Journal Club May 2021 from scientific paper

Scientific paper discussion

1. JESSICA ROSARIO-FALERO, PGY-2 CHRISTIAN NIEVES-RIVERA, PGY-3 DR NICOLAS ROSARIO, MENTOR Journal Club May 2021

2. JOURNAL: Pediatric Cardiology YEAR: 2020

3. BACKGROUND Chest pain is a common complaint in pediatric population. Most common causes are musculoskeletal and pulmonary. Cardiac etiology is less than 1% Despite low incidence, chest pain remains a significant reason for referral to pediatric cardiology This leads to unnecessary testing: echocardiogram and cardiopulmonary exercise testing (CPET)

4. WHY THIS STUDY? Institutions are implementing algorithms to minimize unnecessary testing (i.e., SCAMPs) Minimal research if whether these algorithms increase the diagnostic yield while decreasing the amount of total testing ordered No research into whether adding PFTs to the standard CPET increases the ability to detect meaningful pathology

5. ARTICLE #1

6. STUDY BACKGROUND OBJECTIVES The objectives of this study are to describe the current practice trends in the evaluation of chest pain by pediatric cardiologists. To evaluate whether a mechanism to standardize care will lead to a reduction in unnecessary resource use while still capturing all important cardiac etiologies of chest pain. METHODS - Reviewed the records of all patients, aged 7 to 21 years, presenting to our outpatient division of pediatric cardiology in 2009 for initial evaluation of chest pain. The institutional review board for clinical research at Children’s Hospital Boston approved the use of patient medical records for this retrospective review.

7. Inclusive criteria Medical history Family history (First degree) Symptoms: > Syncope > Palpitations > Dyspnea Physical Exam: Pathologic murmur, gallop, pericardial rub, abnormal second heart sound, distant heart sounds, hepatomegaly, decreased femoral or peripheral pulses, peripheral edema, painful or swollen extremities, tachypnea, and fever.

8. All patients in this cohort had at least 1 cardiology clinic visit.

9. RESULTS 417 patients between the ages of 7 and 21 years presented to our out- patient division for a first-time evaluation with chest pain as the major diagnosis code. 406 patients as the cohort for this study. A total of 44 of 406 (11%) patients had pertinent positive findings. Thirty-eight patients had 2 or more clinic visits, accounting for a total of 55 repeat visits, with the remaining 368 patients having a single clinic visit. A cardiac etiology for chest pain was found in 5 of 406 patients. Total estimated charges for chest- pain evaluation in the entire cohort were $1,166,465.

10. CONCLUSIONS: Our results emphasize the findings of previous reports showing that cardiac etiologies for pediatric chest pain. We show that implementation of a pediatric chest pain SCAMP could lead to a 21% reduction in charges We suggest that careful history, physical examination, and screening ECGs can detect essentially all cardiac causes of chest pain, Propose that a standardized approach to pediatric chest pain evaluation could lead to a reduction in resource use and cost of care while maintaining or even improving quality of care. Echocardiography is our diagnostic test of choice for patients with concerning past medical or family histories or abnormal EKG or physical examination findings. Propose eliminating ESTs in the routine evaluation of pediatric chest pain. Our results suggest that many patients in this cohort could have been adequately evaluated by their primary care provider using careful history, physical examination, and ECG.

11. ARTICLE #2

12. STUDY BACKGROUND OBJECTIVES: - Compare 2009 historic cohort with actual resource and charge reduction by use of the Chest Pain SCAMP in cardiology clinics. - Analyzed the chest pain SCAMP data base at Boston Children Hospital over the first several years of implementation. METHODS: 1. Clinicians was provided a chest pain SCAMP packet during the clinic visit. 2. Data from packets are collected and enter in the data base. 3. The SCAMP database was analyzed for presenting complaints, medical and family and physical examination and ECG findings for which an echocardiogram is or is not recommended by the algorithm.

13. RESULTS: > N: 1517 patients (55% M, 45% F). > Echo performed in 622 (78%) patients. > Two patients among the 1517 were found to have cardiac etiology for chest pain. > A drop of 18% in overall echo use with a 6% rate reduction by the SCAMP.. > Exercise stress test dropped drastically from Pre- SCAMP. > Overall adjusted charges associated with testing and returns to visit were reduced by 22%.

14. Resource reduction in pediatric chest pain: Standardized clinical assesment and management plan , Congenital H e art Disease, 2017

15. Resource reduction in pediatric chest pain: Standardized clinical assesment and management plan , Congenital H e art Disease, 2017

16. Conclusions: - Chest pain SCAMP has been shown to succesfully reduce resource utilization and pediatric cardiology practice variation. - Reducing unnecesarry testing and practice variation in the assesment of pediatric chest pain. Adjustance charge reduction.

17. ARTICLE #3

18. OBJECTIVES determine if clinical indicators ( red-flags ) identified a subpopulation of children with chest pain in whom cardiac disease explained their chest pain. measure the incidence of low-probability referrals (NAMCS) measure the magnitude of charges from resultant cardiac testing of these referrals (PHIS)

19. METHODOLOGY Retrospective study to determine if clinical indicators ( red-flags ) identified a subpopulation whose CP was from cardiac diseases Study population: All patients from 7 to 21 years of age with chest pain as the primary complaint at the participating sites WITHOUT previous diagnosis of heart disease N = 3,167 Red-Flag Criteria were used to divide population in 2 groups: with & without red flags; patients meeting criteria undergo an echocardiogram Compared incidence of cardiac causes of chest pain between 2 groups

20. RESULTS

21. Distribution of Charges

22. CONCLUSION Red-flag criteria were an effective screen for children with chest pain. In the absence of red-flags, patients need not be referred to cardiology nor do they need additional cardiac testing. Recognition of red flags will result in reduction of unnecessary referrals and testing and help allay parental anxiety Eliminating cardiac testing of low probability referrals would save US $3,775,182 annually.

23. MAIN ARTICLE

24. OBJECTIVES To determine the effect of the newly instituted local consensus guideline on testing ordered To examine if the overall yield for pathology changed after local consensus guideline implementation To examine if adding pulmonary function testing to CPET can increase the diagnostic yield in these patients.

25. METODOLOGY

26. METHODS October 1, 2016 - Heart Institute at Cincinnati Children’s Hospital Medical Center implemented a new local consensus guideline to be used by all pediatric cardiologists for the initial evaluation and management of chest pain Chart review ( retrospective ) of all new pediatric patients with chest pain from April 1, 2015, to April 1, 2018 Compared outcomes before and after CPG implementation**

27. STUDY PARTICIPANTS N: 1547 patients referred to cardiology clinics from April 1, 2015 to April 1, 2018 with a chief complaint of chest pain INCLUSION CRITERIA No previous cardiac diagnosis Presenting complaint of chest pain (new visit) EXCLUSION CRITERIA patients older than 21 years of age patients previously seen for chest pain

28. STATISTICAL ANALYSIS Differences between study and control patients were assessed using Unpaired t-test for normally distributed data Wilcoxon Signed-Rank Test for non-normally distributed data A p value < 0.05 was considered significant. Statistical analyses were performed using JMP®, Version 14 from SAS Institute Inc. (Cary, NC).

29. RESULTS

30. Fig. 2 Bar graph showing the difference between total tests ordered before and after local consensus guideline implementation.

31. DISCUSSION

32. As healthcare cost continue increasing, reducing unnecessary resource utilization and thus decreasing unnecessary spending is essential. This study demonstrates that the use of a local consensus guideline can reduce resource utilization , as there was a significant decrease in the total echocardiograms (↓36%) and CPETs (↓39%) performed following implementation There was no concerning pathology noted before or after guideline implementation, no conclusion can be made about the effect of guideline implementation on the diagnostic yield of testing

33. While there was an exceptionally low-yield for identifying cardiac pathology with echocardiography and cardiopulmonary exercise testing, 1 in 5 patients had abnormal PFTs when evaluated. This may offer additional support to the non-cardiac nature of most cases of pediatric chest pain. Based on these findings, PFTs may be a higher-yield initial test for the evaluation of pediatric chest pain than either standard echocardiogram or exercise stress tests in an otherwise low cardiac risk patient.

34. LIMITATIONS Single tertiary care medical center. No way to monitor if physicians followed the guideline. The study may have been insufficiently powered to detected underlying pathologies. Data only included patients seen in the outpatient setting and does not reflect patients seen in other settings such as the emergency department.

35. CONCLUSION Consensus Guidelines are a feasible and reasonable tool for the initial evaluation and management of pediatric chest pain in outpatient setting. Its implementation can decrease practice variation and limit unnecessary tests ( ie ., ECHO, CPETs) without negatively affecting the diagnostic yield. Adding PFTs in the work-up of pediatric chest pain may lead to increased diagnostic accuracy

36. INTERNAL VALIDITY Was the question clearly stated? Were the criteria used to select participants for inclusion appropriate? Were the included participants appropriate for the type of question asked? Were the methods for performing the test described in sufficient detail to permit replications?

37. EXTERNAL VALIDITY Will the results help me in caring for my patient? Is my patient so different to those in the study that the results cannot apply?

38. REFERENCES Rathod RH, Farias M, Friedman KG, Graham D, Fulton DR, Newburger JW, Colan S, Jenkins K, Lock JE. A novel approach to gathering and acting on relevant clinical information: SCAMPs. Congenit Heart Dis. 2010 Jul-Aug;5(4):343-53. doi : 10.1111/j.1747-0803.2010.00438.x. PMID: 20653701; PMCID: PMC3376528. Saleeb , S. F., McLaughlin, S. R., Graham, D. A., Friedman, K. G., & Fulton, D. R. (2017). Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan. Congenital Heart Disease, 13(1), 46–51. https://doi.org/10.1111/chd.12539 Harahsheh AS, O'Byrne ML, Pastor B, Graham DA, Fulton DR. Pediatric Chest Pain-Low-Probability Referral: A Multi-Institutional Analysis From Standardized Clinical Assessment and Management Plans (SCAMPs®), the Pediatric Health Information Systems Database, and the National Ambulatory Medical Care Survey. Clin Pediatr (Phila). 2017 Nov;56(13):1201-1208. doi : 10.1177/0009922816684605. Epub 2017 Jan 12. PMID: 28081617; PMCID: PMC6388765. Powell AW, Pater CM, Chin C, Wittekind SG, Mays WA, Anderson JB, Statile CJ. Implementation of a Pediatric Chest Pain Local Consensus Guideline Decreases the Total Tests Performed Without Negatively Affecting the Yield of Abnormal Cardiac Results. Pediatr Cardiol . 2020 Dec;41(8):1580-1586. doi : 10.1007/s00246-020-02414-y. Epub 2020 Jul 24. PMID: 32710284.