Financial impact of a targeted reduction in cardiac enzyme testing at a community hospital

Abstract

ObjectivesNearly one-third of healthcare costs are potentially avoidable and would not compromise medical care if eliminated. Therefore, we sought to evaluate the financial impact of reduction in use of creatinine kinase (CK)-MB and myoglobin tests after removing them from the cardiac enzyme order set at a community hospital.MethodsGrand rounds were held, and an email notification was sent to de-emphasize the use of CK, CK-MB, myoglobin, SGOT (glutamic-oxaloacetic transaminase), and SGPT (serum glutamic-pyruvic transaminase) in acute coronary syndrome (ACS) work up. The above tests were removed from the pre-checked cardiac enzyme order set in the computerized physician order entry on February 13, 2014. The tests continued to be available, but needed to be ordered individually. The mean monthly volume of cardiac enzyme tests for 12 months after this intervention was compared with the mean monthly volume of 12 months before the change. Total cost savings were calculated.ResultsAfter the intervention, the number of CK, CK-MB, myoglobin, SGOT, and SGPT tests utilized for ACS workup decreased dramatically (p<0.001). The volume of troponin testing remained the same (p=0.283). The total annual savings of billable charges to healthcare payers was $463,744.7.ConclusionsRemoval of CK-MB, myoglobin, CK, SGOT, and SGPT tests from cardiac enzyme order sets can successfully reduce unnecessary laboratory testing for ACS workup, leading to significant cost savings to the healthcare system.

Quality Improvement Intervention for Reduction of Redundant Testing

“…In this case, a simplified economic model indicates a >US$635 000 annual savings in 2012, with no additional inputs required for ongoing savings once the intervention was complete. These savings were similar to the savings found by Zhang et al 24 for billing costs, and our calculated reagent savings were greater than the reagent savings calculated for an ED intervention by Le et al 23 likely because of the use of transparently published reagent costs, compared to actual but invisibly discounted reagent costs. More fundamentally, we were not surprised to learn that clinicians responded to the cost data with interest but were not particularly impressed by savings alone.…”

“…Nevertheless, the legitimate need to retain the test did not explain why routine CKMB orders persisted well past 2007 in our region and beyond. 22 – 24 We also planned to determine whether there was a need to intervene, without eliminating clinician-desired access to the CKMB orders. An Emergency Medicine (EM) Department conducted an evaluation of discrepant cases and found no value to the CKMB, followed by successful removal of the CKMB testing from the emergency department (ED) menu, with attendant cost savings.…”

“… 23 A community hospital has also shown that a suite of unneeded MI tests, including CKMB and myoglobin, can be eliminated from the routine evaluation of MI, with substantial cost savings. 24 The individual contributions of education and changes to computerized provider order entry (CPOE) could not be analyzed in this successful intervention. At about the same time as we undertook our intervention, a successful academic intervention was completed and described at another university; the authors pointed out the unmet need to translate interventions from academic settings to external partners.…”

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

“…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.…”

Clinical utility and economic burden of routine serum lipase determination in the Emergency Department

“…In a study at a large academic medical centre evaluating the clinical and financial implications of creatine kinase-muscle/brain (CK-MB) in the ED, it was shown that CK-MB can be safely removed from ordering practices without affecting patient outcome and with cost savings of approximately $47 000 per year 16,17. Zhang et al estimated the financial impact of reduction in CK-MB at a community hospital to be around $463 744 effectively decreasing the unnecessary lab tests for acute coronary syndrome with significant cost savings to the healthcare system 18. These studies confirm the necessity of using an evidence-based approach to assess the utility and proper use of laboratory tests in order to minimise their overutilisation.…”