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Initiative reduces low-risk pediatric cardiology referrals to 0%

Ashraf S. Harahsheh

NEW ORLEANS — A six-step initiative embedded in electronic health records dropped the percentage of low-probability cardiology referrals among pediatric patients with chest pain to zero, according to a study presented at the AAP National Conference & Exhibition.

“Before the initiative, there was no uniform decision support for primary care physicians to identify a patient who needs referral,” Ashraf S. Harahsheh, MD, an associate professor of pediatrics at George Washington University in Washington, D.C., told Healio Primary Care. “PCPs may have chosen to refer patients with chest pain because of parental anxiety.”

The initiative was tested on 77 patients aged 7 to 21 years who presented with chest pain, along with 17 pediatricians and two nurse practitioners. It consisted of:

• using a validated screening tool to triage chest pain in children;
• decision support tool in the child’s EHR that contained nearly 30 red flags for referral, including chest pain with exertion, personal past medical history of arthritis or vasculitis, a family history of hypercoagulability and a tachypnea resting rate of 40 or higher;
• education for medical personnel about the initiative;
• notifications about the initiative that were posted around the workplace;
• linking the initiative to a “sick visit form”; and
• reminders such as faculty meeting discussions and webinars to increase compliance.

Harahsheh and colleagues found that among clinicians who took part in the initiative, cardiology referrals decreased from 21% at baseline to 0% — five percentage points lower than the goal. In addition, the initiative’s use increased from of 0% at baseline to 50% 1 year after the study.

“PCPs can provide patients with reasoning and reassurance based on evidence provided by their cardiology colleagues,” Harahsheh said.

William Mudd

William Mudd, DO, a pediatrician at Cleveland Clinic Children’s Hospital who was not affiliated with the study, told Healio Primary Care that the initiative was “definitely feasible,” and it could fill some educational gaps in the primary care setting.

“Current guidelines recommend against adopting universal screening studies in all pediatric patients, such as electrocardiograms and echocardiograms,” Mudd said. “This is due to a high number of false-positives which would lead to an overwhelming wave of pediatric cardiology referrals. In short, when you consider the numbers, the resource cost and financial cost is not worth the clinical benefit.”

Although Mudd touted the initiative’s success rate in reducing low-risk cardiology referrals, he also said there is potentially some room for improvement.

“Its biggest weakness is that it does not look at other causes of referral, such as cardiac murmur, palpitations and syncopal episodes,” he said, adding that this fault should not discredit the initiative’s strengths.

“Most importantly, however, is that at 1 year following the patient’s initial visit to the ED, 0% of the patients had any type of cardiac event, Mudd said. This suggests the model works to reduce unnecessary referrals while ensuring no serious pathology is missed. I would certainly be open to using the model in my own practice.”

The initiative will next be tested in the greater Washington, D.C., area, according to Harahsheh.

His previous research has shown that eliminating all pediatric cardiac testing associated with all low-probability referrals would save the United States more than $3.7 million annually.

“A referral to cardiology has an impact on parents’ time, time off work, school absence, cost to family and finally the health care system,” Harahsheh said in the interview. “Imagine if we expanded this to all other specialties and common complaints.” – by Janel Miller

Disclosures: Harahsheh reports no relevant financial disclosures. Healio Primary Care could not confirm Mudd’s relevant financial disclosures at the time of publication.

References: Harahsheh AS, et al. Clin Pediatr (Phila). 2017;doi:101177/000992281665-4605.

Harahsheh AS, et al. Reducing low probability cardiology referrals for chest pain from primary care: a quality improvement initiative. Presented at: AAP National Conference & Exhibition; Oct. 25-29, 2019; New Orleans.