Trends in Troponin-Only Testing for AMI in Academic Teaching Hospitals and the Impact of Choosing Wisely®

Journal of Hospital Medicine 12(12). 2017 December;957-962. Published online first September 20, 2017 | 10.12788/jhm.2846

December 1, 2017|Journal of Hospital Medicine

Micah T. Prochaska, MD, MS;Samuel F. Hohmann, PhD, MS-HSM;Matthew Modes, MD, MPH;Vineet M. Arora, MD, MAPP

BACKGROUND: Identifying hospitals that are both early and consistent adopters of high-value care can help shed light on the culture and practices at those institutions that are necessary to promote high-value care nationwide. The use of troponin to diagnose acute myocardial infarction (AMI), and not to test for myoglobin or creatine kinase-MB (CK-MB), is a high-value recommendation of the Choosing Wisely® campaign.

OBJECTIVE: To examine the variation in cardiac biomarker testing and the effect of the Choosing Wisely® troponin-only recommendation for the diagnosis of AMI.

DESIGN: A retrospective observational study using administrative ordering data from Vizient’s Clinical Database/Resource Manager.

SETTING: Ninety-one academic medical centers from the fourth quarter of 2013 through the third quarter of 2016.

PATIENTS: Hospitalized patients with a principal discharge diagnosis of AMI.

INTERVENTION: The Choosing Wisely® recommendation to order troponin-only testing to diagnose AMI was released during the first quarter of 2015.

RESULTS: In 19 hospitals, troponin-only testing was consistently ordered to diagnose AMI before the Choosing Wisely® recommendation and throughout the study period. In 34 hospitals, both troponin and myoglobin/CK-MB were ordered to diagnose AMI even after the Choosing Wisely® recommendation. In 26 hospitals with low rates of troponin-only testing before the Choosing Wisely® recommendation, the release of the recommendation was associated with a statistically significant increase in the rate of troponin-only testing to diagnose AMI.

CONCLUSION: In institutions with low rates of troponin-only testing prior to the Choosing Wisely® recommendation, the recommendation was associated with a significant increase in the rate of troponin-only testing.

RESULTS

Of the 300 hospitals in Vizient’s CDB/RM, 91 (30%, 91/300) had full reporting of data throughout the study period. These hospitals had a total of 106,954 inpatient discharges with a principal diagnosis of AMI during the study period. The overall rates of troponin-only testing for AMI discharges by hospital varied from 0% to 87.4% (Figure 1). The mean rate of troponin-only testing across all patients with a discharge diagnosis of AMI was 29.2% at the start of the study (fourth quarter of 2013) and 53.5% at the end of the study (third quarter 2016; Supplemental Figure). Nineteen hospitals (21%, 19/91; 27,973 discharges) had high rates of troponin-only testing for AMI and were in the top tertile of all hospitals throughout the study period. Thirty-four hospitals (37%, 34/91; 35,080 discharges) ordered both troponin and myoglobin/CK-MB tests to diagnose AMI, and they were in the bottom tertile of all hospitals throughout the study period. In the 38 hospitals (42%, 38/91; 43,090 discharges) that were not in the top or bottom tertile for all study quarters, the rate of troponin-only testing for AMI increased at each hospital during each quarter of the study period (Table).

Pattern of Troponin-Only Testing by Hospital Size

Of the hospitals in the top tertile of troponin-only testing throughout the study period, the majority had ≥500 beds (13/19), but the highest rate of troponin-only testing was in hospitals that had <250 beds (n = 4, troponin-only testing rate of 82/100 patients). Additionally, in hospitals that improved their troponin-only testing during the study period, hospitals that had <500 beds had higher rates of troponin-only testing than did hospitals with ≥500 beds. The differences in the rates of troponin-only testing across the 3 groups of hospitals and hospital size were statistically significant (P < 0.0001; Table).

Pattern of Troponin-Only Testing by Geographic Region

The rate of troponin-only testing also varied and was statistically significantly different when comparing the 3 groups of hospitals across geographic regions of the country (P < 0.0001). Of the hospitals in the top tertile of troponin-only testing throughout the study period, the majority were in the Midwest (n = 6) and Mid-Atlantic (n = 5) regions. However, the rate of troponin-only testing for AMI in this group was highest in hospitals in the West (86/100 patients) and/or Southeast (75/100 patients) regions, although this rate was based on a small number of hospitals in these geographic areas (n = 1 in the West, n = 2 in the Southeast). Of hospitals in the bottom tertile of troponin-only testing throughout the study period, the majority were in the Mid-Atlantic region (n = 10). Hospitals that increased their troponin-only testing during the study period were predominantly in the Midwest (n = 12) and Mid-Atlantic regions (n = 11; Table), with the hospitals in the Midwest having the highest rate of troponin-only testing in this group.

Pattern of Troponin-Only Testing by Volume of AMI Patients

Of the hospitals in the top tertile of troponin-only testing during the study period, the majority cared for ≥1500 AMI patients (n = 9), but interestingly, among these hospitals, those caring for a smaller volume of AMI patients all had higher rates of troponin-only testing per 100 patients (P < 0.0001; Table). There was no other obvious pattern of troponin-only testing based on the volume of AMI patients cared for in hospitals in either the bottom tertile of troponin-only testing or hospitals that improved troponin-only testing during the study period.

Pattern of Troponin-Only Testing by Physician Type

Of the hospitals in the top tertile of troponin-only testing throughout the study period, those where a cardiologist cared for patients with AMI had higher rates of troponin-only testing (71/100 patients) than did hospitals where patients were cared for by a noncardiologist (60/100 patients). However, of the hospitals that improved their troponin-only testing during the study period, higher rates of troponin-only testing were seen in hospitals where patients were cared for by a noncardiologist (48/100 patients) compared with patients cared for by a cardiologist (34/100 patients; Table). These differences in hospital rates of troponin-only testing during the study period based on physician type were statistically significant (P < 0.0001; Table).

Pattern of Troponin-Only Testing by Quality Rating

Hospitals that were in the top tertile of troponin-only testing and were rated highly by Vizient’s quality rating or recognized as a top hospital by the US News & World Report had higher rates of troponin-only testing per 100 patients than did hospitals in the top tertile that were not ranked highly by Vizient’s quality rating or recognized as a top hospital by the US News & World Report. However, the majority of hospitals in the top tertile of troponin-only testing were not rated highly by Vizient (n = 15) or recognized as a top hospital by the US News & World Report (n = 16). The large majority of hospitals in the bottom tertile of troponin-only testing were not recognized as high-quality hospitals by Vizient (n = 32) or the US News & World Report (n = 31). Of the hospitals that improved their troponin-only testing during the study period, the majority were not recognized as high-quality hospitals by Vizient (n = 33) or the US News & World Report (n = 36), but among this group, those hospitals recognized by Vizient as high quality (n = 5) had the highest rate of troponin-only testing (57/100 patients). The differences in the rate of troponin-only testing across the different groups of hospitals and quality ratings were statistically significant (P < 0.0001; Table).

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