Adherence to an Accelerated Diagnostic Protocol for XXXX : Secondary Analysis of the HEART Pathway Randomized Trial.

@entity1 @entity1187 @entity662 @entity2613 @entity299 @entity583 @entity857
OBJECTIVES: Accelerated diagnostic protocols (ADPs), such as the HEART Pathway, are gaining popularity in emergency departments (EDs) as tools used to risk stratify @entity1 with acute @entity662 . However, provider nonadherence may threaten the safety and effectiveness of ADPs. The objective of this study was to determine the frequency and impact of @entity857 nonadherence. METHODS: A secondary analysis of @entity1 enrolled in the HEART Pathway RCT was conducted. This trial enrolled 282 adult @entity2613 @entity1 with symptoms concerning for @entity1187 without ST-elevation on electrocardiogram. @entity1 randomized to the HEART Pathway (N  =  141) were included in this analysis. Outcomes included index visit disposition, nonadherence, and major adverse @entity299 (MACEs) at 30 days. MACE was defined as death, @entity583 , or revascularization. Nonadherence was defined as: 1) undertesting-discharging a high-risk @entity1 from the @entity2613 without objective testing (stress testing or coronary angiography) or 2) overtesting-admitting or obtaining objective testing on a low-risk @entity1 . RESULTS: Nonadherence to the HEART Pathway occurred in 28 of 141 @entity1 (20%, 95% confidence interval [CI]  =  14% to 27%). Overtesting occurred in 19 of 141 @entity1 (13.5%, 95% CI  =  8% to 19%) and undertesting in nine of 141 @entity1 (6%, 95% CI  =  3% to 12%). None of these 28 @entity1 suffered MACE. The net effect of nonadherence was 10 additional admissions among @entity1 identified as low-risk and appropriate for early discharge (absolute decrease in discharge rate of 7%, 95% CI  =  3% to 13%). CONCLUSIONS: Real-time use of the HEART Pathway resulted in a nonadherence rate of 20%, mostly due to overtesting. None of these @entity1 had MACE within 30 days. Nonadherence decreased the discharge rate, attenuating the HEART Pathway's impact on health care use.
