In a report published in the Journal of General Internal Medicine, a research team from Johns Hopkins describes 2 interventions designed to reduce overuse of troponin and other biomarker testing without compromising patient care. If adopted widely, the team says, cost savings could be substantial.
The research team used 2 relatively simple tactics to significantly reduce the number of unnecessary blood tests to assess symptoms of heart attack and chest pain and to achieve a large decrease in patient charges.
The team provided information guidelines and education to physicians about proven testing guidelines and made changes to the computerized provider order entry system. The guidelines call for more limited use of blood tests for so-called cardiac biomarkers. A year after implementation, the guidelines saved the medical center an estimated $1.25 million in laboratory charges.
Part of the focus was on tests to assess levels of troponin, a protein whose components increase in the blood when heart muscle is damaged. Frequently, troponin tests are repeated 4 or more times in a 24-hour period, which studies have suggested is excessive, and they are often done along with tests for other biomarkers that are redundant. The new guidelines suggest ordering troponin alone, without creatine kinase or creatine kinase-MB, for patients suspected of having acute coronary syndrome. It specifies that troponin should be assessed no more than 3 times over 18 to 24 hours.
In the computerized provider order entry system, orders for creatine kinase and creatine kinase-MB were removed from all standardized order sets. Troponin orders were removed from all order sets, except 2 that are used for evaluating new acute coronary syndrome symptoms. A pop-up warning alerted providers when a troponin test was ordered sooner than 6 hours after a previous one, or when a provider attempted to order creatine kinase or creatine kinase-MB at the same time.
Twelve months after the interventions, doctors’ use of the new guidelines increased from 57.1% percent to 95.5% and led to a 66% decrease in the absolute number of tests ordered. There was also a small but statistically significant increase in the primary or secondary diagnosis of acute coronary syndrome after the intervention period.
The authors believe that provider education and changes to the ordering system were effective in aligning physician ordering behavior with evidence-based guidelines and reducing wasteful healthcare spending.
- Larochelle MR, Knight AM, Pantle H, Riedel S, Trost J. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Int Med. 2014. Epub ahead of print. June 28, 2014. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/24973056. Accessed July 2, 2014.