Chest Pain Hospitalizations: How Varying Emergency Clinician Tendencies Impact Care, Outcomes, and Costs
- 1UCSF
Abstract
BackgroundThe practice of hospitalizing emergency department (ED) patients with chest pain after ruling out acute myocardial infarction (AMI) varies widely. The long-term outcome and cost implications of this variation are uncertain.
MethodsAnalyzing 2007-2021 claims from a national commercial insurer, we identified 223,569 adults ([≥]18 years) ED visits with a principal diagnosis of chest pain without major secondary cardiopulmonary diagnoses, seen by 19,001 clinicians in 2,273 EDs. Within each ED, clinicians with the highest and lowest terciles of risk-adjusted hospitalization rates were classified as high-versus low-admitting. Primary outcomes were 30-and 180-day subsequent AMI hospitalizations. Secondary outcomes included 7-day cardiac testing, 30-day coronary intervention, and 30-day total and out-of-pocket costs. We estimated adjusted rate ratios (aRRs) and relative cost differences using generalized estimating equations, adjusting for patient and visit characteristics.
ResultsPatients had a mean age of 48.6 years, and 53.9% were female; measured characteristics were similar between groups. Compared with low-admitting clinicians, visits to high-admitting clinicians had higher 7-day cardiac testing (13.1% vs 10.8%; aRR 1.22, 95% CI 1.17-1.27) and 30-day coronary interventions (4.3% vs 3.8%; aRR 1.16, 95% CI 1.09-1.23). AMI hospitalization did not differ at 30 days (0.60% vs 0.60%; aRR 1.00, 95% CI 0.84-1.15) or 180 days (0.85% vs 0.87%; aRR 0.97, 95% CI 0.85-1.10). Thirty-day total costs were higher after visits to high-admitting clinicians (relative change 11.3%, 95% CI 8.8-13.8), and out-of-pocket costs [≥]$1,000 were more common (32.0% vs 29.6%; relative change 8.2%, 95% CI 6.1-10.3).
ConclusionsHigher clinician hospitalizing tendency for ED chest pain is associated with greater downstream testing, more coronary interventions, and higher costs without lower short-or intermediate-term AMI risk. Reducing marginal admissions among high-admitting clinicians may decrease spending and practice variation with minimal impact on AMI outcomes.
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BibTeX
@misc{chou2026chest,
title = {{Chest Pain Hospitalizations: How Varying Emergency Clinician Tendencies Impact Care, Outcomes, and Costs}},
author = {S.-C. Chou and R. Y. Hsia and F. Zhang and J. F. Wharam},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.02.26364626},
url = {https://www.medrxiv.org/content/10.64898/2026.10.02.26364626v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - Chest Pain Hospitalizations: How Varying Emergency Clinician Tendencies Impact Care, Outcomes, and Costs
AU - S.-C. Chou
AU - R. Y. Hsia
AU - F. Zhang
AU - J. F. Wharam
PY - 2026
DA - 2026/10/02
PB - medRxiv
DO - 10.64898/2026.10.02.26364626
UR - https://www.medrxiv.org/content/10.64898/2026.10.02.26364626v1
AB - BackgroundThe practice of hospitalizing emergency department (ED) patients with chest pain after ruling out acute myocardial infarction (AMI) varies widely. The long-term outcome and cost implications of this variation are uncertain. MethodsAnalyzing 2007-2021 claims from a national commercial insurer, we identified 223,569 adults ([≥]18 years) ED visits with a principal diagnosis of chest pain without major secondary cardiopulmonary diagnoses, seen by 19,001 clinicians in 2,273 EDs. Within each ED, clinicians with the highest and lowest terciles of risk-adjusted hospitalization rates were classified as high-versus low-admitting. Primary outcomes were 30-and 180-day subsequent AMI hospitalizations. Secondary outcomes included 7-day cardiac testing, 30-day coronary intervention, and 30-day total and out-of-pocket costs. We estimated adjusted rate ratios (aRRs) and relative cost differences using generalized estimating equations, adjusting for patient and visit characteristics. ResultsPatients had a mean age of 48.6 years, and 53.9% were female; measured characteristics were similar between groups. Compared with low-admitting clinicians, visits to high-admitting clinicians had higher 7-day cardiac testing (13.1% vs 10.8%; aRR 1.22, 95% CI 1.17-1.27) and 30-day coronary interventions (4.3% vs 3.8%; aRR 1.16, 95% CI 1.09-1.23). AMI hospitalization did not differ at 30 days (0.60% vs 0.60%; aRR 1.00, 95% CI 0.84-1.15) or 180 days (0.85% vs 0.87%; aRR 0.97, 95% CI 0.85-1.10). Thirty-day total costs were higher after visits to high-admitting clinicians (relative change 11.3%, 95% CI 8.8-13.8), and out-of-pocket costs [≥]$1,000 were more common (32.0% vs 29.6%; relative change 8.2%, 95% CI 6.1-10.3). ConclusionsHigher clinician hospitalizing tendency for ED chest pain is associated with greater downstream testing, more coronary interventions, and higher costs without lower short-or intermediate-term AMI risk. Reducing marginal admissions among high-admitting clinicians may decrease spending and practice variation with minimal impact on AMI outcomes.
ER -