Analysis of diagnostic process of chest pain patients on waiting time, processing time, test performance, costs and cost consequences

Background: A new blood test has been developed which can determine coronary artery disease (CAD). The blood test indicates whether the heart suffers from a lack of oxygen. The current diagnostic process to determine CAD is complex. The degree of certainty about the diagnosis of chest pain is low and golden standards are scarce. The hospitals average waiting period before the tests take place is usually two months, while the Dutch norm is four weeks. There is also a wide variation in care processes that are completed by the patients and a variation in the order of the tests. It is also proven that at least 70% of the referred patients to the cardiologist do not have CAD. This leads to unnecessary costs and inefficient work. Therefore the current diagnostic process of chest pain patients of the Fast Track outpatient clinic (FTP AP) of the Erasmus Medical Centre (EMC) is analysed in this study. This project forms an initial exploration and is intended as a tool for a future economic evaluation of the added value of the blood test compared to the current diagnostic process. Methods: Both 1. qualitative, including participatory observations, literature review and interviews and 2. quantitative research methods including analyzing patient statuses and cost-consequences analysis (CCA) were used. Three participatory observations are done; four articles were used from PubMed/Medline; and four interviews were conducted, mainly with Mr. P.J. Musters. Also conversations were conducted with the laboratory technician, the cardiac technician and the radiologist. In total 54 patient statuses (54 +/- 12 years, 36 males) have been analyzed of patients who visited the FTP AP with chest pain, referred by the GP or an internal department of the EMC. For the CCA the information from the EMC site and the site of the Dutch Federation of University Medical Centers (NFU) were used. Also the results of the analyses of the current diagnostic process have contributed to this analysis. Results: There is hardly any variation in the standard care program of chest pain patients visiting the FTP of the EMC. Most of the patients undergo all standard examinations. After the diagnostic process, 8 of the 54 patients (14,8%) were identified with CAD. 45 of the 54 patients (83,3%) completed all tests in one day. The average processing time was 3 days. However, it is a very labor-intensive process. There are a lot of different specialists present during the tests. The time elapsed from the first visit to the outpatient clinic to the final diagnosis letter stays within the norm of 4 weeks for 50 of the 54 patients (92,6%), with an average of 12 days. The average waiting time for the FTP AP is well above the norm, more than 35 days. The waiting time was within the Treek standard for 19 of the 40 patients (47,5%). The accuracy of the current tests is sufficient in relation to the literature. Two exercise ECGs (XECG) were false-negative and two false-positive. The MSCT scan demonstrated no false-positive or false-negative values. In total 9 of the 51 XECGs were inconclusive, due to patients who not reached the Target Heart Rate. 1 MSCT scan was inconclusive. Moreover, 2 patients were wrongly diagnosed. The new blood test will be 1/3 cheaper than current diagnostics. The new blood test is also less labor intensive and is probably able to reduce the waiting time within the Treek standard. Conclusion: There is a possibility for the new blood test to improve the current diagnostic process. One way to accomplish this is by reduction of the current waiting time. The current waiting time is far above the Treek. The GP can perform the new blood test and is considered to be able to exclusively refer CAD suspected patients (20%), which will decrease the inflow and thus the waiting time. So the new blood test can be a solution for the long waiting time. Therefore the blood test can result in a tremendous cost saving for health care expenditures. In addition to cost saving from less unnecessary referrals, the new diagnostic process will be less labor intensive and more convenient for the patient. Last, the new blood test is probably 1/3 cheaper than the current diagnostic process. Although the first results are promising, much more has to be investigated about the blood test to determine its possible contribution to the current process or to even replace the current process in the future.