Provider-directed imaging stress testing reduces health care expenditures in lower-risk chest pain patients presenting to the emergency department

Chadwick D. Miller, James W. Hoekstra, Cedric Lefebvre, Howard Blumstein, Craig A. Hamilton, Erin N. Harper, Simon Mahler, Deborah B. Diercks, Rebecca Neiberg, W. Gregory Hundley

Research output: Contribution to journalArticlepeer-review

21 Scopus citations


Background-Among intermediate- to high-risk patients with chest pain, we have shown that a cardiac magnetic resonance (CMR) stress test strategy implemented in an observation unit (OU) reduces 1-year health care costs compared with inpatient care. In this study, we compare 2 OU strategies to determine among lower-risk patients if a mandatory CMR stress test strategy was more effective than a physicians' ability to select a stress test modality. Methods and Results-On emergency department arrival and referral to the OU for management of low- to intermediate-risk chest pain, 120 individuals were randomly assigned to receive (1) a CMR stress imaging test (n60) or (2) a provider-selected stress test (n60: stress echo [62%], CMR [32%], cardiac catheterization [3%], nuclear [2%], and coronary CT [2%]). No differences were detected in length of stay (median CMR24.2 hours versus 23.8 hours, P0.75), catheterization without revascularization (CMR0% versus 3%), appropriateness of admission decisions (CMR 87% versus 93%, P0.36), or 30-day acute coronary syndrome (both 3%). Median cost was higher among those randomly assigned to the CMR-mandated group ($2005 versus $1686, P<0.001). Conclusions-In patients with lower-risk chest pain receiving emergency department- directed OU care, the ability of a physician to select a cardiac stress imaging modality (including echocardiography, CMR, or radionuclide testing) was more cost-effective than a pathway that mandates a CMR stress test. Contrary to prior observations in individuals with intermediate- to high-risk chest pain, in those with lower-risk chest pain, these results highlight the importance of physician-related choices during acute coronary syndrome diagnostic protocols.

Original languageEnglish (US)
Pages (from-to)111-118
Number of pages8
JournalCirculation: Cardiovascular Imaging
Issue number1
StatePublished - Jan 2012


  • Chest pain diagnosis
  • Cost-benefit analysis
  • MRI
  • Trials

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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