Clinical and financial impact of removing creatine kinase-MB from the routine testing menu in the emergency setting

Le, Rachel D.; Kosowsky, Joshua M.; Landman, Adam B.; Bixho, Ida; Melanson, Stacy E.F.; Tanasijevic, Milenko J.

doi:10.1016/j.ajem.2014.10.017

Cited by 23 publications

(22 citation statements)

References 10 publications

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“…Thus, 19 CPOE modification studies were meta-analyzed in relation to the primary outcome measure. Eight of these studies (Bates et al, 26 Bridges et al, 27 Fang et al, 28 Feldman et al, 29 Le et al, 34 Lippi et al, 36 Probst et al, 41 and Waldron et al 46 ) additionally supported derivation of the secondary outcome—the cost of test orders—and (along with Tierney et al 1993 [available in Supplemental Table 2 ]) are further discussed in the “Additional Outcomes Data” subsection of the “Results” section.…”

Section: Resultsmentioning

confidence: 99%

Effectiveness of Practices to Support Appropriate Laboratory Test Utilization

Rubinstein

Hirsch

Bandyopadhyay

et al. 2018

American Journal of Clinical Pathology

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ObjectivesTo evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization.MethodsThis review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality).ResultsEighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient.ConclusionPractice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.

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Section: Resultsmentioning

confidence: 99%

Effectiveness of Practices to Support Appropriate Laboratory Test Utilization

Rubinstein

Hirsch

Bandyopadhyay

et al. 2018

American Journal of Clinical Pathology

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“…Before the development of more-sensitive cTn assays, varying combinations of cTn, CK-MB, and myoglobin have been used to improve early diagnostic sensitivity and reduce the time to rule-out AMI. However, contemporary cTn assays have high early diagnostic accuracy, such that use of other markers adds cost [14][15][16] without providing additional diagnostic utility. 17,18 This led the 2014 American College of Cardiology/American Heart Association non-ST-segment elevation myocardial infarction guidelines to indicate that there is no benefit (class III recommendation) of using myoglobin and CK-MB, supported with a grade A level of evidence.…”

Section: Discussionmentioning

confidence: 99%

Trends in Use of Biomarker Protocols for the Evaluation of Possible Myocardial Infarction

Hachey

Kontos

Newby

et al. 2017

JAHA

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BackgroundVarious combinations of creatine kinase‐MB, myoglobin, and cardiac troponin I or T (cTnI/cTnT) have been used to evaluate patients with suspected acute coronary syndromes. The current recommendation is to use the 99th percentile of cTnI/cTnT as the sole marker for diagnosis of acute myocardial infarction.Methods and ResultsWe retrospectively analyzed cardiac marker protocols collected from 824 US hospitals undergoing Chest Pain Center Accreditation through the Society of Cardiovascular Patient Care from 2009 to 2014. Data were obtained by a self‐reported survey that addressed cardiac marker(s), sampling time periods, and cut points used for evaluation of suspected acute myocardial infarction. The combination of cTnI or cTnT with creatine kinase‐MB was the most commonly used biomarker strategy. Use of cTnI or cTnT as the sole marker increased over time (14–37%; P<0.0001), as did use of the 99th percentile cut point for cTnI/cTnT (30–60%; P<0.0001).ConclusionThere is considerable variation in cardiac marker testing strategies used in US hospitals for evaluation of suspected acute myocardial infarction. Although increasing, 24% of hospitals used a cTn alone strategy, and only 49% used cTn at the recommended 99th percentile cut point. This has important implications for the diagnosis and treatment of patients with acute myocardial infarction.

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“…The timed intervals for serial cTn analysis are also dependent upon the analytical and clinical performance characteristics of the assay used; some cTn assays may not yield a positive result above the 99 th percentile until up to 12 hours after the onset of chest pain(13).Inappropriate utilization of cardiac biomarkers that are not guideline recommended such as CK-MB and myoglobin remains problematic, particularly when routinely ordered in conjunction with troponin. Several studies have highlighted the duplication of information with this strategy(10,14,15). The recent NSTEMI guidelines for the first time have given measurement of CK-MB and myoglobin a Class IIIA recommendation (No Benefit, Highest…”

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confidence: 99%