U.S. hospitals are still using an obsolete test for diagnosing heart attack—and they could improve patient care while saving millions of dollars in health care spending by eliminating it, according to a paper published last week in JAMA Internal Medicine.
The new paper is the first of several peer-reviewed implementation guidelines from the High Value Practice Academic Alliance. The Johns Hopkins University School of Medicine created the alliance—which consists of faculty from more than 80 academic institutions—to further quality-driven improvements in value, HealthLeaders Media reports.
An outdated test
The paper focuses on the use of creatine kinase-myocardial band (CK-MB) testing to diagnose acute myocardial infarction (AMI)—or heart attack.
The authors explain that while CK-MB was "once the cornerstone of AMI diagnosis," leading heart associations for years have considered another biomarker—cardiac troponin (cTn)—"the biomarker of choice" for heart attack diagnosis. The authors write that the American College of Cardiology and the European Society of Cardiology endorse cTn over CK-MB because of cTn's "nearly absolute myocardial tissue specificity and high clinical sensitivity for myocardial injury."
However, "CK-MB has not yet been eliminated from practice despite considerable evidence supporting cTn as the preferred biomarker," the authors write. They cite a 2013 survey by the College of American Pathologists that found about three-quarters of U.S. labs were using CK-MB as a marker for heart attacks. In fact, Jeffrey Trost, contributing author and director of Johns Hopkins Bayview Medical Center's Cardiac Catheterization Laboratory, said CK-MB and cTn are routinely ordered together.
The authors used Medicare's 2016 Clinical Diagnostic Laboratory Fee Schedule to estimate about $416 million is spent on cardiac biomarker tests annually. Trost said cutting one of the two widely used tests would result in significant cost savings. Further, the authors argue "that elimination of routine CK-MB ordering is not only high value because it offers no benefit and results in considerable cost but also because elimination of CK-MB may reduce physician confusion, improve understanding of the proper use of cTn, and consequently reduce potential patient harm."
According to the authors, now, CK-MB should only be used when cTn isn't available.
The authors acknowledge that "academic medical centers have implemented interventions to eliminate the routine ordering" of CK-MB testing but note that it "is still ordered in many hospitals and EDs." The authors cite existing research suggesting that this is due to "clinicians' reluctance to rely on cTn in certain clinical situations" and "clinician familiarity."
A blueprint for change
The authors provide a four-step plan to phase out CK-MB testing based on the Health Resources & Services Administration's quality improvement initiative. They recommend providers:
1. Create and implement a hospital-wide educational campaign;
2. Build partnerships across the institution—in cardiology, emergency medicine, internal medicine, and pathology—to eliminate CK-MB from standardized heart disease routine order sets;
3. Use IT and laboratory staff to develop an "alert" for the computerized order entry system regarding CK-MB; and
4. Measure use of the test and patient care quality and safety outcomes ahead of the intervention and once it's implemented (Commins, HealthLeaders Media, 8/14; Allar, Cardiovascular Business, 8/17; Joyce, HealthNewsReview, 8/17).
Advisory Board's take
Megan Tooley, Cardiovascular Roundtable
Cardiovascular services have a wealth of society guidelines, appropriate use criteria, and recommendations available to guide care decisions. However, many programs still struggle to incorporate these evidence-based guidelines into practice, which can lead to undesirable outcomes as well as unnecessary clinical and operational costs. The CK-MB testing example illustrates this challenge, given troponin has been largely accepted as the ideal biomarker, yet utilization of CK-MB has widely persisted at significant costs with little clinical value.
As CV service lines are increasingly measured against metrics assessing the overall value of care delivery, it has become critical for programs to develop a deliberate approach to identifying and eliminating unwarranted variations in CV care delivery at their own institutions. This will take more than just society guidelines and recommendations: Service lines will need to partner with physicians to develop institution-specific, flexible protocols for selecting the most appropriate and highest-value care option for each patient, and design workflows that will embed these standards into practice.
At the 2017-2018 Cardiovascular Roundtable National Meeting Series, we’ll provide an in-depth review of how to reduce unwarranted variation in CV care, including how to effectively design and embed care standards. Register now to secure your spot.