Sickest, smallest to be hit hardest by Commonwealth cuts

The Federal Government has been warned that more people are likely to die because of an increasing shortfall of thousands of doctors, nurses and other health professionals in public hospitals as a result of Commonwealth cutbacks.

AMA President Associate Professor Brian Owler said the Abbott Government’s decision to reduce public hospital by $57 billion over 10 years would have a devastating effect on the State and Territory health systems.

“The AMA has warned of a perfect storm if funding is not increased,” A/Professor Owler said. “We already see hospitals struggling to achieve performance targets. We know that overcrowding, we know that delays in getting into a bed from the emergency department, is not just a matter of the headlines, it is matter of increased morbidity. People have more complications or are more likely to die if they spend more and more time in an emergency department.”

The AMA National Conference was told that in Queensland alone, the Federal Government’s decision to slash growth in public hospital funding from 2017 will rip $11.8 billion out of the State health system over 10 years, resulting in 1503 fewer doctors and 5319 fewer nurses being employed in the time.

A/Professor Owler said the outlook for the smaller states and territories, which had limited revenue-raising capacity, was particularly worrying.

“I really fear for those states, because we know that their economies are quite small. They don’t have the ability to make up the shortfall in revenue, and those states are going to be really badly affected,” he said.

Queensland Health Minister Cameron Dick told the AMA National Conference that the Commonwealth was shoving more of the burden of public hospital funding on to the states.

Mr Dick released modelling by his Department showing that the Commonwealth’s share of national efficient public hospital expenditure would peak at 35.5 per cent in 2016-17 before rapidly falling away to just 32.1 per cent by 2024-25 – virtually 10 percentage points below the level committed to in the 2011 National Health Reform Agreement.

“There will be greater pressure on the hospital system as a result,” the Queensland Minister said. “People will have to wait longer for surgery, people will have to wait longer for patient appointments. We will not be able to deliver the services we need. As the population gets older and costly medical technology increases, there will be a gap.”

AMA Tasmania President Dr Tim Greenaway described to the AMA National Conference how the Commonwealth funding cut would hit his State particularly hard.

Tasmania has the nation’s oldest, fattest, poorest and – by many measures – least healthy population, and Dr Greenaway warned the Federal Government’s policy would only make the situation worse.

Despite having greater health needs than most other states and territories, Tasmania’s spending on health care ($1275 per capita) is below the national average ($1735 per capita), and Dr Greenaway said the Commonwealth’s funding cuts would only “lock in” the State’s inadequate investment in health, “which will inevitably increase health disparity”.

The states and territories are furious the Federal Government has walked away from its commitments under the National Health Reform Agreement, and the issue is set to be near the top of the agenda when Prime Minister Tony Abbott meets with his State and Territory counterparts to discuss reform of the Federation at a leader’s retreat in July.

A/Professor Owler said the Federal Government’s decision was indefensible.

“It’s up to the Commonwealth to live up to its responsibility to make sure that all Australia’s get access to the services they deserve,” he said, adding that the squeeze on hospitals would also have a significant effect on doctor and nurse training.

A video of the Quality public hospital services: funding capacity for performance policy session can be viewed at: media/ama-national-conference-30-may-2015-session-1

Adrian Rollins

Access to health services by Australians with disability 2012

In 2012, 17% of people with disability who needed to see a GP delayed or did not go because of the cost; 20% who needed to see a medical specialist did not go mainly due to the cost; and 67% who needed to see a dentist delayed seeing or did not go because of the cost. Compared with people with disability living in Major cities, people with disability living in Outer regional and Remote areas had lower use rates of services provided by GPs, medical specialists and dentists as well as coordinated care provided by different types of health professionals. They were more likely to visit a hospital emergency department for health issues that could potentially be dealt with by non-hospital services, and to face barriers to accessing health services.

Briefs – 2 June 2015

Medical Research Future Fund on the way

More than a year after it was first announced, the Federal Government has finally introduced legislation to establish the Medical Research Future Fund.

The Fund, which the Government expects to grow to $20 billion by the end of the decade, has been under a cloud because several of the savings measures originally intended to finance it – particularly the GP co-payment – have been dumped or not yet passed.

But AMA President Associate Professor Brian Owler recently challenged the Government to stop dithering on the issue and set the Fund up, pointing out that a large swag of the measures designated to finance it were in place.

In introducing the enabling legislation, Treasurer Joe Hockey said the Fund would receive an initial endowment of $1 billion from the Health and Hospitals Fund and would build to reach $20 billion in 2019-20.

Mr Hockey said the first $10 million from the Fund would be distributed next financial year, and estimated that $400 million would be disbursed in the next four years.

The Fund will be managed by the Future Fund Board of Guardians, while a separate board will be established to provide expert advice on medical research priorities and strategy.

Adrian Rollins

Mersey Hospital two-year funding deal

Funding for Tasmania’s Mersey Community Hospital has been extended for two years following an in-principle agreement struck between the Commonwealth and Tasmanian governments.

Health Minister Sussan Ley said the Federal Government would pay its State counterpart $148.5 million to continue to manage and operate the hospital over the next two years.

The Mersey Hospital became the first and only public hospital to be directly funded by the Commonwealth when the Howard Government controversially assumed responsibility for the institution after the Tasmanian Government wanted to downgrade it to a day procedure centre, with only a limited overnight emergency capacity.

The intervention, which occurred just weeks before the 2007 Federal election that the Howard Government lost, was unprecedented at the time, and has not been repeated since.

Ms Ley said the deal provided certainty for the hospital while the Tasmanian Government undertakes reforms of the State health system.

Adrian Rollins

A bolt out of the blue: the night of the blue pills

Clinical record

A cluster of 10 patients presented during the night of 31 December 2013 to the emergency department of Royal Perth Hospital with states of agitated delirium or exhibiting unusual behaviour. Eight of the patients had attended an open-air dance party in the city close to the hospital, and nine had arrived by ambulance. All except one admitted to taking non-prescription drugs in tablet form, most believing they were consuming ecstasy (3,4-methylenedioxymethamphetamine, MDMA) in the form of blue or grey pills, in several cases imprinted with a lightning bolt. Media warnings had already been issued in response to similar cases involving acute psychosis reported by another metropolitan emergency department (Fremantle Hospital).1,2

The median age of the patients in our cluster was 20 years (interquartile range [IQR], 18–22 years). The median initial heart rate was 115 beats per minute (IQR, 84–155 beats per minute). Four patients were febrile (temperature ≥ 37°C) but only one had a temperature greater than 38°C. All patients had dilated pupils (median width, 6 mm [IQR, 5–7 mm]). Five patients required intravenous sedation, and in two cases more than 50 mg diazepam was required.

The patients had posed a significant risk to themselves before attending the emergency department: one had been found collapsed on the dance floor, another had wandered through vehicular traffic, and a third had fallen after climbing an 11 metre-high lighting rig.

The clinical syndrome included a state of agitated delirium, with labile mood, tachycardia, dilated pupils, sweating and, in several patients, involuntary movements. Clonus was present in only one case. One patient tried several times to hit staff members, while another spat at them. The most severely affected patient developed status epilepticus, and required intubation and admission to the intensive care unit. After recovery, he stated it was only the second time he had used non-prescription drugs.

The cluster of patients had a significant impact on emergency department resources. They comprised 10 of the 83 patients who presented to the department in the 7-hour period between 19:55 and 02:55. Many required intensive nursing care and intravenous sedation. One patient flipped over the safety railing of his trolley and landed on his head, but was not significantly injured. The median hospital length of stay was 5.4 hours (IQR, 3.0–11.9 hours).

Emergency treatment of the patients followed standard procedures for a sympathomimetic syndrome,3 and included oral or intravenous administration of benzodiazepines and fluids, observation and, in one case, intubation and cooling for status epilepticus. In patients for whom benzodiazepines were indicated, unusually large doses were needed to achieve adequate sedation.

Blood samples were taken from nine of the patients when intravenous cannulae were inserted as part of routine clinical care. Retrospective analysis of stored plasma samples using liquid chromatography–mass spectrometry was undertaken 40 days later by ChemCentre forensic laboratories (Perth, WA) to attempt to identify the substances responsible for the patients’ symptoms. Results were compared with a large library of conventional and novel recreational drugs.

No novel synthetic agents were identified, but methamphetamine was detected in samples from two patients. The clinical syndrome observed and the absence of evidence for conventional drugs of misuse in all but two of the samples aroused suspicions of unidentified synthetic drugs. As analysis of drugs recently seized by police indicated that many “ecstasy tablets” contained high amounts of caffeine, caffeine levels were assessed in our samples, but were found to be uniformly low. Most of the tablets taken by the patients had been marketed as ecstasy, but no MDMA was detected in any of the plasma samples. Interestingly, lactate levels were elevated in all patients (median concentration, 3.1 mmol/L; IQR, 2.5–3.8 mmol/L), and all samples but one contained high levels of ethanol (median concentration, 180 mg/100 mL; IQR, 140–220 mg/100 mL).

Discussion

The continued emergence of novel synthetic recreational drugs is a growing problem in many countries, and the short- and long-term effects of these compounds are poorly understood. There have been recent deaths in Australia linked with such substances.4 Little reliable information is readily available to inform either users or clinicians.

There are several possible technical reasons why new synthetic drugs were not detected in our patients’ plasma samples. These could include adsorption of the drug by gel in the collecting tube5 and instability of the drug at room temperature or when refrigerated at 4°C.6–7 These problems may have been compounded by the 40-day delay between collection and analysis.

Ongoing research into new synthetic drugs is needed to identify which harmful substances are currently circulating in the community and to inform potential users of their harms. Public warnings about clusters of cases, if deemed appropriate, should be issued on the basis of clinical presentations rather than of definitive analyses, given the time delay involved in performing these. The optimal treatment of patients is unknown and will vary according to the compound ingested. Future research should also consider the most appropriate methods for collecting samples to optimise analysis outcomes, including the temperature at which samples should be stored to preserve the chemicals of interest.

Public health warnings about a dangerous batch of “ecstasy” tablets had been issued to the media earlier in the day on which our patients had taken their pills,1,2 but the effectiveness of these messages is unknown. Most of our patients erroneously thought they had taken MDMA, and all had consumed only a small number of tablets. Media reports often mention the dangers of an “overdose”, implying the consumption of many tablets, which could mislead users into believing that one or two tablets (of an unknown substance) are safe. Public health messages should consider the need to communicate risk effectively, but there may also be unintended adverse consequences. These include encouraging experimentation by alerting naive or non-consumers to potential new drugs.

Lessons from practice

The use of novel synthetic drugs is an increasing problem.
There is little reliable information to inform users or clinicians about these drugs.
The optimal use of the media to warn potential users is yet to be defined.
Future storage and analysis of substances should take into account their potential instability and low plasma concentrations.

Quality selection, training vital to safeguarding GP future

By Dr Penelope Need, Director of General Practice training at Southern Adelaide Local Health Network; tutor in Medical Professional and Personal Development, University of Adelaide; Partner, Pioneer Medical Centre, Tea Tree Gully, South Australia.

General practice training is having its first shake up since the implementation of the training providers more than 10 years ago.

The last couple of years have seen large numbers of applicants. General practice is a specialty of choice for many junior doctors. We need to keep it that way.

Quality general practice training is mandatory if we wish to maintain high standards in primary care.

General practice is a challenging career. Future GPs need to be carefully selected and trained to a high standard.

We all know that primary care is the most cost effective area of the health system. Why then is it being targeted for so much reform?

I have a tutorial group of nine year 3 medical students, none of whom have a GP. If these carefully selected medical students don’t see the value in general practice then how can the rest of the community?

At interviews, potential GP registrars can tout “continuity of care”, but is this still a reality?

Access is a real issue in general practice at the moment. Chronic disease management, and an aging and increasingly overweight and mentally distressed population puts a strain on well-meaning general practitioners.

The current model of funding rewards throughput. Is this what we want to see into the future? Are we going to be palliating our own patients or leaving it to the ambulance officers?

Pharmacists are providing vaccinations, physiotherapists are requesting referral rights. Why? How has this gap been created that someone wants to fill?

That other catch cry of general practice, “holistic care”, is also under threat.

The solution to these problems starts with selection. We need to select appropriate individuals. Selecting rural students has been shown to increase rural retention.

We then need to ensure they are adequately trained.

The loss of the Prevocational General Practice Placements Program is a real blow for general practice. It was vital for improving inter-professional communication and respect. Emergency, medicine and surgery are all mandated in internship. Why not primary care? Like anything, until you are exposed to general practice you do not understand the complexity and the challenges.

The AMA is looking at alternative models of reviving prevocational exposure to general practice. I personally feel this is vital for the ongoing health of the profession.

Just because we have a lot of applicants for general practice training does not mean that we will have a lot of quality GPs in another three years. We need to select the right people for the job and train them to a high standard.

Maybe a litmus test – would you be happy to be treated by doctors trained under this program? Don’t be like my third year medical students – everyone needs a good GP. Let’s just hope there will be enough to go around.

[Correspondence] Rising food insecurity in Europe

People queueing for food aid is an image reminiscent of the Great Depression in the 1930s, but one that has come to characterise many European nations in the grip of austerity today. In 2013–14, the UK’s Trussell Trust, a national network of food banks, provided emergency food aid to more than 900 000 adults and children, a 163% increase from the previous year.1 Greek, Spanish, and French charities have also reported marked rises in the number of people seeking emergency food support.2 Alongside clinical evidence of rising nutritional deficiencies,2,3 these reports suggest that a problem is emerging, but to what extent is food insecurity rising across Europe?

2015 Health Budget – at a glance

Main measures

· Medicare rebate freeze to mid-2018

· public hospital funding wound back

· MBS review

· e-health records re-boot – $485m

· Emergency response capacity – $98m

· Cancer screening and medication – $628m

· National Drugs Campaign and Ice Action strategy – $20m

· Boosting immunisation coverage – $188m

· Developing tropical health expertise – $23.8m

Cuts

· Slashing health programs and funds – $962.8m

· $5000 cap on FBT exemption for hospital doctors – $295m

· Child dental benefits – $125.6m

· GP child health assessments – $144.6m

· PBS price and safety net changes – $257.3m

· Health Dept and TGA cuts – $113.1m

· Consolidating health work force scholarships – $72.5m

· Adult public dental services – $45m

Budget breakdowns

Organ and Tissue Donation

Despite programs to encourage more donors there has been a decline in the rate of organ donations over the past two years according to ShareLife.

The Australian Government hope to improve organ and tissue donation rates by providing $10.2 million over the next two years. The funding will go towards delivering clinical education to hospitals, developing a new Australian Organ Matching System and enhancing the Australian Organ Donor Register.

Currently around 1500 people are on Australian organ transplant waiting lists at any time. One organ and tissue donor can transform the lives of 10 or more people.

The Government will also continue to provide minimum wage for up to nine week to employers of people who have taken leave to donate organs as part of the Supporting Leave for Living Organ Donors Programme. The aim of the Programme is to help alleviate the financial stress that can be experienced by living organ donors by reimbursing employers for payments or leave credits provided to their employees for leave taken to donate an organ and recover from the procedure. The Government announced that the Programme will continue for the next two years.

Tropical health

The Government will provide $15.3 million over four years to invest in research into exotic disease threats to Australia and the region.

The National Health and Medical Research Council will receive 6.8 million to support research into tropical diseases, build collaboration and capacity in the health and medical research workforce, and promote the translation of this research into health policy and practice.

The Government will also provide $8.5 million to establish an Australian Tropical medicine Commercialisation grants program to support Australian researchers to commercialise therapeutics and diagnostics in tropical medicine.

National Drugs Campaign

The Government will provide $20 million over two years to renew the National Drugs Campaign. The Campaign aims to reduce young Australians’ motivation to use illicit drugs by increasing their knowledge about the potential negative consequences of drug use. It is a media campaign to promote the avoidance and cessation of illicit drug use.

The campaign will focus on raising awareness to young people and their parents about the harm caused by illicit drug use, in particular methamphetamine also known as ice.

Royal Flying Doctor Service

The Government has committed additional funding to support the Royal Flying Doctors Service to deliver emergency and primary health care services to people in rural and remote communities of Australia.

The Service will receive an extra $20 million as part of the Government’s commitment to rural and remote communities.

Kirsty Waterford

Copayments and the evidence-base paradox

To the Editor: The recent perspective by Keane on the effects of copayments on low-income populations1 overlooked the results of the 1968 decision in the Canadian province of Saskatchewan to impose a fee of $1.50 (all amounts are in Canadian dollars) for office visits and $2.00 for home, emergency department or hospital outpatient visits.

At the time the fees were introduced, the definition of low income was $1550 for single-person families to $4800 for families of five or more. The result of the fee was a statistically significant 14% decrease in the use of general practitioner services and a non-statistically significant decrease of 5% in specialist services by the poor.2 The health outcomes effect of this decrease in the use of services was not examined.

The Saskatchewan natural experiment should serve as a reminder that even small amounts of money can affect the volume of services that the poor receive.

Cost and outcomes of assessing patients with chest pain in an Australian emergency department

Patients presenting with chest pain represent a large group of adult emergency department (ED) presentations.1 The most common serious underlying causes for this symptom are acute coronary syndromes (ACS), incorporating acute myocardial infarction and unstable angina pectoris. Over 5.5 million people presented to EDs in the United States in 2007–2008 with a primary complaint of chest pain, yet only 13% of those were diagnosed with an ACS.1 The number of patients presenting to EDs in Australia with a possible ACS is unknown.

Many conditions cause chest pain, yet discriminating between an ACS and alternative and generally less serious aetiologies, such as gastro-oesophageal reflux, is difficult. The 2006 National Heart Foundation and Cardiac Society of Australia and New Zealand (NHF/CSANZ) guidelines on the management of ACS recommended stratifying patients into low-, intermediate- and high-risk categories,2 a strategy that remained unchanged in more recent updates.3 The guidelines recommended that low-risk patients be assessed using serial cardiac biomarkers and electrocardiography. High-risk patients require admission to hospital and intensive management, often including early invasive strategies. The largest group is the intermediate-risk cohort, who require serial testing of biomarkers and electrocardiography. If results of these are negative, further objective testing is required. The most commonly performed objective test in this intermediate-risk group is an exercise stress test (EST). Other more costly tests may include computed tomography coronary angiography, stress echocardiography, myocardial perfusion scanning and invasive angiography.

The costs of applying such guidelines to an undifferentiated population presenting with chest pain to EDs in Australia have not been described. The final diagnoses and 1-year outcomes of patients presenting to the ED with chest pain have also not been described. We aimed to characterise the demographics, length of hospital stay (LOS), final diagnoses, long-term outcome and costs associated with the population who presented to an Australian ED with symptoms of possible ACS.

Methods

Design and participants

We conducted a prospective, single-centre observational study between November 2008 and February 2011. Patients were included if they presented to the ED with at least 5 minutes of chest pain suggestive of an ACS (acute chest, epigastric, neck, jaw, or arm pain; or discomfort or pressure without an apparent non-cardiac source). Data were collected between 08:00 and 17:00.

Patients were excluded if they had a clear non-ACS cause for their symptoms, were unwilling or unable to provide informed consent (eg, dementia), were considered inappropriate for recruitment (eg, terminal illness), were pregnant, were recruited to the study within the past 45 days or were unable or unwilling to be contacted after discharge. Patients transferred to or from another hospital were excluded from the study, as we did not have data on costs or management for these patients. Consecutive eligible cases at the Royal Brisbane and Women’s Hospital’s ED were included. The study protocol was approved by the hospital’s human research ethics committee (no 2008/101 and HREC/11/QRBW/493).

Patients were classified into risk groups according to the Queensland chest pain pathway (Appendix), based on the 2006 NHF/CSANZ guidelines.2 Low-risk and intermediate-risk patients were typically managed in the ED with admission to the ED short-stay unit (Box 1). High-risk patients and patients unable to perform an EST, owing to contraindication or inability, were referred to inpatient cardiology and general medical units for admission and further assessment. A small proportion of patients were managed in the ED (3.9%), while the remainder were transferred to the ED short-stay unit (46.7%) or the inpatient ward (49.4%). Patients requiring urgent cardiac surgery were transferred to another institution after inpatient admission.

Data collection

Research staff collected data using a standardised patient interview as soon as ED clinical assessment was complete. Interviews were cross-checked with patient notes. Blood samples taken on presentation (0 hour) and ≥ 6 hours later were sent to our laboratory for measurement of troponin and analysed using the second-generation AccuTnI (Beckman Coulter) assay. The 0-hour and ≥ 6-hour test results were used for patient care and cardiology end point adjudication. We used the manufacturer’s 99th percentile cut-point to indicate a raised troponin value.

Data on the costs associated with investigation and care of patients during the index admission were extracted from hospital administration records. Inpatient costs were derived from procedure-related Australian refined diagnosis-related group reimbursement codes used for activity-based funding. These cost codes guide federal government payments and are designed to reflect the health care services used during each patient episode.4 To determine appropriate payments to hospitals, the weighted cost combines inputs such as staff time and consumables used for patient care.

ED costs reflect the payments received by the hospital based on triage categories of urgency. Total costs include fixed costs, which make up about 80% of overhead costs, and a variable activity-based component for pathology, imaging, pharmacy, clinical supplies and hotel services.4 Costs from 2008–2010 were adjusted for inflation by 3.4% per year to equate to 2011 costs.5 The 30-day clinical outcome was adjudicated independently by local cardiologists using predefined standardised reporting guidelines, with knowledge of all clinical information collected within a 30-day period.6 A second cardiologist conducted a blind review of all ACS cases and 10% of non-ACS cases. In cases of disagreement, end points were agreed by consensus. This was achieved for all end points.

The 30-day clinical outcomes were grouped into three categories that included cardiac-ACS-related, other cardiac and non-cardiac diagnoses. Cardiac-ACS-related diagnoses included ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction and unstable angina pectoris. These were categorised according to the universal definition.7 An end point of unstable angina pectoris was given for patients with negative serial troponin results, ischaemic symptoms and objective evidence of ischaemia on the EST, stress echocardiography, myocardial perfusion scanning, computed tomography coronary angiography or significant findings on coronary angiography.

Other diagnoses, such as cardiac but non-ACS (cardiac-other), and non-cardiac, were based on all available clinical data including investigations that had occurred within the 30-day period after presentation. A National Death Registry audit was performed in July 2014 to provide mortality data for patients who had consented to longer-term study participation.

Data analysis

Data were analysed using Stata, version 12 (StataCorp). Baseline characteristics of the sample were reported by outcome category using standard descriptive statistics. The baseline characteristics of patients with and without an ACS were compared using the χ2 test for categorical data and t test for continuous data.

Data on diagnosis, LOS and costs were also reported by outcome category. The LOS and cost data were right skewed and were reported in several ways. First, the median and interquartile range were reported to provide a good estimate of the LOS and cost for a typical patient. Second, for economic analysis, mean costs were reported. The mean is the correct estimator because decisionmakers need to understand total costs, which are predicted by the mean and the quantity of services used. Bias-corrected and accelerated bootstrap confidence intervals were calculated using 1000 replications.

One-year mortality was reported for a subset of patients who consented to ongoing participation in the study. Kaplan–Meier survival curves for time to death were generated by diagnostic group, and log-rank tests were used to compare survival curves.

The mean and median LOS and cost per patient were reported by NHF/CSANZ risk category. These data were broken down by ACS and non-ACS outcomes and included all patients within the diagnostic category, irrespective of whether objective testing was performed.

Results

Nine hundred and twenty-six patients were included (566 [61.1%] men; mean age 54.7 years). No patients were lost to 30-day follow up (Box 2) and 693 (74.8%) consented to one-year follow-up. Baseline characteristics are shown in Box 3.

Non-cardiac chest pain was diagnosed in 622 (67.2%) of the 926 patients (Box 3). One hundred and ninety-three patients (20.8%) were diagnosed with other cardiovascular conditions including pericarditis, atrial fibrillation and heart failure. Among those diagnosed with an ACS (103 [11.1%]), the most common condition was non-ST-segment elevation myocardial infarction (51.5% of total ACS group).

Three of the 926 patients died within 30 days; two of these were during the index admission. Two of the deaths were cardiac related. An additional 14 of the 693 patients involved in long-term follow-up died within 12 months (total, 17/693 patients [2.5%]; 95% CI, 1.4%–3.9%) (Box 4).

Kaplan–Meier curves for deaths within the diagnostic categories are shown in Box 5.

The outcomes and costs by NHF/CSANZ risk group are shown in Box 6. ACS events occurred in 0 and 11 (1.9%) of the low-risk and intermediate-risk groups, respectively. Ninety-two (28.0%) of the 329 high-risk patients had an ACS event. Ten patients were transferred for acute cardiac surgery.

Patients with an ACS, high-grade atrioventricular block, heart failure, syncope, pulmonary embolism and respiratory conditions had the longest median LOS (Box 4). Patients with an ACS incurred the highest mean cost per patient ($13 509), followed by other cardiovascular conditions ($7283). Patients with non-cardiac disease had the lowest cost of $3331 per patient.

Three hundred and fifty of the 580 intermediate-risk patients (60.3%) had an EST during the index admission. These patients incurred lower mean costs ($2316; 95% CI, $2126–$2507) than those who did not undergo an EST ($4806; 95% CI, $4094–$5516). Three hundred and six ESTs (87.4%) yielded a negative result. In contrast, 124 (53.9%) of the 230 patients who did not undergo an EST during the index presentation were admitted to an inpatient unit and incurred higher costs. Four hundred and sixty-six (80.3%) of the intermediate-risk patients received some objective testing within 30 days. The total cost for intermediate-risk patients was $1 916 100; if divided across the 11 ACS patients, this equates to $174 191 to identify one ACS event.

In the high-risk group, the mean LOS was 5 days and the mean cost was $8919. The cost of treating the 237 patients in this group who did not have an event was $7075 per patient, while the 92 patients who had an event incurred costs of $13 669. The total cost of investigating high-risk patients in this study was $2 934 317. If this value is divided across the 92 ACS events, this equates to an average of $31 895 spent to identify and treat one ACS event.

Overall, the total ED cost for investigating the 926 patients in this study was $904 221, while inpatient costs totalled $3 977 234. Total ED LOS was 5575.9 hours, making the average cost per hour in ED $162. Total LOS as an inpatient was 59 061.9 hours, making the average inpatient cost $67 per hour.

Discussion

This is the first evaluation of the characteristics, final diagnoses, outcomes and costs for an Australian ED cohort investigated for possible ACS based on the NHF/CSANZ guidelines.2,3 In keeping with other international reports, the final proportion of patients with a diagnosis of ACS was 11.1%, with 20.8% of patients having other cardiovascular causes diagnosed.8–11

Our study shows that significant resources are consumed in investigating ACSs; however, in the absence of research identifying a “negligible risk” group who do not require objective testing, such resource use is necessary. Alternative strategies to reduce the LOS in a low-risk cohort have been reported,9,12–16 and some studies have reported on the implementation and effect of such accelerated protocols.17,18 At the time of this study, such strategies were not in use in our institution. Further research efforts should be directed to identifying patients who could be discharged without requiring additional cardiac investigations.

About one-fifth of intermediate-risk patients did not have objective cardiac testing in hospital or within 30 days of their presentation, against guideline recommendations.2 We did not record the reasons why clinicians deviated from the NHF/CSANZ guidelines; however, it is possible that clinical gestalt, prior recent investigation or known coronary artery disease may have influenced care.19 In addition, decision making may have been influenced by significant debate about the utility of objective testing such as EST for patients thought to be at minimal risk.20,21

No previous study in the Australian setting has examined the cost of assessing patients presenting with chest pain. We were able to show that costs are substantial and varied across the risk categories. The high-risk group incurred the highest cost per patient, but this group had a high rate of ACS. In contrast, the intermediate-risk group was the most resource-intensive, yet these costs were expended to diagnose a very small proportion (1.9%) of patients with ACS. The overall costs per event in the intermediate group were high ($174 191 per ACS event). An ideal accelerated diagnostic protocol would exclude from testing patients who have no risk of ACS. The effect would be to reduce the size of the intermediate-risk group and define them as low risk, saving resources but not having an adverse impact on health outcomes.

Few previous studies have reported the costs related to chest pain assessment in the ED, specifically. A recent publication by KP Health for Queensland Health titled “Report of the evaluation of the clinical services redesign program in Queensland hospitals” recorded an estimated released value of 1 hour of ED cubicle time to be $98 and of an inpatient bed-day to be $779 in the financial year 2013–14 (Sarah Bright, Senior Project Officer, Health Technology Assessment and Evaluation, Queensland Health, personal communication, March 2014). This figure is less than that reported in this study of $162 per hour for an ED bed. The difference is likely to be due to the high triage category assigned to patients presenting with chest pain and the extensive investigations required. These data provide the basis to test accelerated diagnostic protocols and build full cost-effectiveness models that quantify the potential changes to costs and health outcomes from their widespread adoption.

All patients were followed up at 30 days from presentation, and the death registry audit of survival at 1 year was done for patients who had consented; however, overseas deaths may have been missed. This is unlikely to be a significant number. All end points were adjudicated by cardiologists using available information. As such, the subcategories within the non-cardiac end points may not have the same diagnostic rigour as the cardiac end points. Non-cardiac investigations occurring away from the recruitment hospital were not obtained for outcome adjudication.

Patient recruitment was within midweek working hours, owing to the availability of research staff, and the extent of potential selection bias cannot be quantified; however, we have previously reported that there are no statistically significant differences in the demographics or outcomes of the two groups.22 A significant number of patients with ACS may present atypically, or without chest pain, and this cohort was not included in our study.

The cost estimates were derived from activity-based funding cost codes. While our cost estimates do not include microcounts and values for each resource used, they are likely to reflect the resources engendered for care of patients with chest pain. We did not include the surgical costs associated with patients transferred for acute surgical management of ACS.

In conclusion, most ED patients with symptoms of possible ACS do not have a cardiac cause for their presentation. The current guideline-based process of assessment of this cohort is lengthy and requires significant resources. Investigation of strategies to shorten this process or safely reduce the need for objective cardiac testing in patients at intermediate risk according to the NHF/CSANZ guidelines is required.

1 Process of care for patients with possible acute coronary syndrome

ECG = electrocardiography. EST =exercise stress test. ED = emergency department. SSU = short-stay unit. * Risk classifications according to the Queensland chest pathway (Appendix) based on the 2006 NHF/CSANZ guidelines.2

2 Patient flow within the study*

ACS = acute coronary syndromes. * According to Standards for the reporting of diagnostic accuracy studies (see http://www.stard-statement.org).

3 Baseline demographics of patients according to their final diagnosis category*

Baseline characteristics	Cardiac-ACS	Cardiac-other	Non-cardiac	No diagnosis (LAMA)

	(n = 103)	(n = 193)	(n = 622)	(n = 8)
Mean age, years (range)	64.50 (33–96)	59.32 (23–97)	51.6 (19–93)	55.13 (37–66)
Women	30 (29.1%)	71 (36.8%)	258 (41.5%)	1
European ancestry	97 (94.2%)	166 (86.0%)	542 (87.1%)	7
Risk factors
Dyslipidaemia	65 (63.1%)	113 (58.5%)	280 (45.0%)	1
Diabetes	24 (23.3%)	36 (18.7%)	68 (10.9%)	1
Hypertension	64 (62.1%)	119 (61.7%)	269 (43.2%)	2
Obesity (BMI > 30)†	26 (27.1%)	63 (33.2%)	221 (36.4%)	2
Smoking	33 (32.0%)	52 (26.9%)	188 (30.2%)	6
Medical history
Angina	40 (38.8%)	78 (40.4%)	111 (17.9%)	2
Coronary artery disease	43 (41.7%)	81 (42.0%)	93 (15.0%)	1
AMI	29 (28.2%)	55 (28.5%)	79 (12.7%)	1
Arrhythmia	15 (14.6%)	49 (25.4%)	38 (6.1%)	0
Congestive heart failure	11 (10.7%)	29 (15.0%)	21 (3.4%)	0
CABG surgery	14 (13.6%)	21 (10.9%)	24 (3.9%)	1
Prior angioplasty	19 (18.4%)	37 (19.2%)	51 (8.2%)	0
Stroke	10 (9.7%)	30 (15.5%)	47 (7.6%)	2
Presentation with chest pain in the past year	26 (25.2%)	79 (40.9%)	139 (22.3%)	1

ACS = acute coronary syndromes. AMI = acute myocardial infarction. BMI = body mass index. CABG = coronary artery bypass graft. LAMA = Left against medical advice. * Data are no. (%) unless otherwise specified. † Denominators vary due to missing data: 26/96, 63/190, 221/608.

4 Hospital length of stay, mortality, median and mean costs by diagnostic group

Diagnostic category

No. of patients (% of diagnostic group)

Median hospital length of stay, hours (25th–75th percentile)

Mean hospital length of stay, hours (95% CI)

No. of patients deceased at 1 year/no. in category*

Median costs (25th–75th percentile)

Mean costs (95% CI)

Cardiac-ACS

103 (100.0%)

97.6 (70.7–188.8)

187.0 (125.3–248.8)

$12 002 ($7861–$16 517)

$13 509 ($11 794–$15 223)

STEMI

22 (21.4%)

91.9 (74.1–142.9)

151.5 (95.7–207.2)

0/17

$14 643 ($12 002–$17 323)

$18 297 ($13 487–$23 107)

NSTEMI

53 (51.5%)

101.3 (70.4–173.0)

215.5 (105.0–325.9)

5/35

$11 705 ($8198–$15 196)

$12 829 ($11 028–$14 629)

UAP

28 (27.2%)

96.8 (44.2–191.2)

161.1 (68.0–254.3)

0/23

$8311 ($4728–$17 860)

$11 033 ($8000–$14 067)

Cardiac-other

193 (100.0%)

52.1 (23.3–123.8)

92.2 (75.5–108.8)

$4826 ($2020–$9297)

$7283 ($6152–$8415)

Coronary vasospasm

2 (1.0%)

–

0/2

Stable CAD

50 (25.9%)

47.2 (22.0–97.1)

81.4 (51.5–111.2)

2/39

Pericarditis

27 (14%)

28.2 (10.8–65.9)

46.5 (29.6–63.4)

0/20

Atrial fibrillation

33 (17.1%)

53.7 (30.5–116.5)

86.0 (53.7–118.2)

2/30

High-grade atrioventricular block

4 (2.1%)

198.0 (138.2–281.4)

209.8 (135.6–284.0)

0/2

Other arrhythmias

16 (8.3%)

38.9 (10.5–155.8)

86.5 (48.3–124.7)

0/12

Heart failure

15 (7.8%)

196.3 (142.4–338.7)

278.6 (161.3–395.9)

1/9

Cardiomyopathy

3 (1.6%)

–

0/1

Valve disease

7 (3.6%)

30.8 (7.9–76.6)

48.5 (16.4–80.6)

0/4

Hypertension

8 (4.1%)

41.4 (17.5–77.8)

53.5 (22.4–84.6)

0/6

Syncope/presyncope

10 (5.2%)

76.1 (9.3–122.4)

75.0 (36.9–113.2)

0/8

Pulmonary embolism

6 (3.1%)

112.7 (101.0–172.8)

140.0 (65.9–214.0)

0/5