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Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.37956.664236.EE (Published 29 January 2004) Cite this as: BMJ 2004;328:254
  1. Steve Goodacre, senior lecturer in health service research and emergency medicine (s.goodacre{at}sheffield.ac.uk)1,
  2. Jon Nicholl, director, Medical Care Research Unit1,
  3. Simon Dixon, senior lecturer in health economics1,
  4. Elizabeth Cross, research associate1,
  5. Karen Angelini, chest pain nurse2,
  6. Jane Arnold, chest pain nurse2,
  7. Sue Revill, chest pain nurse2,
  8. Tom Locker, specialist registrar2,
  9. Simon J Capewell, chair of clinical epidemiology4,
  10. Deborah Quinney, research fellow4,
  11. Stephen Campbell, consultant3,
  12. Francis Morris, consultant2
  1. 1School of Health and Related Research, University of Sheffield, Sheffield S1 4DA
  2. 2Emergency Department, Northern General Hospital, Sheffield S5 7AU
  3. 3Department of Cardiology, Northern General Hospital
  4. 4Department of Public Health, University of Liverpool, Liverpool L69 3GB
  1. Correspondence to: S Goodacre
  • Accepted 13 November 2003

Abstract

Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain.

Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective.

Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom.

Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance.

Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service.

Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, −7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (−£56 to £210, P = 0.252).

Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care.

Footnotes

  • Contributors SG conceived the idea for the study, and JN and SJC developed it. All authors contributed to the study design. SG, EC, KA, JA, SR, and DQ collected and managed data. KA, JA, SR, TL, FM, and SC provided care in the chest pain observation unit. SG, JN, and SD performed statistical and economic analysis. SG wrote the first draft of the paper, and all authors contributed to the final draft. SG is the guarantor.

  • Funding The Northern General Hospital received a grant of £94 000 from the Department of Health, to establish the chest pain observation unit. The study was supported by a £30 000 grant from NHS Trent Policy and Practice research funds. SG was funded by a NHS Trent Health Services research fellowship. DQ was funded by Merseyside Health Action Zone.

  • Competing interests SG, FM, SC, KA, JA, SR, and TL were involved in establishing and developing the Northern General Hospital chest pain observation unit. KA, JA, and SR are currently employed as chest pain nurses running this chest pain observation unit. JN, SD, EC, SJC, and DQ have no competing interests to declare.

  • Ethical approval North Sheffield Research Ethics Committee.

  • Accepted 13 November 2003
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