Abstract 13239: Variation in Cost by HEART Score in Patients With Suspected Acute Coronary Syndrome

Introduction: The variation in medical cost by risk stratification using history, electrocardiogram, age, risk factors and troponin (HEART), after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS), is not well understood. Hypothesis: We hypothesized that annual total all cause cost will increase significantly with increasing HEART score and the primary driver of the total cost will be cardiovascular disease (CVD) related care. Methods: This was a retrospective cohort study of adults (age ≥18) with chest pain and complete data for HEART score, presenting at EDs within the Kaiser Permanente Southern California health system from 1/2016-12/2018. We analyzed direct medical cost associated with medical office visits, hospital facility and ED visits, pharmacy utilization, hospice stays, skilled nursing stays, home health, dialysis, laboratory, and radiology utilization during the 1-year following the index ED visit. Stratified by HEART score categories, we used one part and two part generalized linear models (log link & gamma family distribution) adjusted for socio-demographics, cardiovascular disease (CVD) history and treatment and non-CVD comorbidities, to estimate average adjusted total all cause expenditure as well as subgroups of utilization. Results: The cohort included 33,990 patients (60% Low risk; 37% intermediate risk and 3% high risk). The adjusted annual total cost varied from $6,544 (95% CI $6,228 to $6,860) in the low risk to $21,210 ($19,458 to $22,962) in the high-risk group (Table 1). In each group, the primary driver of total cost was CVD related care accounting for 41% to 46% of total cost. CVD care provided in a hospital setting accounted for 44%-76% of CVD total cost. Conclusions: Increased follow-up medical office visits, improved medications and lifestyle management may reduce the near exponential increase in cost driven by catastrophic hospital utilization, in higher HEART risk stratified patients.