Reducing excess cardiac biomarker testing at an academic medical center

J Gen Intern Med. 2014 Nov;29(11):1468-74. doi: 10.1007/s11606-014-2919-5. Epub 2014 Jun 28.

Abstract

Background: Elimination of wasteful diagnostic testing will improve value for the United States health care system.

Objective: Design and implement a multimodal intervention to improve evidence-based ordering of cardiac biomarkers for the diagnosis of acute coronary syndrome (ACS).

Design: Interrupted times series.

Subjects: 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.

Intervention: Multimodal intervention introduced August through October 2011 that included dissemination of an institutional guideline and changes to the computerized provider order entry system.

Main measures: 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.

Key results: 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.

Conclusions: 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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Academic Medical Centers / organization & administration*
  • Acute Coronary Syndrome / diagnosis*
  • Acute Coronary Syndrome / economics
  • Adolescent
  • Adult
  • Aged
  • Biomarkers / blood
  • Diagnostic Tests, Routine / economics
  • Diagnostic Tests, Routine / statistics & numerical data*
  • Female
  • Guideline Adherence / statistics & numerical data
  • Hospital Charges / statistics & numerical data
  • Humans
  • Male
  • Maryland
  • Middle Aged
  • Patient Admission / statistics & numerical data
  • Practice Guidelines as Topic
  • Unnecessary Procedures / statistics & numerical data*
  • Young Adult

Substances

  • Biomarkers