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Improved Utilization of Serial Testing Without Increased Admissions after Implementation of High-Sensitivity Troponin I: a Controlled Retrospective Cohort Study

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Abstract

Background

Guidelines recommend high-sensitivity cardiac troponin (hs-cTn) for diagnosis of myocardial infarction. Use of hs-cTn is increasing across the U.S., but questions remain regarding clinical and operational impact. Prior studies have had methodologic limitations and yielded conflicting results.

Objective

To evaluate the impact of transitioning from conventional cardiac troponin (cTn) to hs-cTn on test and resource utilization, operational efficiency, and patient safety.

Design

Retrospective cohort study in two New York City hospitals during the months before and after transition from conventional cTn to hs-cTn at Hospital 1. Hospital 2 served as a control.

Participants

Consecutive emergency department (ED) patients with at least one cTn test resulted.

Intervention

Multifaceted hs-cTn intervention bundle, including a 0/2-h diagnostic algorithm for non-ST-elevation myocardial infarction, an educational bundle, enhancements to the electronic medical record, and nursing interventions to facilitate timed sample collection.

Main Measures

Primary outcomes included serial cTn test utilization, probability of hospital admission, ED length of stay (LOS), and among discharged patients, probability of ED revisit within 72 h resulting in hospital admission. Multivariable regression models adjusted for age, sex, temporal trends, and interhospital differences.

Key Results

The intervention was associated with increased use of serial cTn testing (adjusted risk difference: 48 percentage points, 95% CI: 45–50, P < 0.001) and ED LOS (adjusted geometric mean difference: 50 min, 95% CI: 50–51, P < 0.001). There was no significant association between the intervention and probability of admission (adjusted relative risk [aRR]: 0.99, 95% CI: 0.89–1.1, P = 0.81) or probability of ED revisit within 72 h resulting in admission (aRR: 1.1, 95% CI: 0.44–2.9, P = 0.81).

Conclusions

Implementation of a hs-cTn intervention bundle was associated with an improvement in serial cTn testing, a neutral effect on probability of hospital admission, and a modest increase in ED LOS.

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Data Availability

The datasets generated and analyzed during the current study are available from the corresponding authors on reasonable request.

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Acknowledgements:

We thank Arthur T. Evans, MD, MPH (Weill Cornell Medicine) for his invaluable guidance in developing the statistical analysis plan and Patrick Rumble, BS (Weill Cornell Medicine), for his instrumental assistance in data acquisition.

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Author notes

  1. Laura Warren and Brett G. Fischer contributed equally to this work.

Authors and Affiliations

  1. Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA

    Laura Warren MD, PhD, Sophie Rand MPH, Jim Yee BS, Stacia Semple MD, Amy Chadburn MD, He S. Yang PhD & Zhen Zhao PhD

  2. Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA

    Brett G. Fischer MD, Nekee Pandya MD & Robert J. Kim MD

  3. Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA

    Amos Shemesh MD, Jean Scofi MD & Peter A. D. Steel MD

  4. Division of Biostatistics, Weill Cornell Medicine, New York, NY, USA

    Caroline Andy MS

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  1. Laura Warren MD, PhD
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Corresponding authors

Correspondence to He S. Yang PhD, Peter A. D. Steel MD or Zhen Zhao PhD.

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Conflict of Interest:

LW is pending a patent for “Methods for detecting and treating endometriosis” Publication number: 20210096137. JS had a registration fee waived as a speaker at XGM Conference May 2023 and is the Co-Chair of the didactics Sub-committee for the Society of Academic Emergency Medicine 2022–2023 (unpaid). RJK has stock options in Cleerly Health, Inc. AC has received consulting fees from Leica Biosystems (Immunohistochemistry) and Boehringer-Ingelheim (hematopoietic neoplasms) and lecture fees at McGill University, Medical College of Wisconsin, and Northshore University Hospital (Evanston, IL). HSY received a speaker fee from Siemens Healthineers. PADS received consulting fees for ET health, speaker fees for the American College of Emergency Physicians Directors Academy, and is on the David Lynch Foundation National Advisory Board. ZZ has sponsored research supported by Novartis, Waters, Siemens Healthineers, Polymedco, Waters, Roche and ET Healthcare and has received consulting/speaker fee from Siemens Healthineers, Roche and ET Healthcare.

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Warren, L., Fischer, B.G., Shemesh, A. et al. Improved Utilization of Serial Testing Without Increased Admissions after Implementation of High-Sensitivity Troponin I: a Controlled Retrospective Cohort Study. J GEN INTERN MED 39, 739–746 (2024). https://doi.org/10.1007/s11606-023-08535-3

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