A Myth in Better Patient Care: Study of Trending Troponin

From the 2018 HVPAA National Conference

Muhammad Usman Ali (Crozer-Chester Medical Center), Hassaan Sattar (Crozer-Chester Medical Center), Jonathan Finkel (Crozer-Chester Medical Center), Neha Puri (Crozer-Chester Medical Center), Jugeet Kanwal (Crozer-Chester Medical Center), Christopher Struby (Crozer-Chester Medical Center), Mirnouve Domond (Crozer-Chester Medical Center)

Background

It is estimated that 5-8 million patients present to the emergency department annually for chest pain and differentiating acute coronary syndrome (ACS) from non-cardiac chest pain is the primary diagnostic challenge. Serial cardiac troponins are measured to aid the diagnosis.

Objectives

Low risk patients (TIMI score 0-1) presenting with chest pain are frequently checked for more than 2 troponins. Although there are guidelines regarding frequency of troponin measurements, it is frequently trended inappropriately. This study seeks to evaluate troponin trending practice and its effects on patient care.

Methods

This was a retrospective study of 1120 patients admitted to the academic hospital. Our study had two arms: rule out ACS and NSTEMI. Inclusion criteria were age >25 years with the first two troponins negative. Study excluded patients who had any of the first two troponins positive or admitted to the Surgical, Burn/Intensive Care Unit. Data collection includes age, TIMI score, Number of Troponins Trended, positive third or later troponins which resulted in a change in management (Cardiac Catheterization) and length of stay.

Results

After applying exclusion criteria, 864 patients were included in the study. In the rule out ACS arm, 381 patients admitted in 2013-2017 to rule out ACS were included. We found forty five percent patients (174/381) had TIMI score 0-1, out of which thirty seven percent (66/174) patients had more than two troponin trended out of which five percent (10/174) had later troponin positive and one percent (2/174) had change in management based on later positive troponin. Overall, fifty percent patients (191/381) had more than two troponins trended out of which only eight percent (32/381) had third or later troponin positive and only one percent (8/381) of patients had change in management based on later troponin positive. We found that high TIMI score and older age are independent factors contributing to more number of troponins tended. Up to seventy two percent (274/381) patients had length of stay of more than one day due to inappropriate troponin trending practice. There were no statistically significant differences between the hospitalist and teaching services regarding length of stay. In NSTEMI arm, only one percent patients (4/483) had third or later troponins positive that leads to change in management.

Conclusion

Although American Heart Association guidelines says that obtain additional troponin after six hours when initial serial troponins negative if patients have EKG changes or intermediate/high risk, our study found that we are frequently trending more than two troponins even in low risk patients.

Implications for the Patient

Our data supports that patients had increase in length of stay due to this practice and trending more than two troponins in low risk patients rarely changes management. The recognition of inappropriate troponin trending practices can significantly reduce healthcare expenditures and better high value care.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPAA on Health Affairs Blog