Reducing Excess Cardiac Biomarker Testing at an Academic Medical Center
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Elimination of wasteful diagnostic testing will improve value for the United States health care system.
Design and implement a multimodal intervention to improve evidence-based ordering of cardiac biomarkers for the diagnosis of acute coronary syndrome (ACS).
Interrupted times series.
A total of 60,494 adult inpatient admissions from January 2009 through July 2011 (pre-intervention) and 24,341 admissions from November 2011 through October 2012 (post-intervention) at an academic medical center in Baltimore, Maryland.
Multimodal intervention introduced August through October 2011 that included dissemination of an institutional guideline and changes to the computerized provider order entry system.
The primary outcome was percentage of patients with guideline-concordant ordering of cardiac biomarkers, defined as three or fewer troponin tests and zero CK-MB tests in patients without a diagnosis of ACS. Secondary outcomes included counts of tests ordered per patient, incidence of diagnosis of ACS, and estimated change in charges for cardiac biomarker tests in the post-intervention period.
Twelve months following the intervention, we estimated that guideline-concordant ordering of cardiac biomarkers increased from 57.1 % to 95.5 %, an absolute increase of 38.4 % (95 % CI, 36.4 % to 40.4 %). We estimated that the intervention led to a 66 % reduction in the number of tests ordered, and a $1.25 million decrease in charges over the first year. At 12 months, there was an estimated absolute increase in incidence of primary diagnosis of ACS of 0.3 % (95 % CI, 0.0 % to 0.5 %) compared with the expected baseline rate.
We implemented a multimodal intervention that significantly increased guideline-concordant ordering of cardiac biomarker testing, leading to substantial reductions in tests ordered without impacting diagnostic yield. A trial of this approach at other institutions and for other diagnostic tests is warranted and if successful, would represent a framework for eliminating wasteful diagnostic testing.
- Delaune J, Everett W. Waste and inefficiency in the U.S. health care system. NEHI; 2008. www.nehi.net/writable/publication_files/file/waste_clinical_care_report_final.pdf. Accessed April 11, 2014.
- Kelley R. Where can $700 billion in waste be cut annually from the U.S. healthcare system? Thomson Reuters; 2009. www.ncrponline.org/PDFs/2009/Thomson_Reuters_White_Paper_on_Healthcare_Waste.pdf. Accessed April 11, 2014.
- Wennberg J, Brownlee S, Fisher E, Skinner J, Weinstein J. Improving quality and curbing health care spending. The Dartmouth Institute for Health Policy and Clinical Practice; 2008. www.dartmouthatlas.org/downloads/reports/agenda_for_change.pdf. Accessed March 20, 2013
- National Hospital Ambulatory Medical Care Survey 2010 emergency department summary tables. www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed April 11, 2014.
- Morrow DA, Cannon CP, Jesse RL, Newby LK, Ravkilde J, Storrow AB, et al. National academy of clinical biochemistry laboratory medicine practice guidelines: Clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Circulation. 2007;115(13):e356–75. CrossRef
- Volz KA, McGillicuddy DC, Horowitz GL, Sanchez LD. Creatine kinase-MB does not add additional benefit to a negative troponin in the evaluation of chest pain. Am J Emerg Med. 2012;30(1):188–90. CrossRef
- Parker R, Suter R. Survey examines EDs’ use of cardiac markers. ACEP News. September 2009. Accessed April 11, 2014.
- Larochelle M, Trost J. Developing a program to rein in overuse of diagnostic testing in the inpatient setting. JGIM. 2011;26(S1):S566–7.
- Green LW, Kreuter MW. Health program planning: An educational and ecological approach. 4th ed. New York, NY: McGraw-Hill Higher Education; 2005.
- Solomon DH, Hashimoto H, Daltroy L, Liang MH. Techniques to improve physicians’ use of diagnostic tests: A new conceptual framework. JAMA. 1998;280(23):2020–7. CrossRef
- Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther. 2002;27(4):299–309. CrossRef
- Zhang F, Wagner AK, Soumerai SB, Ross-Degnan D. Methods for estimating confidence intervals in interrupted time series analyses of health interventions. J Clin Epidemiol. 2009;62(2):143–8. CrossRef
- Murray R. Setting hospital rates to control costs and boost quality: The Maryland experience. Health Aff (Millwood). 2009;28(5):1395–405. CrossRef
- Casey DE Jr. Why don't physicians (and patients) consistently follow clinical practice guidelines? JAMA Int Med. 2013;173(17):1581–3. CrossRef
- Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health care: A systematic overview. PLoS Med. 2011;8(1):e1000387. CrossRef
- Meng QH, Zhu S, Booth C, Stevens L, Bertsch B, Qureshi M, et al. Impact of the cardiac troponin testing algorithm on excessive and inappropriate troponin test requests. Am J Clin Pathol. 2006;126(2):195–9. CrossRef
- Kumwilaisak K, Noto A, Schmidt UH, Beck CI, Crimi C, Lewandrowski K, et al. Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit. Crit Care Med. 2008;36(11):2993–9. CrossRef
- Calderon-Margalit R, Mor-Yosef S, Mayer M, Adler B, Shapira SC. An administrative intervention to improve the utilization of laboratory tests within a university hospital. Int J Qual Health Care. 2005;17(3):243–8. CrossRef
- Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United states, 1999–2008. NCHS Data Brief. 2010;No. 43:April 24, 2013.
- Blich M, Sebbag A, Attias J, Aronson D, Markiewicz W. Cardiac troponin I elevation in hospitalized patients without acute coronary syndromes. Am J Cardiol. 2008;101(10):1384–8. CrossRef
- Reducing Excess Cardiac Biomarker Testing at an Academic Medical Center
Journal of General Internal Medicine
Volume 29, Issue 11 , pp 1468-1474
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- wasteful diagnostic testing
- acute coronary syndrome
- cardiac biomarkers
- Industry Sectors
- Author Affiliations
- 1. Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
- 2. Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- 3. Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
- 4. Department of Pathology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA