Algorithm Efficiently Guides Pediatric Chest Pain Evaluation

Diedtra Henderson

Sep 09, 2013

Heart disease rarely is to blame for chest pain suffered by children, and the ailment can be evaluated cost-effectively in the ambulatory setting, according to a regional study testing an algorithmic tool to guide the care of symptomatic patients.

Gerald H. Angoff, MD, from the Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Lebanon, New Hampshire, and colleagues report their findings in an article published online September 9 in Pediatrics.

Chest pain is a common complaint among children and adolescents. Clinicians often spend significant time and resources evaluating such complaints to rule out heart disease.

Therefore, Dr. Angoff and colleagues tested a methodology developed at Boston Children's Hospital called Standardized Clinical Assessment and Management Plans (SCAMPs) to see whether it would streamline diagnosis. Unlike typical clinical guidelines, SCAMPs mandate data acquisition, regular analysis of the data, and refinement of the guidance to reflect the evolving data.

In this case, the SCAMP algorithm fed in patient history, physical examination, and electrocardiogram data to glean when further diagnostic testing would be indicated. Echocardiograms were used only when the initial evaluation identified 1 or more prespecified abnormalities.

Dr. Angoff and colleagues enrolled 1016 pediatric patients aged 7 to 21 years who were being seen by a cardiologist for the first time for chest pain. The 109 providers who participated in the study practiced at New England Congenital Cardiology Association sites or Boston Children's Hospital. The researchers measured their adherence to the algorithm by tracking tests that were performed or not performed in accordance with the protocol.

"Echocardiography was performed as recommended in 423 patients (41.6%), when not recommended in 81 (8.0%), and was abnormal in 48 (9.5%) of all studies. In 2 instances, the echocardiogram findings explained the chest pain (0.5% of the recommended tests, 0.4% overall)," Dr. Angoff and coauthors write. None of the nonrecommended echocardiograms uncovered the cause of the chest pain.

In addition to affirming that cardiac disease is rarely the cause of children's chest pain, the authors report that "[t]he great majority of patients can be seen, evaluated, and discharged with a single visit."

A number of high-profile sudden cardiac deaths among young athletes has heightened anxiety on the part of families, referring pediatricians, and pediatric cardiologists, knowing that very rare cases of pediatric cardiac disease exist and can be catastrophic if undiagnosed, Robert M. Campbell, MD, chief of the Children's Healthcare of Atlanta Sibley Heart Center and professor of pediatrics at Emory University School of Medicine in Georgia, told Medscape Medical News.

SCAMPs serve as a "system of red flags" to uncover the warning signs for children more likely to have heart disease combined with a "very disciplined approach, so it doesn't vary doctor to doctor, day to day, site to site," Dr. Campbell said. "It's a move in the right direction, in terms of how much testing needs to be done, how specific can we be," he told Medscape Medical News.

"Using SCAMPs methodology, we have demonstrated that chest pain in children is rarely caused by heart disease and can be evaluated in the ambulatory setting efficiently and effectively using minimal resources," the study authors conclude. "The methodology can be implemented regionally across a wide range of clinical practice settings and its approach can overcome a number of barriers often limiting clinical practice guideline implementation."

Dr. Campbell was less convinced that such implementation would occur at this time in pediatrics, given the current fee-for-service world in which clinicians' incomes and business viability are linked to payments for conducting tests. In the future, if they were "managing a population of patients, then, it would not only be possible but it would be necessary to use these strategies."

Support for this study was provided by the Boston Children's Heart Foundation, Provider-Payor Quality Initiative at Boston Children's Hospital, the Program for Patient Safety and Quality of Boston Children's Hospital, and the Hinden Family Fund. The study authors and Dr. Campbell have disclosed no relevant financial relationships.

Pediatrics. Published online September 9, 2013.