An intervention designed to eliminate unneeded cardiac biomarker testing for acute coronary syndrome saved $1.25 million in one year at one hospital, according to a study published online June 28 in the Journal of General Internal Medicine.
Nine percent of adult patients who visit an emergency room complain of chest pain, observed lead author Marc R. Larochelle, MD, of Johns Hopkins Bayview Medical Center in Baltimore, and colleagues. Clinicians often order cardiac biomarker testing if they suspect these patients have acute coronary syndrome.
Larochelle et al determined that providers ordered tests for troponin, creatine phosphokinase (CK) alone or CK-MB, at average costs per test of $51.90, $12.33 and $30.80, respectively. After talking with cardiologists, they developed guidelines that called for only troponin testing with a limit of three tests evenly spaced over 18 to 24 hours.
They also designed an intervention that included an instructional phase focused on the guidelines and changes to their center’s computerized order entry system. In particular, they deleted CK and CK-MB from the standardized order sets and troponin from all but two used to evaluate new symptoms for acute coronary syndrome. They installed pop-up warnings if a clinician ordered a repeat troponin test before six hours and a warning if a provider tried to order CK or CK-MB, which the provider could override.
The study used a before-and-after design and data extracted from their administrative database, with a primary outcome of the percentage of patients each month meeting cardiac biomarker guideline recommendations. The pre-intervention period spanned January 2009 to July 2011 (60,494 patients); the rollout from August through October 2011; and the post-intervention from November 2011 to October 2012 (24,341 patients).
They found a 34 percent absolute increase in the proportion of patients tested for biomarkers as recommended in the guidelines after the intervention was initiated. At one year, the proportion of patients tested as recommended was 95.5 percent.
Compared to the pre-intervention baseline, they found decreases of 16 percent, 87 percent and 95 percent in testing for troponin, CK and CK-MB, respectively. The reduction eliminated 51,000 tests and avoided costs of $1.25 million over one year.
“If practice patterns at other hospitals mirror ours, the potential charge reduction would be several billion dollars per year nationally,” Larochelle and colleagues proposed. “Furthermore, reduced cardiac biomarker testing results in fewer false positive test results, which may lead to decreased ordering of downstream cardiac tests.”
They pointed out that the study was single-center and lacked a control group. They advocated other centers conduct similar trials to assess its reproducibility and use other diagnostic tests to determine whether this approach can help bring down healthcare costs and increase value.