It makes perfect sense. By sending the hot chest pain (level 5) over for an immediate treadmill test, you cause them to arrest which allows you to respond to the code and thereby get to bill the rare "triple double" (critical plus modifier 25 and add on CPR charge) thereby increasing your rvu's and converting a routine floor admission into more profitable, prolonged ICU stay which keeps the CEO and therefore your CMG employer happy, and which pads the hospital's collections for the quarter, while avoiding any chance of a < 72 hr bounce back, which would upset the CFO. Also, since it's an admission, you have perfected an end around any Press Ganey blowback. Geez, get with the program, man.
As I am prone to saying (as I recall from Robbins Pathology, now 17 years later), it is somewhere between 30% and 50%, but probably closer to 50%, the people whose first indication that they have cardiac trouble is sudden cardiac death (death within the first hour of symptoms) - the first time 1 out of 2 people find out they have heart trouble is when they drop dead.
Yes! I've always said this. You can have pain, especially if it's waxing and waning, up and down or not constant, without troponin leak and cell death, and the severity can tip over to infarction at any point during the pain process, and then and only then does your 4-6 hr troponin clock start. That doesn't even take into account silent ischemia or non-chest pain anginal equivalents, which make it even harder to know when to "start the clock." Real life doesn't always mimic the experimental animal model where you clamp off a coronary, start the clock and measure troponins every hour, not to mention false negative stress tests and other diagnostic imperfections. It makes the science not so exact.
I have heard Greg Henry, MD, JD state that in the case of a bad outcome based on a single trop. the successful argument has been made that the pt had their MI at the end of the 6 hr window(thus the neg trop) and all the prior pain was unstable angina at rest. he believes a single trop. is never acceptable practice (easy for him to say though, he works at a large Michigan hospital with an obs unit...). That being said, there are some folks I feel ok about getting just one trop on and some I don't.
when I learned to do basic stress tests 10 yrs ago the rule of thumb the cards folks taught us was that they were only 70% accurate in the setting of 2 prior neg trops and 2 neg prior ekgs. . If you want more accuracy you need to do a stress echo or thallium stress. At many places the + rate on these is incredibly low because the pt population tends to be folks you don't really worry about. They can exercise. they don't have multiple comorbidities, etc as those would exclude them from our protocol.
Why are you sending them to cath?
Considering they recently crushed the reimbursement for diagnostic (negative) caths, there will be no one available to do them. Your analysis of cost, is way off base by the way, as are cost analyses by most political "health experts." The cheapest thing is to do nothing and let people die of their heart attack young, not to keep them alive with repeated heart caths only to extend their life into the 80's and 90's where they live longer, get more tests/treatments over a longer life and ultimately die of dementia (but have a healthy heart) after a prolonged and expensive nursing home stay.
To play devil's advocate again: After his three days of constant chest pain, something made that man come to the hospital five minutes ago. Maybe it was his wife nagging him, or maybe there was a change in the quality of the pain that he just couldn't put his finger on. If it was the former? Great, your one troponin was enough. If it was the latter, and his UA just converted to an NSTEMI but he hasn't had time for enzymes to rise yet? One isn't enough. Two likely might be. That said, you need at least something going for you. That's either typical chest pain, a positive enzyme, or EKG changes. If you're at 0/3, I'd feel a lot more comfortable straight out calling it non-cardiac.
You could be absolutely right. You know the suits are going to find a way to get huge reimbursement. Even if it means getting the most overly sensitive lab test possible, to trigger reimbursement for the right CPT codes and facility fees. Absolutely, that's how the game played.
Yes, because the expectation is that all of their patients have heart disease, that ultimately will be their downfall. So it's expected, and almost accepted that it'll happen eventually. But the standard the ED is held to and the expectation is totally different, and much more unforgiving. Because everybody knows that a discharge from the ER always comes with a 6 week "I was just checked in the ER and they said nothing was wrong!" guarantee.
It's been a very long day and I'm legitimately unsure if you're trying to troll me or if you just have a very non-standard understanding of medical terminology. But to answer you're question seriously - because they have chest pain that could be coming from a blockage in a coronary artery.
Ok, last time... not all chest pain is angina. Not all chest pain in patients with known coronary disease is angina. I am not aware of any combination of risk factors, EKG, lab, physical exam findings, etc. that is completely reliable at distinguishing anginal chest pain from non-anginal chest pain. Therefore it is quite likely that if you ever have ordered a stress test or admitted a patient to be stressed that you have also stressed someone that wasn't having angina. If you follow a little bit further, it is also likely that some of the people that you stressed that weren't having angina would (as an incidental finding) have CAD that on cath would show a stenosis that is considered appropriate for stenting. I was taught in residency that picking up this incidental finding and stenting this (possibly) culprit lesion saved lives and prevented MIs. This does not seem to be borne out by the literature that has subsequently been published. Clear enough?
