Palpitations are a common emergency department (ED) complaint with etiologies ranging from benign psychiatric disorders to life-threatening cardiac conditions, including cardiac arrhythmias and structural heart disease. Currently, there is no research to guide emergency physicians in the risk-stratification of these patients. As a result, certain patients are admitted to the hospital and undergo potentially harmful and costly investigations and with little or no benefit. Other patients may be discharged from the ED with minimal diagnostic evaluation only to suffer adverse outcomes. More research is needed to elucidate which patients benefit from admission and further investigation and which can be safely discharged. The first steps in addressing this issue are to 1) delineate the scope of the problem, 2) examine the variation in current practice, and 3) identify key factors influencing clinical decision-making.
In Aim 1 a, this study will determine nationally representative weighted estimates of the incidence and prevalence of palpitations among ED patients, and describe their demographic characteristics (age, gender, race/ethnicity), rate of ED testing (EKG, chest x-ray, cardiac enzyme), medication usage, admission patterns, discharge diagnoses and in-hospital mortality. This will be accomplished by conducting a secondary data analysis of the ED portion of the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2000- 2009.
In Aim 1 b, using data from this secondary data analysis, variation in current clinical practice will be examined and factors associated with admission and mortality will be determined.
In Aim 2, using standard qualitative methodology, structured interviews with academic and community emergency physicians will be conducted to identify key factors influencing ED management of patients with palpitations. This will serve to elucidate the clinical decision-making process of physicians managing these patients. The long-term objectives of this project are to develop a diagnostic approach to accurately risk-stratify patients with palpitations which would decrease unnecessary testing and hospital admission while improving patient outcomes. In addition to gaining experience in clinical research through the conduct of the study, the applicant will undertake didactic instruction in epidemiology, research methodology and biostatistics towards a Masters Degree from the School of Public Health at the University of California, Los Angeles.
In 2009, there were an estimated 136 million visits to emergency departments (EDs) of nonfederal short-stay and general hospitals in the United States, a substantial portion of which were for palpitations. Many these patients are admitted and evaluated with little or no benefit consuming valuable health care resources while others may be inappropriately discharged. This study will provide the foundation for future prospective studies to help improve the management of patients with palpitations, decreasing health care resource utilization and improving patient outcomes.
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