Abstract 174: Clinical Redesign Project to Improve Troponin Utilization at a University affiliated Community Hospital

Abstract

Background: Cardiac troponin (CTn) is central to the diagnosis of acute coronary syndromes (ACS), however, in patients with low pre-test probability, the specificity of a positive CTn assay diminishes significantly. Overutilization of CTn assay is a rather prevalent problem and doctors often order further expensive testing for non-specific elevation in CTn. Methods: A clinical redesign team, formed in October 2015, defined four appropriate indications for ordering CTn assays, namely, chest pain, new EKG changes, cardiac arrest and angina equivalents such as shortness of breath and fatigue. We started by administering anonymous questionnaires, pertaining to CTn ordering practices, to different groups of healthcare providers at our hospital. Upon obtaining results of the questionnaire we executed a multifaceted intervention, including educational seminars and insertion of prompts in the electronic medical record system. We divided our study period into pre- and post-intervention periods of 1-year duration each and included a 17-week post-intervention interim analysis. We used Pearson’s correlation to test the null hypothesis that the pre- and post-intervention CTn assay volumes were not correlated and we used ANOVA to compare mean CTn assay volumes in the 38-week pre- and 17-week post-intervention period. Result: Overall: there was a 4% increase in ED patient volume and a 14% decrease in the total cTn order volume. Average cTn assays per ED patient decreased by 19%, from 0.26 to 0.21. The proportion of appropriate cTn assays increased post-intervention (45 vs 40% p=0.03). Interim analysis revealed a statistically significant decrease in weekly cTn order volume (r=0.903, p=0.0001). Percentage of cTn assays associated with a discharge diagnosis of ACS increased from 5.1% to 5.8% post-intervention (p= 0.001). Conclusion: cTn utilization can be effectively addressed by an organized multifaceted step-wise approach. Inappropriate utilization of cTn assays comes with associated cost implications due to the cost of the assay (nearly $50,000 cost savings in a year alone). It is quintessential to understand cTn ordering attitudes among different groups of healthcare providers. Our study also highlights the relevance of pre-test probability of ACS in any given patient before ordering cTn.