Re: Province-wide implementation of the Vancouver Chest Pain Rule

In their April 2024 BCMJ article [66:80-85], the authors present the Vancouver Chest Pain Rule as a tool to “preserve scarce resources for higher-risk patients while alleviating unnecessary hospitalization . . . for lower-risk patients,” thereby “increasing system-wide capacity.” They present evidence that an intervention promoting physician use of this tool reduced hospitalizations (and other measures of health system costs) without increasing mortality.

I’m curious why no mention was made of possible redistributive effects despite an apparent net gain in health system efficiency. This is not precluded by the finding that there was no overall statistically significant increase in mortality between the intervention and nonintervention populations. Mortality may have been redistributed between social groups in the overall population. Harms other than mortality may have been inadvertently created, and the distribution of these harms may be unfair. Did the authors consider health equity impact?

In addition to the issue of equity in general is the issue of the impact on Indigenous people. As has been widely documented, Indigenous people in BC (and elsewhere) have suffered harm from the health system, have significantly higher rates of chronic disease than non-Indigenous people, and have generally poorer access to care. Given the BC government’s declared commitment to redress these problems, and this journal’s fairly frequent editorial exhortations to the same, I’m concerned that the authors (and by implication Emergency Care BC) may not be attending to this issue. To give an obvious example, using age 50 as a cutoff for “safely discharging” patients with normal ECG and troponins implies that age is a valid proxy for cardiac risk. How was the age cutoff determined to be appropriate for populations with high prevalence of cardiac disease? What was the patient experience? Did patients perceive that in being discharged after an ECG and blood tests, they had a safe, positive, and respectful engagement with the ER? There is literature on these and related issues, and Indigenous patient advocates who could be consulted. I wonder if they were.
—Nicolas Lenskyj, MBBS(UQ), CFPC, FRACGP, MA
Vancouver

This letter was submitted in response to “Province-wide implementation of the Vancouver Chest Pain Rule.”

Read the authors’ response in “Re: Province-wide implementation of the Vancouver Chest Pain Rule. Authors reply.” 

hidden

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.