title: Reducing excess cardiac biomarker testing at an academic medical center.
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).
  
  
  METHODS
  Interrupted times series.
  
  
  METHODS
  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.
  
  
  METHODS
  Multimodal intervention introduced August through October 2011 that included dissemination of an institutional guideline and changes to the computerized provider order entry system.
  
  
  METHODS
  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.
  
  
  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.
authors: Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA, Mrl282@mail.harvard.edu.
authors: Marc R
authors: MR
authors: Larochelle
authors: Amy M
authors: AM
authors: Knight
authors: Hardin
authors: H
authors: Pantle
authors: Stefan
authors: S
authors: Riedel
authors: Jeffrey C
authors: JC
authors: Trost
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration*; D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000191:economics; D000293:Adolescent; D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D003955:Diagnostic Tests, Routine / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D017722:Hospital Charges / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008396:Maryland; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D015415:Biomarkers