Computerized, patient-entered medical histories to improve the management of patients with acute chest pain

Introduction: Chest pain is a common complaint in emergency departments (EDs), with causes ranging from benign to life-threatening conditions, such as an acute coronary syndrome (ACS). Self-reported computerized history taking (CHT) may provide automated collection of medical histories for calculating chest pain risk scores recommended for management. The overall aim of this thesis was to investigate the value of CHT in acute chest pain management.

Methods: We examined the first 1,000 patients (mean age 55+17 years; 46% women), in the CLEOS-CPDS (Clinical Expert Operating System-Chest Pain Danderyd Study), a prospective cohort study of patients presenting to the ED at Danderyd University Hospital (Stockholm, Sweden) with acute chest pain in 2017-2019. Clinically stable adults (>18 years) with a non-diagnostic ECG and non-diagnostic serum biomarkers self-reported their medical histories using CHT software on a tablet. Studies conducted include: (I) a study protocol, (II) a utility study assessing CHT interview completion and duration, (III) an agreement study comparing CHT and electronic health record (EHR) data, and (IV-V) diagnostic accuracy studies, using CHT-derived risk scores, with and without the use of troponin testing, against 30-day major adverse cardiac event (MACE) and ACS outcomes.

Results: Risk scores could be calculated in 74-83% of the participants by CHT and 10-31% by EHR data. The median time to collect the History, ECG, Age, Risk factors, Troponin (HEART) score was 23 (18-31) min. Agreement between CHT and EHR data was slight to moderate (kappa 0.19-0.70) for chest pain characteristics and moderate to almost perfect (kappa 0.55-0.91) for risk factors. A 30-day MACE occurred in 7.2% of participants. Using CHT-derived risk scores, the negative predictive value for a 30-day MACE was 0.98-0.99 (95% CI: 0.97-1.00), and a substantial fraction (up to 21%) of patients admitted with acute chest pain could be reclassified from "not low risk" to "low risk".

Conclusions: CHT effectively collects comprehensive medical history data for risk stratification in acute chest pain patients, demonstrating high accuracy in ruling out 30-day MACE. This approach may improve individual patient management and reallocate resources to those in greatest need.

List of scientific papers

This thesis is based on the following papers, which will be referenced by their corresponding Roman numerals:

I. Brandberg H, Kahan T, Spaak J, Sundberg K, Koch S, Adeli A, Sundberg CJ, Zakim D. A prospective cohort study of self-reported computerised medical history taking for acute chest pain: protocol of the CLEOS-Chest Pain Danderyd Study (CLEOS-CPDS). BMJ Open. 2020 Jan 21;10(1):e031871. https://doi.org/10.1136/bmjopen-2019-031871

II. Brandberg H, Sundberg CJ, Spaak J, Koch S, Zakim D, Kahan T. Use of self-reported computerized medical history taking for acute chest pain in the emergency department - the clinical expert operating system chest pain Danderyd study (CLEOS-CPDS): prospective cohort study. J Med Internet Res. 2021;23(4):e25493. https://doi.org/10.2196/25493

III. Brandberg H, Sundberg CJ, Spaak J, Koch S, Kahan T. Are medical history data fit for risk stratification of patients with chest pain in emergency care? Comparing data collected from patients using computerized history taking with data documented by physicians in the electronic health record in the CLEOS-CPDS prospective cohort study. J Am Med Inform Assoc. 2024;31(7):1529-1539. https://doi.org/10.1093/jamia/ocae110

IV. Brandberg H, Sundberg CJ, Spaak J, Koch S, Kahan T. Computerized self-reported medical history taking improves early rule-out of major adverse cardiac events in acute chest pain patients: the CLEOS-CPDS prospective cohort study. [Submitted]

V. Brandberg H, Schierenbeck F, Sundberg CJ, Koch S, Spaak J, Kahan T. Performance of computerized self-reported medical history- taking and HEAR score for safe early rule-out of a major adverse cardiac event in acute chest pain patients: the CLEOS-CPDS prospective cohort study. [Submitted]