RePROgramming the BNP

From the 2019 HVPAA National Conference

Dr. Victor Chun (University of California, San Diego), Dr. Joseph Ryan (University of California, San Diego), Dr. Reema Patel (University of California, San Diego), Dr. Mary Brooks (University of California, San Diego), Dr. Arkady Komsoukaniants (University of California, San Diego), Dr. Gregory Seymann (University of California, San Diego)


There is extensive evidence that both brain natriuretic peptide (BNP) and the biologically inert co-secreted N-terminal BNP (pro-BNP) are similar diagnostic tests for the evaluation of dyspnea concerning for CHF. Unfortunately, there is no standard conversion factor that can be used to easily compare BNP to pro-BNP. Our clinical problem was to investigate the utility of ordering both BNP and pro-BNP to evaluate for congestive heart failure (CHF).


To define local practice patterns and identify clinically useful versus low-value duplicate BNP testing at our institution.


We defined duplicate BNP testing as patients with both BNP and pro-BNP assays ordered within the same defined episode of care. After consulting cardiologists at our institution, we defined clinically useful duplicate testing as testing used to transition patients from one BNP assay to another; all other duplicate testing was classified as low-value.

We conducted an EPIC query over a 6 month time period to identify patients at UC San Diego who had both a BNP and pro-BNP ordered in the same encounter; both outpatients and inpatients were included.


We identified 280 instances of duplicate BNP testing over a 6 month period between October 2018 and March 2019. We randomly reviewed 99 of the cases. In the majority of these instances (94%), both tests were ordered within a 24 hour time period, and 86.9% were ordered by the same service. Clinically useful duplicate testing was noted in 29 cases; the remaining 70 duplicate tests were felt to be low-value.

About half of the duplicate BNP tests (51.2%), were obtained by the cardiology service. Of those, 29.5% were ordered in the inpatient setting while 20.5% were ordered in heart failure clinic.


Low-value duplicate BNP testing was prevalent at our institution, and the vast majority of tests were ordered at the same time. In the Heart Failure admission order set, both BNP and pro-BNP are set to be ordered by default, leading to unnecessary testing. Though the cardiology department was a major contributor, the redundant testing was common across multiple services. Efforts to standardize testing patterns should improve value.

Clinical Implications

  • Duplicate BNP testing can be useful for transitioning patients from one BNP assay to another; other instances of duplicate ordering should be discouraged.
  • Changes in the EMR to facilitate preferential ordering of pro-BNP are underway, with Cardiology support.
  • The Heart Failure admission order set has been updated so that it no longer defaults to duplicate BNP testing.


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 HVPA on Health Affairs Blog