Chest pain is the second most common complaint evaluated in the emergency department (ED), but the physical symptoms among 8 out of 10 patients are not caused by a heart attack or related event. It is also unlikely that these patients will have a heart attack or related event in the foreseeable future. Anxiety is the cause of physical symptoms in about half of the patients deemed low-risk chest pain (LRCP) or non-cardiac. The anxiety may be previously undiagnosed, untreated, or undertreated, as people rarely seek care in any setting specifically for anxiety. In the ED, where people with anxiety often present due to anxiety symptoms that mimic a heart attack, care simply ends with a discharge after ruling out a heart attack or other serious event. Patients leave confused about the cause of symptoms and what to do. As a result, many patients return to the ED when symptoms continue or re-occur for further testing that is likely not beneficial to the patient.
Anxiety disorders are likely to respond to treatment. Efficacy studies for psychological therapies, such as cognitive behavioral therapy (CBT), have been done in the LRCP population, but results are not fully understood. Limitations to existing research include lack of rigor in methods, failure to appreciate variation in multiplicity and severity of anxiety and depressive disorders across the LRCP population, and most importantly, failure to address patient receptivity to a psychological cause of symptoms, and subsequent modest participation rates in psychological treatment for a common mental health problem.
This research will directly refer patients with LRCP and anxiety evaluated in the ED setting to one of three treatment alternatives: specific referral for anxiety to a regular doctor with enhanced care coordination from the ED, self-help CBT sessions on a computer with accountability check-ins from supportive peers, or live-talk CBT sessions with a therapist through a computer or phone. Each option will be measured by reductions in clinical symptoms of anxiety and depression; related physical symptoms; impairments to work, family, and social functioning; and return visits to the ED as well as missed cardiac and other life-threatening events.
Patients and other stakeholders, including providers, researchers, and health system leaders, have worked together to plan and inform this research by addressing potential barriers to feasibility and adoption of effective treatments and ensuring that treatment options align with patient values, lifestyles, and preferences for care. They will continue to work together to conduct this research and disseminate its findings in a timely fashion.
This research will inform future patient and provider decisions about the best treatment options rather than simply sending them away with, at best, a generalized recommendation to follow up with a regular doctor.
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.