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Assessment of Acute Disease to Reduce Imaging Costs (QUAADRICs)

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ClinicalTrials.gov Identifier: NCT01059500
Recruitment Status : Completed
First Posted : February 1, 2010
Last Update Posted : February 17, 2016
Sponsor:
Collaborator:
Agency for Healthcare Research and Quality (AHRQ)
Information provided by (Responsible Party):
Jeffrey Kline, Atrium Health

Study Description
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Brief Summary:
Overtesting for Acute Coronary Syndrome(ACS) and Pulmonary Embolism (PE) in low risk Emergency Department(ED) patients can increase exposure of nondiseased patients to radiation, intravenous contrast and anticoagulation. This project addresses question of whether quantitative Pre-Test Probability(PTP) assessed from two validated web-based computer algorithms (the project "webtool"), can improve the diagnostic evaluation of adult patients with charted evidence of chest pain and dyspnea. After a validation phase, the main study will randomize patients to either the Standard care group or the Intervention group, which will receive the output of the ACS and PE webtool that includes the PTP estimates of ACS and PE and one of three recommendations regarding next steps: 1. No further testing, 2. Exclusion with a biomarker protocol, or 3. Immediate imaging +/- empiric anticoagulation.

Condition or disease Intervention/treatment Phase
Acute Coronary Syndrome Pulmonary Embolism Device: Pilot Phase Device: Intervention group, receive the numeric PTP estimate Device: No Intervention Not Applicable

Study Design
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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 850 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Screening
Official Title: Quantitative Pretest Probability to Reduce Cardiopulmonary Imaging in the ED
Study Start Date : January 2010
Actual Primary Completion Date : May 2012
Actual Study Completion Date : February 2013
Arms and Interventions
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Arm Intervention/treatment
Pilot Phase
First 300 patients will be assigned to arm 1 to test the accuracy of the webtool output.
 Device: Pilot Phase
Non-intervention phase to test webtool technical reliability, accurate low PTP, and calibration.

Device: No Intervention
Standard (no webtool output)
Experimental: Webtool output
Phase 2- Intervention, One group will receive the numeric PTP estimate from webtool output, the other groupwill not receive the nemuric PTP estimate
 Device: Intervention group, receive the numeric PTP estimate
Receive the numeric PTP estimate for ACS and PE, and one of three testing recommendations. For ACS, PTP <2.5% with low clinical suspicion and available follow-up, no further testing; PTP 2.5 to 5.5%: obtain a troponin I measurement at presentation and 120 minutes later, and if both are normal, no further testing; PTP >5.5%: proceed to provocative testing. For PE, PTP<2.5% with low clinical suspicion and available follow-up, no further testing; PTP 2.5-10%, obtain a quantitative D-dimer and if normal, no further testing. PTP 10-20%, proceed directly to pulmonary vascular imaging, and if PTP>20% consider empiric anticoagulation with heparin if no contraindications.


Outcome Measures
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Primary Outcome Measures :
  1. Primary measurements will test if the webtool works properly(observational): A. Technical reliability B. Accurate low PTP C. Calibration [ Time Frame: After 300 patients enrolled ]

Secondary Outcome Measures :
  1. A. Quality: B. Effectiveness: C. Efficiency: D. Safety: E. Patient satisfaction: [ Time Frame: 2 years ]

Eligibility Criteria
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Ages Eligible for Study:   18 Years to 99 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

I. Inclusion criteria

  • Adult (>17 years) ED patient reports a history of chest discomfort and new or worsened shortness of breath or breathing difficulty, documented in the written history of present illness or review of systems.
  • Patient must understand English or have a certified translator present.
  • Physician has ordered or plans to order a 12-lead electrocardiogram.
  • Patient indicates the site hospital was his or her "hospital of choice" in the event of return visit within 14 days.

II. Pre-randomization exclusion criteria

  • 12-lead ECG with ST deviation interpreted as acute infarction or ischemia.
  • Known diagnosis of acute PE within previous 24 hours (e.g., call back for overread of a CT scan).
  • "Code STEMI" patients (patients with suspected acute myocardial infarction).
  • Other obvious condition or diagnosis identified by the emergency physician as mandating admission (evidence of circulatory shock, severe hypoxemia, decompensated heart failure, altered mental status, hemorrhage, sepsis syndrome, arrhythmia, trauma, unstable social or psychiatric situation, stroke, aortic disaster, pneumonia ).
  • Myocardial infarction, intracoronary stent placement, or CABG within the previous 30 days.
  • Known cocaine use within past 72 hours, based upon patient or laboratory report.
  • Referral to the emergency department by a personal physician.
  • Patients undergoing voluntary medical clearance for a detox center or any involuntary court or magistrate order.
  • Computer interpretation of the 12-lead ECG containing either "ischemia" or "infarction".
  • Homelessness, out-of-town residence or other condition known to preclude follow-up in 14 days.
  • Patients in police custody or currently incarcerated individuals.
  • Patients who know they are pregnant or in whom a pregnancy test was drawn as part of usual care and was found to be positive.

III. Post-randomization exclusions

  • Positive urine cocaine test.
  • Incarceration within 14 days of enrollment.
  • Patient elopement from medical care (i.e., patients who leave against medical advice).
Contacts and Locations
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Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01059500


Locations
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United States, Massachusetts
Beth Israel Deaconess Medical Center
Boston, Massachusetts, United States, 02215
United States, Mississippi
University of Mississippi Medical Center
Jackson, Mississippi, United States, 39216
United States, North Carolina
Carolinas Medical Center
Charlotte, North Carolina, United States, 28203
Forsyth Medical Center
Winston-Salem, North Carolina, United States, 27103
Sponsors and Collaborators
Atrium Health
Agency for Healthcare Research and Quality (AHRQ)
Investigators
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Principal Investigator: Jeffrey A Kline, MD Indiana University School of Medicine
More Information
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Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

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Responsible Party: Jeffrey Kline, Research Director, Atrium Health
ClinicalTrials.gov Identifier: NCT01059500    
Other Study ID Numbers: 1R18HS018519-01 ( U.S. AHRQ Grant/Contract )
First Posted: February 1, 2010    Key Record Dates
Last Update Posted: February 17, 2016
Last Verified: February 2016
Keywords provided by Jeffrey Kline, Atrium Health:
Computer-derived, quantitative pretest probability (PTP)
Overtesting
Radiation
Intravenous Contrast
Anticoagulation
Additional relevant MeSH terms:
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Pulmonary Embolism
Acute Coronary Syndrome
Embolism
Myocardial Ischemia
Heart Diseases
 Cardiovascular Diseases
Vascular Diseases
Embolism and Thrombosis
Lung Diseases
Respiratory Tract Diseases