Failure of Information as an Intervention to Modify Clinical Management: A Time-Series Trial in Patients with Acute Chest Pain

Abstract

Objective: To test whether a low-intensity, nonintrusive intervention improved the efficiency of management of patients with acute chest pain.

Design: Time-series trial with six 14-week cycles, each including a 5-week intervention period and a 5-week control period separated by 2-week “washout” periods.

Setting: Urban teaching hospital.

Patients: 1921 patients aged 30 years or older with acute chest pain unexplained by local trauma or chest radiograph.

Intervention: Risk estimates and triage recommendations were made available to physicians at the time of emergency department evaluation and, for hospitalized patients, on a daily basis before morning rounds. Flowsheets and stickers, but no direct human contact, were used to transmit this information.

Measurements: Rates of admission to the hospital and coronary care unit, inpatient costs, and lengths of stay.

Results: Rates of admission during intervention and control periods were similar in both the hospital (52% and 51%, respectively) and the coronary care unit (10% and 10%, respectively). Total lengths of stay in the hospital were similar (4.9 ±5.9 days and 4.9 ±5.7 days, respectively), as were average total costs ($7822 ±$13 217 and $7955 ±$13 400, respectively). No differences in management were detected for the subgroup of patients with low clinical risk for acute myocardial infarction.

Conclusions: The use of information alone—without direct human contact—did not affect management of patients with acute chest pain at this hospital. Although this low-intensity intervention might be more effective for other conditions and in other settings, our data support the use of other strategies to affect physician decision making.