Limited Cardiac Biomarker Testing Decreases Health Care Costs

Cardiac biomarkers, such as the total creatine kinase (CK), the isoenzymes MB-fractions of the creatine phosphokinase enzyme (CK-MB), and troponin, are frequently ordered in the emergency department (ED) and inpatient units to evaluate patients suspected of having an acute coronary syndrome (ACS).

Scientists at Johns Hopkins Bayview Medical Center (Baltimore, MD, USA) designed and implemented a multimodal intervention to improve evidence-based ordering of cardiac biomarkers for the diagnosis of acute coronary syndrome (ACS). A total of 60,494 adult inpatient admissions from January 2009 through July 2011 (preintervention) and 24,341 admissions from November 2011 through October 2012 (postintervention) were included in the study.

The team targeted enabling factors by changing the computerized provider order entry system (Meditech; Westwood, MA, USA) by removing orders for CK and CK-MB from all standardized order sets and troponin orders from all order sets except two that are used for evaluation of new symptoms concerning ACS. They created a duplicate order pop-up warning when a troponin level was ordered sooner than six hours after another troponin level. They created pop-up warnings when a health provider attempted to order CK-MB or CK.

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. Twelve months following the intervention, they estimated that guideline-concordant ordering of cardiac biomarkers increased from 57.1% to 95.5%, an absolute increase of 38.4%. They estimated that the intervention led to a 66% reduction in the number of tests ordered, and a decrease of USD 1.25 million 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 % compared with the expected baseline rate.

The authors concluded that by implementing a multimodal intervention they 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.

Marc R. Larochelle, MD, the lead author of the study, said, “Through review of available evidence and reflection on our own practice, I believe we can proactively identify many practices that may be unnecessary and wasteful. We have demonstrated proof of concept that doctors can be leaders in delivering improved value for our patients and health care systems.” The study was published on June 28, 2014, in the Journal of General Internal Medicine.

Related Links:
Johns Hopkins Bayview Medical Center 
Meditech