Applied Health Economics and Health Policy

, Volume 17, Issue 6, pp 875–882 | Cite as

In-Hospital Healthcare Utilization, Outcomes, and Costs in Pre-Hospital-Adjudicated Low-Risk Chest-Pain Patients

  • Dominique N. van DongenEmail author
  • Jan Paul Ottervanger
  • Rudolf Tolsma
  • Marion Fokkert
  • Aize van der Sluis
  • Arnoud W. J. van ‘t Hof
  • Erik Badings
  • Robbert J. Slingerland
Original Research Article



There is increasing evidence that in patients presenting with acute chest pain, pre-hospital triage can accurately identify low-risk patients. It is, however, still unclear which diagnostics are performed in pre-hospital-adjudicated low-risk patients and what the contribution is of those diagnostic results in the healthcare process.


The aim of this study was to quantify healthcare utilization, costs, and outcomes in pre-hospital-adjudicated low-risk chest-pain patients, and to extrapolate to total costs in the Netherlands.


This was a prospective cohort study including 700 patients with suspected non-ST-elevation acute coronary syndrome in which pre-hospital risk stratification using the HEART score was performed by paramedics. Low risk was defined as a pre-hospital HEART score ≤ 3. Data on (results of) hospital diagnostics, costs, and discharge diagnosis were collected.


A total of 172 (25%) patients were considered as low risk. Of these low-risk patients, the mean age was 54 years, 52% were male, and 84% of patients were discharged within 12 h. Repeated electrocardiography and routine laboratory measurements, including cardiac markers, were performed in all patients. Chest X-ray was performed in 61% and echocardiography in 11% of patients. After additional diagnostics, two patients (1.2%) were diagnosed as non-ST-elevation myocardial infarction and two patients (1.2%) as unstable angina. Other diagnoses were atrial fibrillation (n = 1) and acute pancreatitis/cholecystitis (n = 2); all other patients had non-specific/non-acute discharge diagnoses. Mean in-hospital costs per patient were €1580. The estimated yearly acute healthcare cost in low-risk chest-pain patients in the Netherlands is €30,438,700.


In low-risk chest-pain patients according to pre-hospital risk assessment, acute healthcare utilization and costs are high, with limited added value. Possibly, if a complete risk assessment can be performed by ambulance paramedics, acute hospitalization of the majority of low-risk patients is not necessary, which can lead to substantial cost reduction.

Trial ID

Dutch Trial Register []: trial number 4205.



We thank Sonja Nijhoff and Hans Lafeber for data collection. We thank Ruben Louw for language editing and proofreading.

Author contributions

All authors contributed to the conception or design of the work, the acquisition, analysis, or interpretation of the data. All authors were involved in drafting and commenting on the paper and have approved the final version.

Compliance with Ethical Standards

Conflict of interest

D. van Dongen, R. Tolsma, M. Fokkert, E. Badings, A. van der Sluis, J. Ottervanger, A. van ‘t Hof and R. Slingerland have completed the ICMJE uniform disclosure form at and declare: no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article


This work was supported by Isala Research Fund [Grant number INNO1326]. Roche diagnostics provided POC devices and POC strips. Researchers were independent of funders and funders were not involved in writing this research or performing analyses.

Transparency declaration

The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.


D.N. van Dongen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Patient level data and the full dataset are available from the corresponding author. Consent was not obtained but the presented data are anonymized and risk of identification is low.

Ethical approval

The study was approved by the Regional Medical Ethics Board on the 20 September 2013.


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Dominique N. van Dongen
    • 1
    Email author
  • Jan Paul Ottervanger
    • 1
  • Rudolf Tolsma
    • 2
  • Marion Fokkert
    • 3
  • Aize van der Sluis
    • 4
  • Arnoud W. J. van ‘t Hof
    • 5
    • 6
  • Erik Badings
    • 4
  • Robbert J. Slingerland
    • 3
  1. 1.Department of CardiologyIsala HospitalZwolleThe Netherlands
  2. 2.Regional Ambulance Service IJssellandZwolleThe Netherlands
  3. 3.Department of Clinical ChemistryIsala HospitalZwolleThe Netherlands
  4. 4.Department of CardiologyDeventer HospitalDeventerThe Netherlands
  5. 5.Zuyderland MCHeerlenThe Netherlands
  6. 6.Department of CardiologyMUMCMaastrichtThe Netherlands

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