Targeted Testing Assists Pediatric Chest Pain Evaluation

From Medscape Medical News

Laurie Barclay, MD

July 14, 2011 — Standardized Clinical Assessment and Management Plans (SCAMP) for pediatric chest pain may facilitate targeted, cost-effective workup and management, according to the results of a chart review study reported online July 11 in Pediatrics.

"Chest pain is common in children and is a frequent reason for referral to pediatric cardiologists," write Kevin G. Friedman, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues. "Despite the benign nature of the vast majority of pediatric chest pain, extensive and costly cardiac evaluation is common in these patients."

The goal of the study was to examine current management practices in the evaluation of pediatric chest pain and to assess whether a standardized protocol could decrease unnecessary tests. The study sample consisted of all 406 patients (aged 7 - 21 years) seen in 2009 at the investigators' outpatient pediatric cardiology division for chest pain assessment. Among these patients, the investigators studied demographic and clinical factors, outcomes, and resource use.

More than one third (37%; n = 150) of patients had exertional chest pain, and 44 (11%) had a clinically significant medical or family history, an abnormal cardiac examination result, and/or an abnormal electrocardiogram (ECG) result.
All 406 patients underwent ECG, and echocardiography was also performed in 175 (43%), exercise stress testing (EST) in 114 (28%), event monitoring in 40 (10%), and Holter monitoring in 30 (7%).
However, only 5 (1.2%) of 406 patients had a demonstrated cardiac cause of chest pain, including 2 with pericarditis and 3 with arrhythmias.
Using relevant history, physical examination, and ECG findings, the investigators developed an algorithm to guide use of additional testing. They suggest that using this algorithm in this patient sample would have detected all cardiac diagnoses, while decreasing use of echocardiography and outpatient rhythm monitoring by approximately 20% and eliminating EST.

"Evaluation of pediatric chest pain is often extensive and rarely yields a cardiac etiology," the study authors write. "Practice variation and unnecessary resource use remain concerns. Targeted testing can reduce resource use and lead to more cost-effective care."

Limitations of this study include reliance exclusively on clinical notes, retrospective review, limited follow-up, the potential for missed cardiac diagnoses, and assumption of 100% compliance with the SCAMP.
"For multiple reasons, universal adherence will not be the case, which likely leads to an overestimate of the effect of the SCAMP on resource use and charges," the study authors conclude. "Prospective results from the chest-pain SCAMP, including information regarding diagnostic yield, practitioner compliance, and changes in resource use will become available in the near future.... We show that use of a standard management approach to pediatric chest pain could lead to a reduction in resource use and charges while maintaining quality of care."
This research was supported by the Boston Children's Heart Foundation, the Provider-Payor Quality Initiative, the Program for Patient Safety and Quality, and the Hinden Family Fund. The study authors have disclosed no relevant financial relationships.
Pediatrics. Published online July 11, 2011.