Longstanding threats to education in academic medical centers (AMC) have been exacerbated by the coronavirus disease 2019 (COVID-19) pandemic. Decreased departmental revenue, cessation of in-person learning, and reduced morale have disrupted medical education at both the undergraduate and graduate levels. Educational efforts have traditionally suffered from a lack of dedicated sources of funding, leading to a crisis among educators, and causing them to abandon this field to pursue nonacademic clinical careers.1AMAOrganizational steps to support medical educators. American Medical Association, Chicago (IL)2022Google Scholar Physician-educator's well-being, engagement, and job satisfaction are critical to their functioning as strong role models for students, residents, and fellows. Several threats to the education mission have emerged during the pandemic, as recently outlined by the American Medical Association.1AMAOrganizational steps to support medical educators. American Medical Association, Chicago (IL)2022Google Scholar The loss of in-person learning experiences, a crucial aspect of medical student and resident education, has disrupted the clinical learning environment. Strained, overextended, and undersupported physicians struggle to meet increased service demands. For example, the increased use of residents to cover for sick colleagues during COVID-19 surges added to the baseline stress of constant exposure to patients with COVID-19. Redesigning educational programs to incorporate virtual platforms has been effective in some circumstances, providing flexibility to educators and students, but at the cost of human interaction, leading to mental stress.2Herriott H.L. McNulty M.A. Virtual learning impacts communication and teamwork.Clin Teach. 2022; 19e13514Crossref PubMed Scopus (3) Google Scholar Disruptions to classroom, daycare, and home activities have burdened young educators, especially mothers. Educators have had to navigate steep learning curves to adapt to virtual platform-based teaching. Physician-educators, overburdened by clinical work and lacking adequate time for teaching, experience stress and poor engagement (Figure 1, A). They fail to prioritize learner education and cannot function as good role models. Poor education leads to poor learner performance, dissatisfaction, and low evaluation ratings of the learning experience by trainees. Impaired learner performance and poor evaluations exacerbate physician-educator's stress, leading to further disengagement. The final outcome of this vicious cycle of stress is the retreat of physicians from the educational mission and a loss of educational leaders. We hypothesize that such a vicious cycle leading to educator burnout can be broken through valuing educators by incentivizing their efforts and providing adequate protected time and support. Organizational recognition of the importance of education and assignment of resources to educator well-being and career development should result in enhanced positive interactions and engagement between educators and learners. An aligned funds-flow process has the potential to create such a positive environment.3Lakshminrusimha S. Murin S. Kirk J.D. Mustafa Z. Maurice T.R. Sousa N. et al."Funds flow" implementation at academic health centers: unique challenges to pediatric departments.J Pediatr. 2022; 249: 6-10.e4Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 4Orlowski J.M. Mitchell C.A. Enders T. Merritt M.G. Pfister H.R. Leary T.D. et al.Next-generation funds flow models: enhancing academic health system alignment. Association of American Medical Colleges (AAMC) - Future of Academic Medicine Series, Washington (DC)2018Google Scholar, 5Josephson S.A. Sacco R.L. Czech J.M. Maher R.N. Knutson C.S. Goldstein L.B. Funds flow in academic neurology: a potential path to financial success.Neurology. 2020; 94: 785-791Crossref PubMed Scopus (8) Google Scholar, 6Barnes J. Abrams K.J. Funds flow in academic medical centers: moving toward a transparent and equitable funding model.https://www2.deloitte.com/us/en/pages/risk/articles/funds-flow-model-academic-medical-center.html2021Google Scholar Some prior efforts, as part of a wider mission-based budgeting system, included the creation of an educational value unit as a first step in quantifying educational efforts and placing such efforts on par with the work relative value unit assigned to clinical efforts.7Watson R.T. Romrell L.J. Mission-based budgeting: removing a graveyard.Acad Med. 1999; 74: 627-640Crossref PubMed Scopus (51) Google Scholar Although the concept of the educational value unit is inherently attractive and directs attention toward the educational mission of an academic unit, on a practical level there is huge variation in how the metric is designed, implemented, and used by health systems to allocate or redistribute funds. Data tracking is complex and burdensome, and there is very limited information about the objective outcomes of such efforts.8Mallon W.T. Jones R.F. How do medical schools use measurement systems to track faculty activity and productivity in teaching?.Acad Med. 2002; 77: 115-123Crossref PubMed Scopus (53) Google Scholar Supporting teaching time with aligned funds flow by the AMC seems to be a better alternative, especially because a funds-flow process involves an overhaul of funding of each of the health system's missions, allowing mission-based allocation of funds in a more facile and flexible manner. The goal of our article is to outline challenges to various aspects of the educational mission in our AMC, the implementation of an aligned funds-flow model, and its effect on teaching efforts and quality. AMCs are facing multiple challenges with respect to medical school finances (Table I) Unique challenges in pediatrics include (i) limited direct support for mentoring learners interested in pediatrics; limited support for fourth-year education or educational director to oversee the experience for fourth-year students interested in or committed to a career in pediatrics; (ii) small relative size of most pediatrics departments, compared with internal medicine, such that faculty do not have leeway to engage in robust teaching or take on educational leadership roles in pre-clerkship courses, making pediatrics an orphan subject in the early curriculum; (iii) increasing accreditation and educational quality improvement requirements with little support for these critical efforts; and (iv) decreased census in children's hospitals during the COVID-19 pandemic, leading to less departmental revenue and fewer student learning opportunities, especially as related to common pediatric infectious conditions.10Haddadin Z. Schuster J.E. Spieker A.J. Rahman H. Blozinski A. Stewart L. et al.Acute respiratory illnesses in children in the SARS-CoV-2 pandemic: prospective multicenter study.Pediatrics. 2021; 148e2021051462Crossref PubMed Scopus (55) Google ScholarTable IChallenges faced by AMCs specific to the educational missionIncreasing medical schools class sizesSpecialized medical school pathways with differing structures (eg, tracks focusing on primary care, research, rural service)Limited site/preceptor availabilitySupport for educational innovation and curriculum development/renewalFinancial resources for educational scholarshipLack of direct and transparent funding for front-line teaching activity by faculty educators (including community preceptors, on whom there is increasing reliance)Insufficient financial support of clerkship directors (based on national published guidelines)9Morgenstern B.Z. Roman B.J.B. DeWaay D. Golden W.C. Malloy E. Reddy R.M. et al.Expectations of and for clerkship directors 2.0: a Collaborative statement from the alliance for clinical education.Teach Learn Med. 2021; 33: 343-354Crossref PubMed Scopus (6) Google ScholarInsufficient administrative support for clerkship directors9Morgenstern B.Z. Roman B.J.B. DeWaay D. Golden W.C. Malloy E. Reddy R.M. et al.Expectations of and for clerkship directors 2.0: a Collaborative statement from the alliance for clinical education.Teach Learn Med. 2021; 33: 343-354Crossref PubMed Scopus (6) Google Scholar Open table in a new tab The graduate medical education (GME) enterprise has been supported more transparently than undergraduate medical education (UME) through federal and state funds, as well as support from the AMC (derived from a combination of philanthropy, grant funding, and clinical work). However, funds to supplement GME teaching efforts have not always been allocated systematically among various departments. Moreover, although the Accreditation Council for Graduate Medical Education (ACGME) has defined minimum requirements for administrative time commitments for program directors and program coordinators for residency and fellowship programs based on the number of residents, and fellows, this funding has in the past been the responsibility of individual departments. During interviewing and onboarding periods, residency and fellowship programs need additional resources. Recent proposed changes to pediatrics residency by ACGME are likely to require additional inpatient resources contributing to additional costs for the departments and AMCs (https://www.acgme.org/globalassets/pfassets/reviewandcomment/320_pediatrics_impact-022023.pdf). A change in the funds-flow model provides an opportunity to refine educational support and assign protected time to educators for training and career development, to enhance delivery of educational content, to support mentorship of learners, and to facilitate educational scholarship (Table II). Input solicited from medical students and residents to foster an environment of shared learning can help to redesign workflows that support the educational mission of the school of medicine. UC Davis Health in 2020-2021 implemented an aligned funds-flow methodology that provided adequate funding to support the administrative tasks of medical educators and residency directors and fund core administrative staff (eg, residency program coordinators).3Lakshminrusimha S. Murin S. Kirk J.D. Mustafa Z. Maurice T.R. Sousa N. et al."Funds flow" implementation at academic health centers: unique challenges to pediatric departments.J Pediatr. 2022; 249: 6-10.e4Abstract Full Text Full Text PDF PubMed Scopus (11) Google ScholarTable IIFinancial investment into education (UC Davis model)RoleBefore institution of aligned funds flowYear 1 of aligned funds flowYear 2 of aligned funds flowUME – SOM$2 439 640$7 762 491$10 989 013UME - Department of Pediatrics$149 313$914 969$1 160 945GME – SOM$1 917 693$8 515 776$9 934 455GME- Department of Pediatrics$145 956$675 517$616 332Total educational support at SOM (UME + GME)$4 357 333$16,278 267$20 923 468SOM, school of medicine. Open table in a new tab SOM, school of medicine. To streamline the process of funding UME, the following principles were established through active discussion with the education team. (i) Any activity requiring <5% effort was considered part of the regular, low-intensity, and expected teaching activity of a faculty member and would not be supported by discrete funding. (ii) Efforts of ≥5% would be funded through support agreements.(i) Various clinical roles were identified (eg, clerkship directors, small group facilitators) and the percentage effort for these roles was determined.(ii) Benefits for the portion of full-time equivalent (FTE) relating to UME effort provided by clinical faculty were covered through a payment to the department by the dean's office. Funding was provided to departments for defined, high-intensity teaching roles within UME based on the time-based effort required for the role. These defined roles were standardized to support the time spent away from clinical, work relative value unit-generating activity. The percent effort for defined positions was set by the Vice Dean of Medical Education with the approval of the Dean. The amount of support was calculated by multiplying the percentage of effort required for role with the Association of American Medical Colleges (AAMC) compensation benchmark salary. The faculty member's actual rank and specialty was considered during this calculation. Eight departments in the UC Davis School of Medicine (emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, pediatrics, psychiatry, and surgery) offer required clerkship courses to medical students. Department chairs need discretionary funds available to recognize and compensate faculty in key teaching roles (faculty often take these roles at the potential expense of their own individual productivity). Departments with required third- and fourth-year clerkship courses must provide medical students with clinical learning experiences in a positive learning environment. A flat amount of $100 000 is provided to each department with a required clerkship/course to support their capacity to fund dedicated faculty time for teaching and supervision in the clinical setting, as well as support for key clinical educational initiatives identified annually by the Office of Medical Education, such as enhancing the learning environment, site capacity development, and faculty development in teaching. These resources provide additional funding to the departments that offer clinical electives to medical students that meet graduation requirements. The amount of support was based on prior year clinical elective enrollment (number of weeks per course multiplied by the number of students who completed the course). In 2019, a strategic action plan was developed in response to low AAMC graduate questionnaire (GQ) scores in the department of pediatrics. Faculty on service were busy, leading to low scores for teaching by faculty (Figure 2). In addition, direct observation of students during periods of history taking and examination and student perceptions of effective teaching during the clerkship were important areas of deficiency. To address these issues, the department of pediatrics funded faculty in the role of faculty feedback coaches. These senior faculty members meet with faculty, residents, and students on the pediatric inpatient units; perform direct observation of teaching rounds; and provide feedback to team members (students, residents, faculty). With aligned funds flow (Table III), this cost was covered and was no longer a burden on the department. Pediatric AAMC GQ scores improved with the implementation of the faculty feedback coach action plan (Figure 2).Table IIIDefined roles in UME and percent effort assigned (using department of Pediatrics as an example)Role (No. of faculty)Percent effortAcademic coach (2)20% each Mentoring of students, teaching clinical skillsClerkship director (2)15% each (+10% departmental support for each)Medical student professionalism director (1)20%Competency council20% (chair) Ongoing assessment of students throughout curriculum5% (member ×2)Clinical skills and assessment director (1)30%Course director (4)5% each For example, preclerkship courses, clerkship intersession courseCurriculum Implementation Team chair (1)40% Curriculum committee and curriculum implementation task forceTransition to residency course director (1)10%Discipline leader (2)5%-15% each (total – 35%) Integrated curriculum content leaders: bioethics, clinical skills, health system science, nephrology, pediatricsProblem-based learning small group facilitator for preclinical courses (3)20% eachThread leader (2)10% each Curricular content champions (eg, care for vulnerable populations)Departmental clerkship support$100 000 (mainly for departmental faculty feedback coaches to observe teaching and provide feedback to educational teams on in-patient services and to provide additional time/financial support to clerkship directors (eg, conference attendance, membership dues)Fourth-year specialty advisor/educational director (1)10%Quality improvement director (1)10%Summary Total FTE needed to support a class of 140 students in pediatrics4.0 FTE (support to the department for fiscal 2022-2023): $1 160 945) Open table in a new tab The faculty effort for the residency program directors is supported by the funds-flow process. All residency program directors of ACGME-accredited programs are supported for the dedicated time required by the ACGME (often based on the number of trainees). For ACGME programs without a specified minimum FTE required for the program director, a default of 0.1 FTE was assigned. The funds transferred to the department were calculated by multiplying the ACGME FTE requirement with an AAMC compensation benchmark set at the actual rank and specialty of the faculty member in the position. The percentage of dedicated time for residency program coordinators required by the ACGME is supported. For ACGME programs without a specified minimum FTE required for the program coordinator, a default of 0.25 FTE was assigned to the program. The cost of benefits for these program coordinators is also covered. Because fellows contribute to clinical workflow and revenue, only 50% of the time required by the ACGME for fellowship program directors is supported. Non-ACGME fellowship program directors and coordinators are not supported by the funds-flow process and are funded by the departments, and such fellowships in our health system only have 1-2 fellows. The aligned funds-flow methodology centralized the expense of all ACGME residents and fellows, so that they are no longer the responsibility of individual departments. All salary and benefit expenses for ACGME residents and fellows that are not already covered by an outside contract are funded by the health system. Because of the very recent implementation of the funds flow process at our institution, data on the impact of changes in educational support on outcomes are limited (Figure 1, B). Nevertheless, this realignment of support to better match educational effort has resulted in several discernable favorable changes in meeting the educational missions of the department. Greater financial support for clerkship directors and support for some frontline faculty educational efforts have led to improved learner satisfaction (as evidenced by student evaluations and the AAMC GQ scores on the pediatrics experience) (Figure 2). The percentiles for quality of pediatric clerkship ratings in Mission Management Tool steadily increased over the years (Figure 3). Faculty are able to be more focused and engaged in teaching and can, in turn, be held accountable for their teaching activities. Support of the departmental faculty feedback coaching program has enabled faculty time to be bought out and protected. Coaches have been instrumental in providing performance feedback to third-year medical students and to pediatrics residents and faculty on their teaching efforts and in creating a safe learning environment. This practice has resulted in improved ratings of the pediatrics clerkship experience (student end-of-clerkship evaluations) and helped to meet Liaison Committee on Medical Education requirements for provision of feedback to all students. Support of a faculty specialty advisor for fourth-year students has helped both with career advising efforts and to ensure that students interested in pediatrics continue to match into their desired residency programs, despite the increasing competition for residency positions. The restructuring of the entire medical school curriculum that occurred in parallel with the funds-flow process resulted in the creation of new courses, which required the recruitment of new course directors. A formal and structured application process was developed with clear expectations (including the time commitment) for the course director role, transparent funding, and approval by the department chair. Consequently, courses that had been taught and led predominantly by internists traditionally (based on historical precedent) were now open to pediatric educators with interest and expertise in teaching pedagogies. In addition, a pediatric discipline leader position was created. A Stages of Life curriculum thread was implemented to integrate child health and lifecycle medicine issues in a seamless manner throughout the curriculum. With the new curriculum format, many course, discipline, and thread leader positions have been awarded to pediatrics faculty, supporting faculty in their passions. A natural and direct consequence of this change has been the early and consistent exposure of medical students to pediatrics content and pediatrician role models. We anticipate that this strategy will translate into better student performance when they enter the third-year pediatric clerkship and potentially increase the number of students who choose pediatrics as a career. Improved, but ongoing suboptimal, funding support for clerkship directors, based on published guidelines; additional funding provided to the departments has increased support for clerkship directors (Table I), increasing complexity of the UME educational enterprise (ever increasing class sizes, a push toward more individualized pathways for learners with different needs). As this complexity continues to increase, faculty time support will need to be adjusted upward at a commensurate rate to prevent burnout. The funding of faculty effort based on the median benchmark, not actual salaries, may discourage more senior and/or higher paid subspecialist educators from taking on these educational leadership positions. This factor may affect educational outcomes, if participation decisions are made based on salary shortfalls as opposed to interest and expertise in education. Current profit margins under aligned funds flow have enabled chairs to have adequate departmental funds to support senior subspecialists to actively engage in medical education. However, sustainability of increased funds flow to education at AMCs is being challenged by tight budgets, with decreasing federal funding for research and increasing competition in the clinical marketplace. Funds flow provides a useful model for supporting clinical faculty educators and is tied to significant improvements in education outcome metrics. Whether these positive changes will be sustained, and expectations of other favorable hypothesized outcomes realized, remains to be seen. Recent proposed changes to Pediatric residency by ACGME are likely to require additional inpatient resources to staff ICUs contributing to additional costs to AMCs (https://www.acgme.org/globalassets/pfassets/reviewandcomment/320_pediatrics_impact-022023.pdf). The ability of the AMCs to sustain additional expenses to support education in an environment of diminishing clinical margins will be a challenge. Given the financial circumstances of lower margins across all AMC's reported in 2022, and expectations that those conditions will not get better in the near future, organizations' ability to further finance expanded funds-flow models may be diminished for the foreseeable future.11Gamble M. Hospital margins see no relief to start the year. Becker's Healthcare, Chicago, IL2023Google Scholar Ongoing evaluation of GQ scores, faculty and resident/fellow wellness, and trainee and faculty teaching evaluations will help us to assess the long-term impact of this additional funding.

Academic health centers aim to advance their traditional tripartite mission of advancing clinical care, education, and research, which is now expanding to a quadripartite mission, addressing social determinants of health and promoting health equity.1 However, academic health centers face significant challenges in the current marketplace.2 Competition from the private sector, regulatory issues, payer mix, decreased work hours, increased provider cost, and lack of alignment between hospitals and schools of medicine have contributed to the financial woes of pediatric departments.

The COVID-19 pandemic has created multiple, complex and intense demands on hospitals, including the need for surge planning in the many locations outside epicenters such as northern Italy or New York City. We here describe such surge planning in an Academic Health Center that encompasses a children's hospital. Interprofessional teams from every aspect of inpatient care and hospital operations worked to prepare for a COVID-19 surge. In so doing, they successfully innovated ways to integrate pediatric and adult care and maximize bed capacity. The success of this intense collaborative effort offers an opportunity for ongoing teamwork to enhance efficient, effective, and high-quality patient care.

BACKGROUND Professional society guidelines suggest early stress testing (within 72 hours) after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS). However, there is increasing concern that current practice results in over-testing without evidence of benefit. We test the hypothesis that early stress testing improves outcomes. METHODS We analyzed prospectively collected data from 9 EDs on patients with suspected ACS, 1999-2001. We excluded patients with an ED diagnosis of ACS. The primary outcome was 30-day major adverse cardiac events (MACEs), including all-cause death, acute myocardial infarction, and revascularization. We used the HEART score to determine pretest ACS risk (low, intermediate, and high). To mitigate potential confounding, patients with and without early stress testing were matched within pretest risk strata in a 1:2 ratio using propensity scores. RESULTS Of 7127 potentially eligible patients, 895 (13%) received early stress testing. The analytic cohort included 895 patients with early stress testing matched to 1790 without early stress testing. The overall 30-day MACE rate in both the source and analytic population was 3%. There were no baseline imbalances after propensity score matching (P > 0.1 for more than 30 variables). There was no association between early stress testing and 30-day MACE [odds ratio, 1.0; 95% confidence interval (CI), 0.6-1.7]. There was no effect modification by pretest risk (low: odds ratio, 1.0; 95% CI, 0.2-3.7; intermediate: 1.2; 95% CI, 0.6-2.6; high: 0.4; 95% CI, 0.1-1.6). CONCLUSIONS Early stress testing is not associated with reduced MACE in patients evaluated for suspected ACS. Early stress testing may have limited value in populations with low MACE rate.

Introduction: The emergency department (ED) evaluation of suspected acute coronary syndrome (ACS) is a common, challenging, and costly task with high clinical stakes. Professional society guidelines recommend early stress testing (within 72 hours of ED visit); however, there are no data to demonstrate improved outcomes with this approach. Hypotheses: 1.) Early stress testing improves outcomes, and 2.) The association between early stress testing and outcomes is modified by pre-test ACS risk. Methods: We analyzed prospectively collected registry data from 9 emergency departments on patients with suspected ACS. The primary outcome was 30-day major adverse cardiovascular events (MACE), including all-cause death, acute myocardial infarction, and urgent revascularization. The exposure variable of interest was early stress testing. We used the HEART score to determine pre-test ACS risk (low, intermediate, high). To mitigate potential confounding by indication, patients with and without early stress testing were matched in a 1:2 ratio using propensity score methods. The propensity score model included over 40 demographic, clinical, biomarker, and ECG covariates. Results: The analytic cohort included 946 patients with early stress testing and 1,892 without early stress testing. There were no significant baseline imbalances after propensity score matching (p>0.1 for all covariates). There was no association between early stress testing and 30-day MACE in the overall cohort (OR 1.3; 95%CI 0.8-2.1). There was evidence of effect modification by pre-test ACS risk strata (low: OR 1.2, 95%CI 0.2-5.3; intermediate: 2.1, 95%CI 1.1-4.1; high: 0.4, 95%CI 0.1-1.4). In intermediate risk patients, early stress testing is associated with increased rates of revascularization (OR 2.8, 95%CI 1.3-6.0), but not with death/ acute myocardial infarction (OR 0.9, 95%CI 0.1-4.6). Conclusions: Early stress testing does not reduce 30-day MACE in the ED evaluation of suspected ACS. In intermediate-risk patients, early stress testing may result in increased revascularization rates without reduction in the objective outcomes of death or myocardial infarction. These findings challenge existing care guidelines and require confirmation by randomized trials.

Management of heart failure patients who present with signs and symptoms of acute decompensation remains challenging. Because of limited data from randomized controlled trials, evidence-based guidelines for the management of these patients in the emergency department and observation unit are just now emerging. Although treatment protocols and management algorithms appear vital to the successful treatment of these patients, they are based largely on anecdotal experience or at best, data from small trials. Cornerstones of these algorithms are appropriate patient risk stratification and recognition of those primarily with pulmonary congestion versus those with cardiogenic shock. Further delineation based upon (1) severity of volume overload, (2) associated renal insufficiency, and (3) relationship to presenting blood pressure appears to aid with management decisions. This chapter will focus on therapeutic management, with respect to general supportive measures, pharmacologic therapy, and, most importantly, specific treatment protocols or algorithms that can be implemented in your institution.

Aim Our aim was to set up a system to help UK clinical research units to prevent healthy volunteers from participating in more than one non-therapeutic trial simultaneously, or from starting a second trial too soon after the first. Methods TOPS (The Over-volunteering Prevention System) is internet-based, simple and quick to use, free to users and a charity run by a Board of Trustees. Users enter only two or three pieces of information: (1) ‘National Insurance number’ (NINO) of UK citizens, or ‘passport number’ and country of origin of non-UK citizens, as their identifier, (2) ‘date of last dose’ of trial medicine or (3) ‘never dosed’. Subjects must consent, but TOPS collects only non-personal data, so it does not require Ethics Committee approval and is not covered by the Data Protection Act. Results A total of 55 research units (29 clinical research organisations, 5 pharmaceutical companies, 13 universities and 8 hospitals) throughout the UK have registered to use TOPS, and have entered 124,906 volunteers since we launched it. All commercial and many non-commercial units now use TOPS. In our unit, no subject has to the best of our knowledge participated in two trials simultaneously. TOPS has reduced to <1% the incidence of subjects attempting to volunteer within 3 months of completing another trial elsewhere, and very few have to our knowledge succeeded. Conclusion TOPS is widely used and effective, and helps research units to comply with UK clinical trial regulations.

OBJECTIVES:The primary purpose was to compare the odds of acute coronary syndrome-pertinent diagnostic testing between self-reported cocaine users and non-users at the turn of the century. The secondary purpose was to compare the odds of acute coronary syndrome outcomes between cocaine users and non-users. DESIGN:Nested matched case-control study using data from the Internet Tracking Registry of Acute Coronary Syndromes. SETTING:Extracted data of patients from eight US institutions composed of six academic and two community hospitals, with census varying between 10 000 and 160 000 visits per year. PARTICIPANTS:249 cases of self-reported cocaine users and 249 matched controls. Matching was based on age, race, sex and any history of known coronary artery disease. Exclusion criteria were new ST elevations on initial ECG and initial physician impression of acute myocardial infarction. PRIMARY AND SECONDARY OUTCOME MEASURES:Primary outcome was the conditional odds of undergoing non-invasive and invasive testing for coronary artery disease. Secondary outcome was the occurrences of adverse cardiac outcomes within 30 days. RESULTS:Cocaine users underwent diagnostic testing at similar rates compared with non-users (9.6% vs 8.0%, OR 1.24, CI 0.65 to 2.34). Adverse cardiovascular outcomes occurred in four (1.6%) cocaine users and in seven (2.8%) controls. CONCLUSIONS:There was no increase in tendency for testing associated with self-reported history of cocaine use between 1999 and 2001. This suggests that even 10 years ago, cocaine use already had only a limited role in the Emergency Department (ED) physician's decision-making process. Similar data analyses of detailed registries can offer important contextual information that can better direct resources for future comparative effectiveness research.

Heart failure requiring urgent therapy represents a burgeoning health care burden. Although acute heart failure syndromes are commonly defined as a change in chronic heart failure signs and symptoms requiring urgent therapy, the presentation, development, and response to treatment is highly dependent on individual patient characteristics. This heterogeneity has led to challenges in interpreting widely differing study methods, including eligibility requirements and outcome measures. To improve interpretation of results and translate such information to better patient care, it is essential to present an accurate description of the patient population and study design. Based on existing recommendations and expert consensus, the authors present standardized reporting criteria to improve interpretability of research in this challenging cohort.

OBJECTIVE:High-sensitivity C-reactive protein (hs-CRP) rises with cardiac injury/ischemia. We evaluated its efficacy in aiding in the identification of an acute coronary syndrome (ACS) in patients (pts) admitted to the chest pain unit (CPU) for possible ACS.METHODS:Retrospective study of all patients admitted to the CPU with chest pain who underwent hs-CRP testing as part of their CPU evaluation from January 2004 to October 2008. Patients were low risk for ACS (compatible symptoms, nondiagnostic initial ECG, and negative cTnI). ACS was diagnosed by positive functional study, cardiac catheterization, or cardiac event during 30-day follow-up. Positive hs-CRP was defined based on local laboratory levels (>1.0 mg/l or >3.0 mg/l), and population-based and prior study values >2.0 mg/l. Chi-square analysis was performed, and odds ratios (OR) are presented. Multivariate analysis was done to determine whether hs-CRP was independently associated with the diagnosis of ACS. Cardiac risk factors, demographics, and diagnosis of ACS were included in the model. Medians with IQR are presented for continuous data. Ninety-five percent confidence intervals are presented where applicable.RESULTS:A total of 958 patients had hs-CRP testing as part of their CPEU evaluation. Excluded from the analysis were 39 patients lost to follow-up. The final cohort comprised 478 (52%) women and 441 (48%) men with a median age of 56 (IQR 48-64). ACS was diagnosed in 128 (13.4%). The median cohort hs-CRP value was 2.2 mg/l (IQR 0.7, 5.8) and 2.3 mg/l (IQR 0.6, 5.9) in those with and without ACS, respectively. In the multivariate analysis hs-CRP was not independently associated with the diagnosis of ACS (0.99; 95% CI 0.98 - 1.01).CONCLUSION:In large patient cohort managed in a single-center CPU, measurement of hs-CRP did not enhance the diagnostic accuracy for ACS. Routine hs-CRP as a diagnostic tool should not be recommended in the CPU setting.

OBJECTIVES It has been well documented that screening, prevention, and treatment disparities in cardiovascular care exist. Most studies have focused on the outpatient setting. The purpose of the present analysis was to assess if a disparity of care exists in the care of emergency department (ED) patients with acute heart failure in a secondary analysis of the Heart Failure and Audicor Technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational study. METHODS Only patients with an adjudicated diagnosis of acute heart failure were included in this analysis. Racial groups included in this analysis were limited to white and African American or black patients, due to their predominance in the cohort. Logistic regression including clinically relevant demographics, past medical history, exam, diagnostic tests, and adjudicated diagnosis of acute heart failure as covariates was performed to assess the association of race with treatment with a diuretic or nitroglycerin and 30-day death or readmission. RESULTS Of the cohort, 418 of 1,076 (38.8%) were included in the analysis. Median age was 69 years (interquartile range [IQR]=55-79 years), 49% were white, and 51% were African American or black. There was no difference in the correct admitting diagnosis in the two groups (p=0.83). Multivariate adjustment revealed that African American or black race was not associated with treatment with diuretics (adjusted odds ratio [OR]=1.00, 95% confidence interval [CI]=0.55 to 1.82) or nitrates (adjusted OR=1.27, 95% CI=0.76 to 2.13) in the ED. In a separate regression analysis there was no association with African American or black race with 30-day adverse events (adjusted OR=1.22, 95% CI=0.68 to 2.16). CONCLUSIONS This secondary analysis of HEARD-IT data did not identify racial disparities in the treatment of adults with acute heart failure in the ED.

Rapid risk stratification, selection of downstream management options, and institution of initial pharmacotherapy are essential to ensure that patients admitted to the emergency department with acute coronary syndromes receive optimal care. A broad range of antiplatelet and antithrombotic medications is available that permits tailoring of initial pharmacotherapy to each patient's risk status. In the urgent setting, thienopyridines (clopidogrel and prasugrel) carry limitations including response variability and increased risk for bleeding in patients requiring subsequent coronary artery bypass graft surgery. Glycoprotein IIb-IIIa receptor inhibitors, although they are highly effective in preventing ischemic events, must be used with care to reduce bleeding risk. Bivalirudin, a relatively new direct thrombin inhibitor, represents another upstream option but is costly and does not have approval for this indication. Simplified institutional management paradigms can streamline the process of selecting appropriate pharmacotherapy and aid in care delivery that will optimize patient outcomes.

The management of patients with chest pain is a common and challenging clinical problem. Although most of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent management of a serious problem such as acute coronary syndrome (ACS) and those with more benign entities who do not require admission. Although clinical judgment continues to be paramount in meeting this challenge, new diagnostic modalities have been developed to assist in risk stratification. These include markers of cardiac injury, risk scores, early stress testing, and noninvasive imaging of the heart. The basic clinical tools of history, physical examination, and electrocardiography are currently widely acknowledged to allow early identification of low-risk patients who have less than 5% probability of ACS. These patients are usually initially managed in the emergency department and transitioned to further outpatient evaluation or chest pain units. Multiple imaging strategies have been investigated to accelerate diagnosis and to provide further risk stratification of patients with no initial evidence of ACS. These include rest myocardial perfusion imaging, rest echocardiography, computed tomographic coronary angiography, and cardiac magnetic resonance imaging. All have very high negative predictive values for excluding ACS and have been successful in reducing unnecessary admissions for patients at low to intermediate risk of ACS. As patients with acute chest pain transition from the evaluation in the emergency department to other outpatient settings, it is important that all clinicians involved in the care of these patients understand the tools used for assessment and risk stratification.

AIMS:Results from investigations in one area of the world may not translate to another if patient characteristics and practices differ. We examine differences in the presentation and management of emergency department (ED) patients with dyspnoea from acute heart failure syndromes (AHFS) between the USA, Western Europe, and Eastern Europe. METHODS AND RESULTS:The URGENT Dyspnoea study was a multinational prospective observational study of dyspnoeic ED patients with AHFS from 18 countries. Acute heart failure syndrome patients from the USA and Western and Eastern Europe underwent dyspnoea assessments within 1 h of the first physician evaluation. Patient characteristics, evaluation, and treatments were compared between geographical regions using analysis of variance and χ(2) tests. Four hundred and ninety-three patients with AHFS met the inclusion criteria. Participants in the USA were more frequently non-white, younger, on chronic beta-blocker therapy, and with an ejection fraction ≤40% when compared with Eastern and Western Europe. Patients from Eastern Europe were more likely to present with de novo heart failure and have ischaemic electrocardiogram changes. Pulmonary oedema was more common on chest radiograph in Western Europe, but natriuretic peptide levels were elevated in all three regions. Diuretic use was similar across all the regions. Intravenous nitroglycerin was used more frequently in Eastern (32.8%) and Western Europe (24.4%) compared with the USA (2.5%). CONCLUSION:International differences in AHFS presentations and management between regions suggest results from clinical trials in one region may not translate directly to another. These differences should be considered when designing trials and interpreting the results from clinical investigations.