A combined care model using early access to specialists off-hours to reduce cardiac admissions

  • Michael GavinEmail author
  • Bruce Landon
  • Jonathan Lu
  • Leila Ganjehei
  • Kalon Ho
  • Larry Nathanson
  • Edward Ullman
  • Shamai Grossman
  • Peter Zimetbaum


Despite the implementation of diagnostic and treatment algorithms for many common cardiovascular (CV) complaints, identifying low- and intermediate-risk cardiac patients presenting to the emergency department (ED) who could be managed without hospital admission remains difficult. We hypothesized that the presence of an attending cardiologist in the ED after normal working hours would decrease the proportion of these patients admitted to the hospital. We conducted a retrospective study of patients seen in the ED with cardiac diagnoses identified by ICD-9 codes during the time period when the cardiologist was available (6 p.m.–midnight) compared with patients seen at other times of the day in the 12 months before and after the consultation program was implemented. The primary outcome was disposition at the time of discharge from the ED. Logistic regression was used to model the primary outcome. A difference-in-differences approach was used as the primary statistical test .Following the start of the consultation program, the odds of discharge home from the ED with or without observation increased (OR 1.69, 95% CI [1.45–1.96]). There was a significant interaction between pre-/post-intervention status and time of day in the odds of discharge home from the ED (P = 0.04) suggesting an association between the consultation program and disposition patterns that is independent of concurrent programs aimed to reduce utilization. An ED-based cardiology consultation program may reduce the need for inpatient stays by identifying low- to intermediate-risk patients safe for discharge from the ED with or without a period of active management/observation.


Chest pain Observation unit Care systems Atrial fibrillation Congestive heart failure 



This work was conducted with support from Harvard Catalyst| The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic healthcare centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.

Compliance with ethical standards

Conflict of interest

The author(s) declare that they have no conflict of interest.

Statement of human and animal rights

All procedures performed were in accordance and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards and ethical approval was obtained from the Beth Israel Deaconess Medical Center Institutional Review Board.

Informed consent

Informed consent for this retrospective study was waived by the Beth Israel Deaconess Medical Center Institutional review board given no more than minimal risk to the privacy of individuals given protection of health information identifiers.

Supplementary material

11739_2019_2076_MOESM1_ESM.docx (12 kb)
Supplementary material 1 (DOCX 11 kb)


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Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  1. 1.Division of Cardiology, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Division of General Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  3. 3.Department of Healthcare PolicyHarvard School of Public HealthBostonUSA
  4. 4.University of TorontoTorontoCanada
  5. 5.Cardiology, Self Regional Health HospitalGreenwoodUSA
  6. 6.Department of Emergency Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA

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