Successful regional implementation of pediatric chest pain algorithm

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1. In the investigating the effectiveness of a diagnostic algorithm for pediatric chest pain, only minimal deviations from guidelines were noted between  Boston Children’s Hospital and participating New England area providers. 

2. Chest pain in children was rarely attributable to heart disease as only 0.2% of patients were diagnosed with an underlying cardiac problem.

Study Rundown:  Each year, many children undergo extensive and costly testing when seeking medical attention for chest pain. Previous research has shown that the overwhelming majority of children presenting with chest pain do not have cardiac pathology. Researchers in the current study attempted to evaluate the adaptability of a previously tested chest pain-specific Standardized Clinical Assessment and Management Plan (SCAMP), in the New England area. The chest pain SCAMP directs physicians in the diagnosis of chest pain based on patient history, physical exam and electrocardiogram (ECG). Physician adherence to guidelines was compared between the origination site of the SCAMP (Boston Children’s Hospital, BCH) and participating New England Congenital Cardiology Association (NECCA) practices. A large number of physicians from both locations strictly adhered to guidelines, and tests not recommended by the SCAMP were rarely performed. Only 0.2% of patients were diagnosed with a cardiac disorder. This study affirms the low incidence of pediatric cardiac chest pain with the potential to lower costs and improve quality of care across healthcare settings through algorithm guidelines.

Click to read the study, published today in Pediatrics

Relevant Reading: Effectiveness of screening for life-threatening chest pain in children

Study Author, Dr. David R. Fulton, MD, talks to 2 Minute Medicine: Cardiology Outpatient Services, Department of Cardiology, Boston Children’s Hospital

“This report confirms the general understanding among pediatric cardiologists that children and adolescents referred for chest pain rarely have a demonstrable cardiac etiology.  The SCAMPs quality improvement methodology enabled cardiology providers within New England to arrive at this conclusion while reducing the use of unnecessary resource utilization.  Not only is this approach applicable to other conditions, processes and disease states, the lack of difference among the sites supports the scalable nature of this tool.  Ultimately, the recommendations offered in the SCAMP could be adopted for practice by primary care providers, since the central screening parameters involve history, physical examination and electrocardiography from which the need for further referral to a specialist can be determined.  As such, SCAMPs can offer an important interface for interdisciplinary management that should result in improved health care delivery at a reduced cost, a future mandate for physicians.” 

In-Depth [quality report]: Researchers gathered demographic and clinical data for 1016 patients from BCH and participating NECCA sites across New England. All patients presented with first-time chest pain and were aged 7-21 years. The SCAMP was designed to identify cardiac causes of chest pain, and to guide physicians in diagnosis based on pertinent patient history, physical exam, and ECG findings. Adherence to the algorithm was defined by the performance of or deviation from SCAMP-recommended tests, and was compared between the BCH and NECCA sites. Both locations were adherent to SCAMP echocardiography guidelines with BCH performing an echo  81.7% of the time when recommended compared to 85.7% in NECCA locations. Some providers performed additional exams based on findings which were not recommended such as exercise testing and rhythm monitoring. It was found that these additional exams did not aid in chest pain diagnosis. Two patients (0.2%) were found to have cardiac causes of chest pain (one pericarditis and one anomalous origin of right coronary artery), and both were diagnosed according to SCAMP guidelines. Musculoskeletal chest pain (32.9%) was the most common diagnosis made by physicians.

By Brandon Childs and Leah H. Carr

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