Researchers at Johns Hopkins Bayview Medical Center, Baltimore, used two relatively simple tactics to significantly reduce the number of unnecessary blood tests to assess symptoms of heart attack and chest pain, and to achieve a large decrease in patient charges.
The team provided information about testing guidelines and made changes to the computerized physician order entry system at the medical center, part of the Johns Hopkins Health System. The guidelines call for more limited use of blood tests for cardiac biomarkers. A year after implementation, the guidelines saved the medical center an estimated $1.25 million in laboratory charges.
Part of the focus was on tests to assess levels of troponin, a protein whose components increase in the blood when heart muscle is damaged. Frequently, troponin tests are repeated four or more times in a 24-hour period, which studies have suggested is excessive, and they are often done along with tests for other biomarkers that are redundant. The new guidelines suggest ordering troponin alone, without creatine kinase or creatine kinase-MB, for patients suspected to have acute coronary syndrome. It specifies that troponin should be assessed no more than three times over 18 to 24 hours.
In the computerized provider order entry system, orders for creatine kinase and creatine kinase-MB were removed from all standardized order sets. Troponin orders were removed from all order sets, except two that are used for evaluating new acute coronary syndrome symptoms. A pop-up warning alerted providers when a troponin test was ordered sooner than six hours after a previous one, or when a provider attempted to order creatine kinase or creatine kinase-MB at the same time.
Twelve months after the interventions, doctors use of the new guidelines increased from 57.1 percent to 95.5 percent and led to a 66 percent decrease in the absolute number of tests ordered.
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