overall, 79% of patients received an initial pain assessment in the emergency department, but follow-up was poor, with only 17% receiving more than one pain assessment in the ED.

Communication problems were common and contributed to poor pain management. In the follow-up phone interviews, 72% of patients said they felt they had needed pain medication while in the ER, and 63% received analgesics; but only 26% said they had asked for pain relief. “Patients don't tend to ask,” Dr. Todd said. “This is an area ripe for education–teaching people how to talk to doctors about pain.”

Patients with chronic pain composed 44% of the cohort, with a median 2-year duration of pain. They used the emergency department much more often (a mean of four visits in the past year), compared with patients without chronic pain (one visit in the past year).

Approximately 60%-70% of people who come to emergency departments do so because of pain, he said, making pain the top reason for ED visits.

SAN FRANCISCO – Many patients who come to emergency departments complaining of pain remain in pain after being sent home, even if they're discharged with pain medications, according to two prospective studies.

Either pain management plans are inadequate, or patients aren't using the medications properly–or both–the investigators suggested.

In one study, 326 adults rated their pain levels when leaving the emergency department and were contacted by phone 1 week after discharge. Average pain intensity ratings on an 11-point scale were 5.1 at the time of discharge and 4.5 at the 1-week follow-up for the 67% of patients who used prescribed pain medication after discharge.

Patients who did not use prescribed pain medication after discharge rated their pain intensity as an average of 4.1 at the time of discharge and 3.3 a week later, reported Matthew J. Larsen of the University of Utah, Salt Lake City.

Both groups reported experiencing some pain since discharge that was worse than the pain level at discharge. At the 1-week follow-up, patients rated their worst pain since discharge at 6.6 in the prescription pain medication group and 5.6 in the group that did not use prescription pain medication, he said at the annual meeting of the American College of Emergency Physicians.

“Patients continue to have high levels of average and worst pain 1 week after discharge from the emergency department. The use of prescription pain medication did not provide pain relief,” said Mr. Larsen, a medical student who worked on the study with David E. Fosnocht, M.D., and Eric R. Swanson, M.D., both of the university.

Preliminary results from a separate, ongoing study provided some clues to improving pain management, Knox H. Todd, M.D., said at a meeting of the American Society of Law, Medicine, and Ethics.

The study included 304 patients (mostly adults) seen in 13 U.S. and Canadian emergency departments for moderate to severe pain. The investigators reviewed patient charts and conducted phone interviews with patients a median of 6 days after discharge.

Only 36% of patients were pain free at the follow-up, and more than 30% were still in severe pain. Of the 196 patients who still suffered pain, 70% said that it interfered with their general activities, said Dr. Todd, who led the study while at Emory University, Atlanta, and who is currently at Beth Israel Medical Center, New York.

During their ED visits, which lasted a mean of 192 minutes, 110 minutes elapsed before patients received their first analgesic. “That's the same data we found 6-7 years ago when we studied emergency departments in Atlanta and Chicago. This is something structural that we can deal with,” Dr. Todd said.

Overall, 79% of patients received an initial pain assessment in the emergency department, but follow-up was poor, with only 17% receiving more than one pain assessment in the ED.

Communication problems were common and contributed to poor pain management. In the follow-up phone interviews, 72% of patients said they felt they had needed pain medication while in the ER, and 63% received analgesics; but only 26% said they had asked for pain relief. “Patients don't tend to ask,” Dr. Todd said. “This is an area ripe for education–teaching people how to talk to doctors about pain.”

Patients with chronic pain composed 44% of the cohort, with a median 2-year duration of pain. They used the emergency department much more often (a mean of four visits in the past year), compared with patients without chronic pain (one visit in the past year).

Approximately 60%-70% of people who come to emergency departments do so because of pain, he said, making pain the top reason for ED visits.

SAN FRANCISCO — Most adults seen in emergency departments have health insurance and a usual source of care besides the ED, countering the common notion that uninsured patients are clogging up emergency departments because they have nowhere else to go, Ellen J. Weber, M.D., said at the annual meeting of the American College of Emergency Physicians. (See box on p. 73.)

Using data on a population-based sample of 49,603 adults, she and her associates estimated that more than 45 million U.S. adults made nearly 80 million visits to EDs during a recent 1-year period. Of those who went to emergency departments, 83% said they had a usual source of care other than the ED (accounting for 82% of ED visits), and 85% had some form of health insurance (accounting for 85% of ED visits), she said.

Improving the delivery of outpatient care may be the key to decreasing use of the ED, the investigators concluded.

The study—one of a few to compare ED users with nonusers in these respects—showed that uninsured adults were no more likely to visit the ED during the study period than were people with private insurance. Compared with privately insured patients, those with Medicaid or Medicare were 51% and 19% more likely, respectively, to use the ED.

Adults with no usual source of care were 25% less likely to visit the ED than were adults whose usual care came from a private physician. Patients who used the ED for their usual care or who had no source of usual care were responsible for only 17% of ED visits.

People who used the ED most had poor health or changes in their usual care or insurance, the study found.

People with poor physical health were more than twice as likely to have visited an ED as were people in good health, and they accounted for nearly half of all ED visits. People with poor mental health were 51% more likely to go to an ED than were people with good mental health. People who had had a change in their usual source of care were 30% more likely to seek help in an ED than were people with stable care. A change in insurance increased the odds of an ED visit by 15%. Poverty increased the likelihood of an ED visit, but patients with incomes below the poverty level accounted for only one in five visits.

“People affected by ED overcrowding and closures of emergency departments are the seriously ill,” said Dr. Weber, medical director of the emergency department at the University of California, San Francisco.

Data for the study came from the Community Tracking Study Household Survey. The Center for Studying Health System Change, a nonpartisan policy research group in Washington, conducted the survey. The survey data, from July 2000 through June 2001, included interviews in English or Spanish with up to eight adults per household in 60 communities and in a national sample, plus administration of the SF-12 Health Survey.

Several factors often thought to decrease the use of EDs were not associated with fewer ED visits, including enrollment in an HMO, early availability of appointments, and patients' satisfaction with their primary physicians.

Previous studies reported conflicting data about whether people visiting EDs were more likely to be uninsured or to have no usual source of care, perhaps because they studied individual departments, focused on special populations, and didn't compare ED visitors to nonvisitors, Dr. Weber said.

A separate population-based study reported at the meeting both complemented and contradicted Dr. Weber's findings.

Adults who came to the ED were more likely to have chronic medical conditions, to lack prescription insurance, or to have a poor perception of their mental and physical health. They were more likely to be poor, female, or nonwhite, compared with people who did not visit EDs, said Thomas L. Zickgraf, D.O., of the Philadelphia College of Osteopathic Medicine.

The analysis of data on 17,556 adults in the 2000 Medical Expenditure Panel Survey found that 23% had a chronic condition, and 19% of those with a chronic condition visited the ED during the study period, vs. 11% of people without such a condition.

Nonwhite race increased the odds of an ED visit by 83%. Lack of prescription insurance increased the likelihood of an ED visit by 82%, he reported in a poster.

SAN FRANCISCO — Most adults seen in emergency departments have health insurance and a usual source of care besides the ED, countering the common notion that uninsured patients are clogging up emergency departments because they have nowhere else to go, Ellen J. Weber, M.D., said at the annual meeting of the American College of Emergency Physicians. (See box on p. 73.)

Using data on a population-based sample of 49,603 adults, she and her associates estimated that more than 45 million U.S. adults made nearly 80 million visits to EDs during a recent 1-year period. Of those who went to emergency departments, 83% said they had a usual source of care other than the ED (accounting for 82% of ED visits), and 85% had some form of health insurance (accounting for 85% of ED visits), she said.

Improving the delivery of outpatient care may be the key to decreasing use of the ED, the investigators concluded.

The study—one of a few to compare ED users with nonusers in these respects—showed that uninsured adults were no more likely to visit the ED during the study period than were people with private insurance. Compared with privately insured patients, those with Medicaid or Medicare were 51% and 19% more likely, respectively, to use the ED.

Adults with no usual source of care were 25% less likely to visit the ED than were adults whose usual care came from a private physician. Patients who used the ED for their usual care or who had no source of usual care were responsible for only 17% of ED visits.

People who used the ED most had poor health or changes in their usual care or insurance, the study found.

People with poor physical health were more than twice as likely to have visited an ED as were people in good health, and they accounted for nearly half of all ED visits. People with poor mental health were 51% more likely to go to an ED than were people with good mental health. People who had had a change in their usual source of care were 30% more likely to seek help in an ED than were people with stable care. A change in insurance increased the odds of an ED visit by 15%. Poverty increased the likelihood of an ED visit, but patients with incomes below the poverty level accounted for only one in five visits.

“People affected by ED overcrowding and closures of emergency departments are the seriously ill,” said Dr. Weber, medical director of the emergency department at the University of California, San Francisco.

Data for the study came from the Community Tracking Study Household Survey. The Center for Studying Health System Change, a nonpartisan policy research group in Washington, conducted the survey. The survey data, from July 2000 through June 2001, included interviews in English or Spanish with up to eight adults per household in 60 communities and in a national sample, plus administration of the SF-12 Health Survey.

Several factors often thought to decrease the use of EDs were not associated with fewer ED visits, including enrollment in an HMO, early availability of appointments, and patients' satisfaction with their primary physicians.

Previous studies reported conflicting data about whether people visiting EDs were more likely to be uninsured or to have no usual source of care, perhaps because they studied individual departments, focused on special populations, and didn't compare ED visitors to nonvisitors, Dr. Weber said.

A separate population-based study reported at the meeting both complemented and contradicted Dr. Weber's findings.

Adults who came to the ED were more likely to have chronic medical conditions, to lack prescription insurance, or to have a poor perception of their mental and physical health. They were more likely to be poor, female, or nonwhite, compared with people who did not visit EDs, said Thomas L. Zickgraf, D.O., of the Philadelphia College of Osteopathic Medicine.

The analysis of data on 17,556 adults in the 2000 Medical Expenditure Panel Survey found that 23% had a chronic condition, and 19% of those with a chronic condition visited the ED during the study period, vs. 11% of people without such a condition.

Nonwhite race increased the odds of an ED visit by 83%. Lack of prescription insurance increased the likelihood of an ED visit by 82%, he reported in a poster.

SAN FRANCISCO — Most adults seen in emergency departments have health insurance and a usual source of care besides the ED, countering the common notion that uninsured patients are clogging up emergency departments because they have nowhere else to go, Ellen J. Weber, M.D., said at the annual meeting of the American College of Emergency Physicians. (See box on p. 73.)

Using data on a population-based sample of 49,603 adults, she and her associates estimated that more than 45 million U.S. adults made nearly 80 million visits to EDs during a recent 1-year period. Of those who went to emergency departments, 83% said they had a usual source of care other than the ED (accounting for 82% of ED visits), and 85% had some form of health insurance (accounting for 85% of ED visits), she said.

Improving the delivery of outpatient care may be the key to decreasing use of the ED, the investigators concluded.

The study—one of a few to compare ED users with nonusers in these respects—showed that uninsured adults were no more likely to visit the ED during the study period than were people with private insurance. Compared with privately insured patients, those with Medicaid or Medicare were 51% and 19% more likely, respectively, to use the ED.

Adults with no usual source of care were 25% less likely to visit the ED than were adults whose usual care came from a private physician. Patients who used the ED for their usual care or who had no source of usual care were responsible for only 17% of ED visits.

People who used the ED most had poor health or changes in their usual care or insurance, the study found.

People with poor physical health were more than twice as likely to have visited an ED as were people in good health, and they accounted for nearly half of all ED visits. People with poor mental health were 51% more likely to go to an ED than were people with good mental health. People who had had a change in their usual source of care were 30% more likely to seek help in an ED than were people with stable care. A change in insurance increased the odds of an ED visit by 15%. Poverty increased the likelihood of an ED visit, but patients with incomes below the poverty level accounted for only one in five visits.

“People affected by ED overcrowding and closures of emergency departments are the seriously ill,” said Dr. Weber, medical director of the emergency department at the University of California, San Francisco.

Data for the study came from the Community Tracking Study Household Survey. The Center for Studying Health System Change, a nonpartisan policy research group in Washington, conducted the survey. The survey data, from July 2000 through June 2001, included interviews in English or Spanish with up to eight adults per household in 60 communities and in a national sample, plus administration of the SF-12 Health Survey.

Several factors often thought to decrease the use of EDs were not associated with fewer ED visits, including enrollment in an HMO, early availability of appointments, and patients' satisfaction with their primary physicians.

Previous studies reported conflicting data about whether people visiting EDs were more likely to be uninsured or to have no usual source of care, perhaps because they studied individual departments, focused on special populations, and didn't compare ED visitors to nonvisitors, Dr. Weber said.

A separate population-based study reported at the meeting both complemented and contradicted Dr. Weber's findings.

Adults who came to the ED were more likely to have chronic medical conditions, to lack prescription insurance, or to have a poor perception of their mental and physical health. They were more likely to be poor, female, or nonwhite, compared with people who did not visit EDs, said Thomas L. Zickgraf, D.O., of the Philadelphia College of Osteopathic Medicine.

The analysis of data on 17,556 adults in the 2000 Medical Expenditure Panel Survey found that 23% had a chronic condition, and 19% of those with a chronic condition visited the ED during the study period, vs. 11% of people without such a condition.

Nonwhite race increased the odds of an ED visit by 83%. Lack of prescription insurance increased the likelihood of an ED visit by 82%, he reported in a poster.

SAN FRANCISCO — An ECG mapping device improved the diagnosis of acute coronary syndrome, compared with standard ECG, and provided information that could help with treatment, said Gregory J. Fermann, M.D., at the annual meeting of the American College of Emergency Physicians.

In a study of 90 adult patients, those evaluated in the emergency department for acute coronary syndrome by ECG and cardiac markers underwent both the standard 12-lead ECG and cardiac mapping using the Prime ECG System. Approved in 2001, the Prime ECG uses 72 unipolar leads placed in a vest-like distribution over the front, back, and sides of the patient's torso to obtain a three-dimensional view of cardiac electrical activity. Standard ECG uses six unipolar leads. Both ECG systems use six additional limb leads.

Meridian Medical Technologies, which makes the Prime ECG System, funded the study.

Physicians managing the patients were first given results of the standard ECG and asked to estimate the probability that the patient had acute coronary syndrome. They then received the cardiac mapping results and were asked the same question. The physicians were also asked whether the cardiac mapping gave them additional information, compared with standard ECG, and whether the mapping might help guide treatment. Patients were followed for objective evidence of acute coronary syndrome in the hospital and assessed 30 days after discharge for adverse outcomes.

The investigators compared physicians' responses with the diagnosis of acute coronary syndrome. Estimates based on cardiac mapping were more sensitive than estimates based on standard ECG at identifying acute coronary syndrome (40% vs. 20%). Standard ECG and cardiac mapping showed similar specificity (93% vs. 92%, respectively) in diagnosing acute coronary syndrome, said Dr. Fermann, director of clinical operations at the University of Cincinnati.

Physicians in the study said cardiac mapping provided additional information in 51 of the 90 cases and said the results would assist in treatment in 53 cases, Dr. Fermann reported. The cardiac mapping results increased the likelihood of a diagnosis of acute coronary syndrome in 11 cases and decreased the likelihood in 32 cases. Cardiac mapping was more sensitive than standard ECG in diagnosing a subset of patients who had acute coronary syndrome, those with non-ST segment elevation MI.

SAN FRANCISCO — An ECG mapping device improved the diagnosis of acute coronary syndrome, compared with standard ECG, and provided information that could help with treatment, said Gregory J. Fermann, M.D., at the annual meeting of the American College of Emergency Physicians.

In a study of 90 adult patients, those evaluated in the emergency department for acute coronary syndrome by ECG and cardiac markers underwent both the standard 12-lead ECG and cardiac mapping using the Prime ECG System. Approved in 2001, the Prime ECG uses 72 unipolar leads placed in a vest-like distribution over the front, back, and sides of the patient's torso to obtain a three-dimensional view of cardiac electrical activity. Standard ECG uses six unipolar leads. Both ECG systems use six additional limb leads.

Meridian Medical Technologies, which makes the Prime ECG System, funded the study.

Physicians managing the patients were first given results of the standard ECG and asked to estimate the probability that the patient had acute coronary syndrome. They then received the cardiac mapping results and were asked the same question. The physicians were also asked whether the cardiac mapping gave them additional information, compared with standard ECG, and whether the mapping might help guide treatment. Patients were followed for objective evidence of acute coronary syndrome in the hospital and assessed 30 days after discharge for adverse outcomes.

The investigators compared physicians' responses with the diagnosis of acute coronary syndrome. Estimates based on cardiac mapping were more sensitive than estimates based on standard ECG at identifying acute coronary syndrome (40% vs. 20%). Standard ECG and cardiac mapping showed similar specificity (93% vs. 92%, respectively) in diagnosing acute coronary syndrome, said Dr. Fermann, director of clinical operations at the University of Cincinnati.

Physicians in the study said cardiac mapping provided additional information in 51 of the 90 cases and said the results would assist in treatment in 53 cases, Dr. Fermann reported. The cardiac mapping results increased the likelihood of a diagnosis of acute coronary syndrome in 11 cases and decreased the likelihood in 32 cases. Cardiac mapping was more sensitive than standard ECG in diagnosing a subset of patients who had acute coronary syndrome, those with non-ST segment elevation MI.

SAN FRANCISCO — An ECG mapping device improved the diagnosis of acute coronary syndrome, compared with standard ECG, and provided information that could help with treatment, said Gregory J. Fermann, M.D., at the annual meeting of the American College of Emergency Physicians.

In a study of 90 adult patients, those evaluated in the emergency department for acute coronary syndrome by ECG and cardiac markers underwent both the standard 12-lead ECG and cardiac mapping using the Prime ECG System. Approved in 2001, the Prime ECG uses 72 unipolar leads placed in a vest-like distribution over the front, back, and sides of the patient's torso to obtain a three-dimensional view of cardiac electrical activity. Standard ECG uses six unipolar leads. Both ECG systems use six additional limb leads.

Meridian Medical Technologies, which makes the Prime ECG System, funded the study.

Physicians managing the patients were first given results of the standard ECG and asked to estimate the probability that the patient had acute coronary syndrome. They then received the cardiac mapping results and were asked the same question. The physicians were also asked whether the cardiac mapping gave them additional information, compared with standard ECG, and whether the mapping might help guide treatment. Patients were followed for objective evidence of acute coronary syndrome in the hospital and assessed 30 days after discharge for adverse outcomes.

The investigators compared physicians' responses with the diagnosis of acute coronary syndrome. Estimates based on cardiac mapping were more sensitive than estimates based on standard ECG at identifying acute coronary syndrome (40% vs. 20%). Standard ECG and cardiac mapping showed similar specificity (93% vs. 92%, respectively) in diagnosing acute coronary syndrome, said Dr. Fermann, director of clinical operations at the University of Cincinnati.

Physicians in the study said cardiac mapping provided additional information in 51 of the 90 cases and said the results would assist in treatment in 53 cases, Dr. Fermann reported. The cardiac mapping results increased the likelihood of a diagnosis of acute coronary syndrome in 11 cases and decreased the likelihood in 32 cases. Cardiac mapping was more sensitive than standard ECG in diagnosing a subset of patients who had acute coronary syndrome, those with non-ST segment elevation MI.

SAN FRANCISCO — In some patients being evaluated for chest pain, stress tests might be avoided through the use of an algorithm designed to predict the probability of cardiac ischemia, David D. Moyer-Diener and his associates said at the annual meeting of the American College of Emergency Physicians.

In a prospective, observational cohort study of consecutive patients evaluated at a chest pain center, investigators obtained Acute Coronary Ischemia-Time Insensitive Predictive Instrument (ACI-TIPI) scores and conventional chest pain work-ups on 1,478 low- or intermediate-risk patients for whom acute myocardial ischemia had been ruled out. The treating physicians were blinded to the ACI-TIPI scores, and patients underwent conventional evaluations including serial enzyme tests and provocative cardiac testing.

Among 400 patients who had ACI-TIPI scores of 20 or less, 265 were men younger than aged 35 years or women younger than aged 45 years, and 217 underwent provocative cardiac testing. None of the 265 patients developed acute coronary syndrome within 30 days, as determined by phone calls to patients and reviews of records and the Social Security Death Index.

If clinicians had used an ACI-TIPI score of 20 or less in these subsets of young patients to exclude provocative cardiac testing and had sent these patients home, 15% of all stress tests in the study cohort could have been avoided without causing any harm, said Mr. Moyer-Diener, a medical student at the University of Michigan, Ann Arbor, who conducted the study with Michael G. Mikhail, M.D., and associates at the university.

At the meeting, physicians on a separate panel discussing cutting-edge research both praised and criticized the study.

“There's been a lot of debate about just how useful” an ACI-TIPI score is, said Charles V. Pollack Jr., M.D., chair of emergency medicine at Pennsylvania Hospital, Philadelphia. Many emergency physicians would rather not have a quantitative number related to the risk of ischemia on a patient's chart, he said, because if the case sparks a lawsuit, they would rather defend their clinical impression that the patient didn't have ischemia.

The ACI-TIPI was designed to predict the probability of cardiac ischemia on a 0- to 100-point scale, to serve as support or a “second opinion” in clinical decision making. The way ACI-TIPI was used in the study to identify patients who don't need further tests “is not really the use for which it was designed,” but the idea is intriguing, Dr. Pollack said.

Jerome R. Hoffman, M.D., lauded the investigators for trying to identify a strategy to cut down on the many unnecessary tests performed for chest pain evaluation that are not backed by evidence-based medicine. “It's very hard to get us out of that rut,” said Dr. Hoffman, professor of emergency medicine at the University of California, Los Angeles.

But physicians are unlikely to adopt these criteria for avoiding stress tests. An ACI-TIPI score of 20 or less is associated with a 19% risk of acute myocardial ischemia, he explained. For medicolegal reasons, physicians will not feel comfortable sending patients home if that number appears on a patient's chart.

“That, more than anything, makes me question the value of an ACI-TIPI—other than as a research tool,” Dr. Hoffman said.

Previous studies have shown that physicians were two to three times more likely to admit patients if given an ACI-TIPI score to include in the patient's chart, said Ian G. Stiell, M.D., of the University of Ottawa.

Dr. Pollack noted that the current study claimed to exclude patients with acute myocardial ischemia. “I think that's a dangerous statement,” he said, “because ordinarily that is done in a chest pain center by measuring serial troponin levels, which excludes only necrosis. It doesn't exclude ischemia.”

SAN FRANCISCO — In some patients being evaluated for chest pain, stress tests might be avoided through the use of an algorithm designed to predict the probability of cardiac ischemia, David D. Moyer-Diener and his associates said at the annual meeting of the American College of Emergency Physicians.

In a prospective, observational cohort study of consecutive patients evaluated at a chest pain center, investigators obtained Acute Coronary Ischemia-Time Insensitive Predictive Instrument (ACI-TIPI) scores and conventional chest pain work-ups on 1,478 low- or intermediate-risk patients for whom acute myocardial ischemia had been ruled out. The treating physicians were blinded to the ACI-TIPI scores, and patients underwent conventional evaluations including serial enzyme tests and provocative cardiac testing.

Among 400 patients who had ACI-TIPI scores of 20 or less, 265 were men younger than aged 35 years or women younger than aged 45 years, and 217 underwent provocative cardiac testing. None of the 265 patients developed acute coronary syndrome within 30 days, as determined by phone calls to patients and reviews of records and the Social Security Death Index.

If clinicians had used an ACI-TIPI score of 20 or less in these subsets of young patients to exclude provocative cardiac testing and had sent these patients home, 15% of all stress tests in the study cohort could have been avoided without causing any harm, said Mr. Moyer-Diener, a medical student at the University of Michigan, Ann Arbor, who conducted the study with Michael G. Mikhail, M.D., and associates at the university.

At the meeting, physicians on a separate panel discussing cutting-edge research both praised and criticized the study.

“There's been a lot of debate about just how useful” an ACI-TIPI score is, said Charles V. Pollack Jr., M.D., chair of emergency medicine at Pennsylvania Hospital, Philadelphia. Many emergency physicians would rather not have a quantitative number related to the risk of ischemia on a patient's chart, he said, because if the case sparks a lawsuit, they would rather defend their clinical impression that the patient didn't have ischemia.

The ACI-TIPI was designed to predict the probability of cardiac ischemia on a 0- to 100-point scale, to serve as support or a “second opinion” in clinical decision making. The way ACI-TIPI was used in the study to identify patients who don't need further tests “is not really the use for which it was designed,” but the idea is intriguing, Dr. Pollack said.

Jerome R. Hoffman, M.D., lauded the investigators for trying to identify a strategy to cut down on the many unnecessary tests performed for chest pain evaluation that are not backed by evidence-based medicine. “It's very hard to get us out of that rut,” said Dr. Hoffman, professor of emergency medicine at the University of California, Los Angeles.

But physicians are unlikely to adopt these criteria for avoiding stress tests. An ACI-TIPI score of 20 or less is associated with a 19% risk of acute myocardial ischemia, he explained. For medicolegal reasons, physicians will not feel comfortable sending patients home if that number appears on a patient's chart.

“That, more than anything, makes me question the value of an ACI-TIPI—other than as a research tool,” Dr. Hoffman said.

Previous studies have shown that physicians were two to three times more likely to admit patients if given an ACI-TIPI score to include in the patient's chart, said Ian G. Stiell, M.D., of the University of Ottawa.

Dr. Pollack noted that the current study claimed to exclude patients with acute myocardial ischemia. “I think that's a dangerous statement,” he said, “because ordinarily that is done in a chest pain center by measuring serial troponin levels, which excludes only necrosis. It doesn't exclude ischemia.”

SAN FRANCISCO — In some patients being evaluated for chest pain, stress tests might be avoided through the use of an algorithm designed to predict the probability of cardiac ischemia, David D. Moyer-Diener and his associates said at the annual meeting of the American College of Emergency Physicians.

In a prospective, observational cohort study of consecutive patients evaluated at a chest pain center, investigators obtained Acute Coronary Ischemia-Time Insensitive Predictive Instrument (ACI-TIPI) scores and conventional chest pain work-ups on 1,478 low- or intermediate-risk patients for whom acute myocardial ischemia had been ruled out. The treating physicians were blinded to the ACI-TIPI scores, and patients underwent conventional evaluations including serial enzyme tests and provocative cardiac testing.

Among 400 patients who had ACI-TIPI scores of 20 or less, 265 were men younger than aged 35 years or women younger than aged 45 years, and 217 underwent provocative cardiac testing. None of the 265 patients developed acute coronary syndrome within 30 days, as determined by phone calls to patients and reviews of records and the Social Security Death Index.

If clinicians had used an ACI-TIPI score of 20 or less in these subsets of young patients to exclude provocative cardiac testing and had sent these patients home, 15% of all stress tests in the study cohort could have been avoided without causing any harm, said Mr. Moyer-Diener, a medical student at the University of Michigan, Ann Arbor, who conducted the study with Michael G. Mikhail, M.D., and associates at the university.

At the meeting, physicians on a separate panel discussing cutting-edge research both praised and criticized the study.

“There's been a lot of debate about just how useful” an ACI-TIPI score is, said Charles V. Pollack Jr., M.D., chair of emergency medicine at Pennsylvania Hospital, Philadelphia. Many emergency physicians would rather not have a quantitative number related to the risk of ischemia on a patient's chart, he said, because if the case sparks a lawsuit, they would rather defend their clinical impression that the patient didn't have ischemia.

The ACI-TIPI was designed to predict the probability of cardiac ischemia on a 0- to 100-point scale, to serve as support or a “second opinion” in clinical decision making. The way ACI-TIPI was used in the study to identify patients who don't need further tests “is not really the use for which it was designed,” but the idea is intriguing, Dr. Pollack said.

Jerome R. Hoffman, M.D., lauded the investigators for trying to identify a strategy to cut down on the many unnecessary tests performed for chest pain evaluation that are not backed by evidence-based medicine. “It's very hard to get us out of that rut,” said Dr. Hoffman, professor of emergency medicine at the University of California, Los Angeles.

But physicians are unlikely to adopt these criteria for avoiding stress tests. An ACI-TIPI score of 20 or less is associated with a 19% risk of acute myocardial ischemia, he explained. For medicolegal reasons, physicians will not feel comfortable sending patients home if that number appears on a patient's chart.

“That, more than anything, makes me question the value of an ACI-TIPI—other than as a research tool,” Dr. Hoffman said.

Previous studies have shown that physicians were two to three times more likely to admit patients if given an ACI-TIPI score to include in the patient's chart, said Ian G. Stiell, M.D., of the University of Ottawa.

Dr. Pollack noted that the current study claimed to exclude patients with acute myocardial ischemia. “I think that's a dangerous statement,” he said, “because ordinarily that is done in a chest pain center by measuring serial troponin levels, which excludes only necrosis. It doesn't exclude ischemia.”

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR. E-mail surveys of the physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after EHR. Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR. E-mail surveys of the physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after EHR. Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR. E-mail surveys of the physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after EHR. Future research should study the impact of EHR on nonclinic time, she said.