Showing papers by "Steve Goodacre published in 2002"

How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?

Abstract: Objectives: To measure the predictive value and diagnostic performance of clinical features used to diagnose coronary syndromes in patients presenting with acute, undifferentiated chest pain. Methods: The clinical features of patients presenting to the authors' chest pain unit with acute, undifferentiated chest pain were prospectively recorded on a standard form. Admitted patients were followed up by case note review. Discharged patients were followed up as outpatients three days later. Six months after the emergency department visit, evidence of adverse events was searched for from the hospital computer database, case notes, and the patient's primary care physician. The authors tested the power of each feature to predict: 1) acute myocardial infarction (AMI) by World Health Organization criteria, and 2) any acute coronary syndrome (ACS), evidenced by cardiac testing, AMI, arrhythmia, death, or revacsularization procedure within six months. Results: Eight hundred ninety-three patients were assessed, 34 (3.8%) with AMI and 81 (9.1%) with ACS. Features useful in the diagnosis of AMI were exertional pain [likelihood ratio (LR) = 2.35], pain radiating to the shoulder or both arms (LR = 4.07), and chest wall tenderness (LR = 0.3). Features useful in the diagnosis of ACS were exertional pain (LR = 2.06) and pain radiating to the shoulder, the left arm, or both arms (LR = 1.62). The site or nature of pain and the presence of nausea, vomiting, or diaphoresis were not predictive of AMI or ACS. Conclusions: Important differences exist when clinical features are specifically investigated in patients with acute chest pain and a nondiagnostic electrocardiogram. Clinical features have a limited role to play in triage decision making.

A prospective, observational study of a chest pain observation unit in a British hospital

Abstract: Objectives: To establish a chest pain observation unit, monitor its performance in terms of appropriate discharge after assessment, and estimate the cost per patient. Methods: Prospective, observational, cohort study of patients attending a large, city, teaching hospital accident and emergency department between 1 March 1999 and 29 February 2000 with acute undifferentiated chest pain. Patients were managed on a chest pain observation unit, entailing two to six hours of observation, serial electrocardiograph recording, cardiac enzyme measurement, and, where appropriate, exercise stress test. Patients were discharged home if all tests were negative and admitted to hospital if tests were positive or equivocal. The following outcomes were measured—proportion of participants discharged after assessment; clinical status three days after discharge; cardiac events and procedures during the following six months; and cost of assessment and admission. Results: Twenty three participants (4.3%) had a final diagnosis of myocardial infarction. All were detected and admitted to hospital. A total of 461 patients (86.3%) were discharged after assessment, 357 (66.9%) avoided hospital admission entirely. At review three days later these patients had no new ECG changes and only one raised troponin T measurement. In the six months after assessment, three cardiac deaths, two myocardial infarctions, and two revascularisation procedures were recorded among those discharged. The mean cost of assessment and hospital admission was £221 per patient, or £323 if subsequent interventional cardiology costs were included. Conclusions: The chest pain observation unit is a practical alternative to routine care for acute chest pain in the United Kingdom. Negative assessment effectively rules out immediate, serious morbidity, but not longer term morbidity and mortality. Costs seem to be similar to routine care.

ABC of clinical electrocardiography: Atrial arrhythmias

Abstract: The ABC of clinical electrocardiography is edited by Francis Morris, consultant in emergency medicine at the Northern General Hospital, Sheffield; June Edhouse, consultant in emergency medicine, Stepping Hill Hospital, Stockport; William J Brady, associate professor, programme director, and vice chair, department of emergency medicine, University of Virginia, Charlottesville, VA, USA; and John Camm, professor of clinical cardiology, St George's Hospital Medical School, London The series will be published as a book in the summer Steve Goodacre is health services research fellow in the accident and emergency department at the Northern General Hospital, Sheffield; Richard Irons is consultant in accident and emergency medicine at the Princess of Wales Hospital, Bridgend

An introduction to economic evaluation

Abstract: linicians working in accident and emer- gency (A&E) medicine will have little diffi- culty accepting the idea that health service resources are scarce. Increasing demands for health care and limited resources with which to meet them are a familiar part of the emergency environment. All clinicians will be aware of the need to make difficult choices in deciding which health care interventions to fund. Health economics tackles this problem of scar- city of resources and the implicit requirement to make choices that will maximise the benefit accrued from their consumption. 1 It therefore entails far more than simply accounting or attempting to cut costs. Yet many of the concepts behind economic evaluation will be unfamiliar to practising clinicians. The aim of this article is to explain some of the basic ideas behind economic evaluation.

ABC of clinical electrocardiography: Paediatric electrocardiography.

Abstract: The ABC of clinical electrocardiography is edited by Francis Morris, consultant in emergency medicine at the Northern General Hospital, Sheffield; June Edhouse, consultant in emergency medicine, Stepping Hill Hospital, Stockport; William J Brady, associate professor, programme director, and vice chair, department of emergency medicine, University of Virginia, Charlottesville, VA, USA; and John Camm, professor of clinical cardiology, St George's Hospital Medical School, London. The series will be published as a book in the summer. Steve Goodacre is health services research fellow in the accident and emergency department at the Northern General Hospital, Sheffield; and Karen McLeod is consultant paediatric cardiologist at the Royal Hospital for Sick Children, Glasgow.

Being economical with the truth: how to make your idea appear cost effective

Abstract: The importance of presentation and evaluation of economic data with regard to the cost effectiveness of a health care intervention are discussed.

Is prehospital thrombolysis for acute myocardial infarction warranted in the urban setting? The case against

Abstract: This paper forms the second part of the debate on prehospital thrombolysis (PHT). It is argued that large scale studies have failed to show a benefit for PHT, even when the time saved over conventional treatment was considerably greater than would be the case in the UK urban setting. In practice, a relatively small proportion of the total population receiving thrombolysis would receive PHT. Other strategies to reduce time to thrombolysis can benefit all patients and are likely to be more cost effective and safer.