Journal of General Internal Medicine

, Volume 29, Issue 11, pp 1468–1474 | Cite as

Reducing Excess Cardiac Biomarker Testing at an Academic Medical Center

  • Marc R. Larochelle
  • Amy M. Knight
  • Hardin Pantle
  • Stefan Riedel
  • Jeffrey C. Trost
Original Research



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.


wasteful diagnostic testing acute coronary syndrome cardiac biomarkers 




We would like to thank Dr. David Hellmann, M.D. for his leadership, guidance, and enthusiastic support of this project. We thank Fang Zhang, PhD, for his guidance in designing and executing the statistical analysis. We thank Angel Sampedro, BS for his assistance in acquiring the data.


This work was supported by a Putting the Charter into Practice grant from the American Board of Internal Medicine Foundation. Dr. Larochelle’s work was supported by HRSA (T32 HP10251, T32 HP12706), the Ryoichi Sasakawa, Fellowship Fund, and the Harvard Pilgrim Health Care Institute. The funding sources had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; or in the preparation, review, and approval of the manuscript.

Prior Presentation

Preliminary 3 month results presented at The Society of General Internal Medicine Annual Meeting, Orlando, FL, May 12, 2012.

Conflicts of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2014_2919_MOESM1_ESM.docx (28 kb)
ESM 1 (DOCX 28 kb)
11606_2014_2919_MOESM2_ESM.docx (33 kb)
ESM 2 (DOCX 32 kb)


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Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Marc R. Larochelle
    • 1
    • 2
  • Amy M. Knight
    • 1
  • Hardin Pantle
    • 3
  • Stefan Riedel
    • 4
  • Jeffrey C. Trost
    • 1
  1. 1.Department of MedicineJohns Hopkins Bayview Medical CenterBaltimoreUSA
  2. 2.Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonUSA
  3. 3.Department of Emergency MedicineJohns Hopkins Bayview Medical CenterBaltimoreUSA
  4. 4.Department of PathologyJohns Hopkins Bayview Medical CenterBaltimoreUSA

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