Advertisement

Decreasing the Overuse of Troponin Testing– An Interventional Study in a Regional Hospital

  • Zvi Shimoni
    Affiliations
    Department of Internal Medicine B, Laniado Hospital, Netanya, Israel

    Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
    Search for articles by this author
  • Paul Froom
    Correspondence
    Requests for reprints should be addressed to Paul Froom, MD, Department of Clinical Utility, Laniado Hospital, Netanya Divrei Khayim St 16, Netanya, 4244916 Israel.
    Affiliations
    Clinical Utility Department, Sanz Medical Center, Laniado Hospital, Netanya, Israel

    School of Public Health, University of Tel Aviv, Israel
    Search for articles by this author

      Abstract

      Introduction

      The purpose of this study was to determine the effect of recommendations to limit troponin testing to patients with either chest pain or ischemic electrocardiographic changes.

      Methods

      We included all adult patients hospitalized in a regional hospital in internal medicine, cardiology, and intensive care departments in 2014-2016 and in 2019 after recommending limiting troponin testing to patients with either chest pain or ischemic electrocardiographic changes.

      Results

      After the intervention, testing decreased from 51.5% (11,634/22,581) to 34.6% (3417/9882). However, if only those with ischemia or chest pain were tested, the frequency would be 9.4% (924/9882) with a 95% confidence interval of 8.8%-9.9%. Variables increasing the odds of ordering a troponin test were older age, male sex, a discharge diagnosis of tachyarrhythmia, congestive heart failure, and dizziness or syncope as well as lower albumin and higher glucose, uric acid, and blood urea nitrogen test results. There were lower odds in those with nonspecific symptoms and infections of the skin, soft tissues, and the urinary tract. Auditing increased the effectiveness of the intervention in 1 internal medicine department (odds ratio 0.70, 95% confidence limit 0.60-0.82) after adjustment for other significant independent variables. The area under the curve was 0.713.

      Conclusion

      We found that an educational program with clear recommendations decreased the proportion of patients with troponin testing in hospitalized internal medicine departments, but the intervention was only partially effective and did not include patients with congestive heart failure and other conditions in which expert recommendations for testing are discordant.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Shah ASV
        • Sandoval Y
        • Noaman A
        • et al.
        Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study.
        BMJ. 2017; 359: j4788https://doi.org/10.1136/bmj.j4788
        • Wilson G
        • Barkley K
        • Slicker K
        • et al.
        Overuse of troponin? A comprehensive evaluation of testing in a large hospital system.
        J Hosp Med. 2017; 12: 329‐331https://doi.org/10.12788/jhm.273
        • Morgan DJ
        • Dhruva SS
        • Coon ER
        • Wright SM
        • Korenstein D
        2018 Update on medical overuse.
        JAMA Intern Med. 2019; 179: 240‐246https://doi.org/10.1001/jamainternmed.2018.5748
        • Shimoni Z
        • Arbuzov R
        • Froom P
        Troponin testing in patients without chest pain or electrocardiographic ischemic changes.
        Am J Med. 2017; 130: 1205‐1210https://doi.org/10.1016/j.amjmed.2017.03.032
        • Meng QH
        • Zhu S
        • Booth C
        • et al.
        Impact of the cardiac troponin testing algorithm on excessive and inappropriate troponin test requests.
        Am J Clin Pathol. 2006; 126: 195-199https://doi.org/10.1309/GK9B-FAB1-Y5LN-BWU1
        • Larochelle MR
        • Knight AM
        • Pantle H
        • et al.
        Reducing excess cardiac biomarker testing at an academic medical center.
        J Gen Intern Med. 2014; 29: 1468-1474https://doi.org/10.1007/s11606-014-2919-5
        • Thygesen K
        • Alpert JS
        • Jaffe AS
        • et al.
        Fourth Universal Definition of Myocardial Infarction (2018).
        J Am Coll Cardiol. 2018; 72: 2231‐2264https://doi.org/10.1016/j.jacc.2018.08.1038
        • Lippi G
        • Cervellin G
        Clinical interpretation of high-sensitivity troponin testing.
        JAMA Intern Med. 2019; 179: 725-726https://doi.org/10.1001/jamainternmed.2019.0371
        • Morgan DJ
        • Dhruva SS
        • Korenstein D
        Clinical interpretation of high-sensitivity troponin testing—reply.
        JAMA Intern Med. 2019; 179: 726https://doi.org/10.1001/jamainternmed.2019.0374
        • Lee KK
        • Noaman A
        • Vaswani A
        • et al.
        Prevalence, determinants, and clinical associations of high-sensitivity cardiac troponin in patients attending emergency departments.
        Am J Med. 2019; 132 (110.e8‐110.e21)https://doi.org/10.1016/j.amjmed.2018.10.002
        • Farber AJ
        • Suarez K
        • Slicker K
        • et al.
        Frequency of troponin testing in inpatient versus outpatient settings.
        Am J Cardiol. 2017; 119: 1153‐1155https://doi.org/10.1016/j.amjcard.2016.12.030
        • Makam AN
        • Nguyen OK
        Use of cardiac biomarker testing in the emergency department.
        JAMA Intern Med. 2015; 175: 67-75https://doi.org/10.1001/jamainternmed.2014.5830
        • Talebi S
        • Ferra RM
        • Tedla S
        • et al.
        Hazards with ordering troponin in patients with low pretest probability of acute coronary syndrome.
        Am J Emerg Med. 2015; 33: 1258‐1260https://doi.org/10.1016/j.ajem.2015.06.00