$3.4M Grant Helps IUSM Docs Better Treat Chest Pain in ER

The researchers will study 375 Hoosiers who visit Indianapolis EDs with chest pain caused by anxiety.

Chest pain is the second most common reason people rush to the emergency room (ER), but only one in five patients is actually having a cardiac event. The vast majority of people with chest pain are sent home with no clear answer about what caused it, and compounding the confusion is fear that it may happen again. Most patients sent home are told anxiety caused their chest pain—but given no treatment plan or strategies to address the root cause—they often land in the ER again. Powered by a $3.4 million award, a study with hundreds of Hoosiers aims to find better methods to address the issue and avoid unnecessary return trips to the ER.

“About half of [patients who go to the emergency department (ED) with chest pain] have significant anxiety symptoms, so it’s an unmet need,” says Regenstrief Institute Research Scientist and IU School of Medicine (IUSM) Chancellor’s Professor of Medicine Dr. Kurt Kroenke. “The question is what do you have and what can we do to help with that? That’s an area this study is targeting that often is not targeted.”

The Patient-Centered Outcomes Research Institute (PCORI) is funding the three-year project to find the best care for these patients, who are sent home confused and also have higher return rates to the ED. IUSM Assistant Professor of Emergency Medicine Dr. Paul Musey says there’s “a big drop off” in patients who follow-up with their primary care physician as advised to address their anxiety after the ED visit, and even people who do visit their doctor slip through the cracks.

“[The primary care doctor] sees they were evaluated at the ED, nothing was found, so they move on to another complaint,” says Musey. “These patients kind of get left in limbo, and many of them continue to access the healthcare system inappropriately, meaning they come back to the ED with the same symptoms, and they cycle back through. We’re trying to actually get them to appropriate treatment earlier on in this course.”      

To study the issue, about 375 Hoosiers who visit Indianapolis EDs with chest pain caused by anxiety will be divided into three groups: low, medium and high intensity support. The low intensity group will experience the “status quo” and be told they have symptoms of high anxiety and to follow up with their primary care doctor. The medium intensity group will be referred to web-based, self-paced cognitive behavioral therapy with a weekly check-in from a peer specialist who understands the challenges of managing anxiety. The high intensity group will also have cognitive behavioral therapy, but with a psychologist via video chat.

“The goal of the study is to see if we get better outcomes in terms of anxiety with the more active interventions, as well as fewer return visits to the ED,” says Kroenke.

“The concept of the study is to provide evidence showing that these interventions initiated in the ED can have a significant impact on the trajectory of these patients, and that it’s important to have these conversations and make these referrals for care,” says Musey. “Also, on the health system side, it’s important to invest in these resources for these patients that [the ED] refers; that’s a big barrier that a lot of us feel [in the ED]—that those resources just aren’t readily available, so it’s hard for us to start having those conversations [with patients] when we don’t know how to close the loop.”

In addition to giving patients better pathways for treatment, the model could also help reduce unnecessary healthcare costs.

“It’s an issue of navigation. The initial [ED visit for chest pain] is not going to be prevented. Preventing repeat ED visits for issues that don’t need to be addressed in the ED is the goal,” says Musey. “And helping people navigate the system to get to the appropriate resources is the definition of cost effectiveness.”

Although the researchers designed the study before the pandemic, they say the methodologies are even more relevant now as telemedicine has grown exponentially. While the study will be an important step forward for patients with chest pain, the concept could expand to other conditions that cause people to visit the ED.

“This can be the model for how we approach these issues in novel and innovative ways going forward,” says Musey, “realizing the way we’ve always done it doesn’t have to be the way we do it going forward, and we can leverage the technology that’s available to us.”