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

We thank Dr Lenskyj for his thoughtful comments. The evaluation of emergency department patients with chest pain, while improving over the past 2 decades,[1] still has few tools to risk stratify patients who do not have an acute coronary syndrome but may require further assessment. The Vancouver Chest Pain Rule (VCPR) is an adjunctive tool that permits clinicians to safely discharge a greater number of low-risk patients, while preserving scarce hospital beds for those at higher risk. Our study of 180 000 British Columbia chest pain patients demonstrated an association between the provincial introduction of the VCPR to physicians[2] and a decrease in hospital admissions, but there are noteworthy caveats. We could not measure physician uptake of the VCPR and did not have data on important clinical information such as ECG characteristics or maximum troponin values. Nor did we have data on critical demographic information such as rurality, income quintile, or ethnocultural background, all of which are associated with outcomes.[3] Therefore, our design and findings cannot provide insight into potentially differential impacts on any subgroup of patients or the potential redistributive effects or health equity questions that Dr Lenskyj raises.

The VCPR was developed and validated in a single Vancouver site, which limits external applicability. It advises that patients younger than 50 years of age with normal ECG and initial and repeat troponin, as well as nonradiating chest pain, can be discharged home without further testing. Age is a powerful predictor of acute coronary syndrome: the only other similarly validated stratification tool—the no objective testing rule[4]—also uses age 50 as a cutoff.

Emergency Care BC is committed to improving the patient experience, as was the BC Emergency Medicine Network that preceded it. Of note, these organizations have worked closely with BC Patient-Centred Measurement, which conducts in-depth surveys of over 10 000 BC emergency department patients annually. The goal of these surveys is to evaluate the patient experience Dr Lenskyj correctly highlights the importance of and to identify opportunities to enhance care for Indigenous patients. Emergency Care BC and the UBC Faculty of Medicine see such actions as priorities. To illustrate, both support the Kwiis hen niip partnership with four remote Nuu-chah-nulth nations (Ahousaht, Hesquiaht, Ka:'yu:'k't'h'/Che:k'tles7et'h', and Tla-o-qui-aht) and the Nuu-Chah-Nulth Tribal Council. This multiyear implementation project is locally and federally funded to improve emergency care in these communities, in true partnership and with cultural sensitivity. Community leadership and guidance identified four priority themes: strengthen first responder programs; enhance community readiness, including resuscitation education; improve digital communications; and develop more efficient transportation.[5] The inequities are stark, and we agree there is much more to be done.
—Frank X. Scheuermeyer, MD, MHSc
—Ross Duncan, MSc
—Riyad Abu-Laban, MD, MSc
—Floyd Besserer, MD
—Sharla Drebit
—Jim Christenson, MD

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

hidden

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

References

1.    Scheuermeyer FX, Mattman A, Humphries K, et al. Safety and efficiency of implementation of high-sensitivity troponin T in the assessment of emergency department patients with cardiac chest pain. CJEM 2024. In press.

2.    Scheuermeyer FX, Duncan R, Abu-Laban RF, et al. Province-wide implementation of the Vancouver Chest Pain Rule. BCMJ 2024;66:80-85.

3.    Wilson CR, Rourke J, Oandasan IF, Bosco C. Progress made on access to rural health care in Canada. Can Fam Physician 2020;66:31-36.

4.    Greenslade JH, Parsonage W, Than M, et al. A clinical decision rule to identify emergency department patients at low risk for acute coronary syndrome who do not need objective coronary artery disease testing: The no objective testing rule. Ann Emerg Med 2016;67:478-489.

5.    Renwick M. Partnership aims to improve emergency care in four remote First Nations. Ha-Shilth-Sa. 22 July 2021. Accessed 4 September 2024. https://hashilthsa.com/news/2021-07-22/partnership-aims-improve-emergency-care-four-remote-first-nations.