Evidence suggests that troponin-only testing is the superior strategy to diagnose acute myocardial infarction (AMI).1 Because of this, in February 2015, the Choosing Wisely® campaign issued a recommendation to use troponin I or T to diagnose AMI, and not to test for myoglobin or creatine kinase-MB (CK-MB).2 This recommendation was in line with guidelines from the American Heart Association and the American College of Cardiology, which recommended that myoglobin and CK-MB are not useful and offer no benefit for the diagnosis of acute coronary syndrome.3 Some institutions have developed interventions to promote troponin-only testing, reporting substantial cost savings and no negative consequences.4,5
Despite these successes, it is likely that institutions vary with respect to the adoption of the Choosing Wisely® troponin-only testing recommendation.6 Implementing this recommendation requires both promoting clinician behavior change and a strong institutional culture of high-value care.7 Understanding the variation across institutions of troponin-only testing could inform how to promote high-value care recommendations nationwide. We aimed to describe patterns of troponin, myoglobin, and CK-MB testing in a sample of academic teaching hospitals before and after the Choosing Wisely® recommendation.
Troponin, myoglobin, and CK-MB ordering data were extracted from Vizient’s (formerly University HealthSystem Consortium, Chicago, IL) Clinical Database/Resource Manager (CDB/RM®) for all patients with a principal discharge diagnosis of AMI at all hospitals reporting all 36 months from the fourth quarter of 2013 through the third quarter of 2016. This period includes time both before and after the Choosing Wisely® recommendation, which was released in the first quarter of 2015. Vizient’s CDB/RM contains ordering data for 300 academic medical centers and their affiliated hospitals and includes the discharge diagnoses for patients cared for by these institutions. Only patients with a principal discharge diagnosis of AMI were included because the Choosing Wisely® recommendation is specific with regard to troponin-only testing for the diagnosis of AMI. Patients with a principal diagnosis code for subcategories of myocardial ischemia (eg, stable angina, unstable angina) were not included because of the large number of diagnosis codes for these subcategories (more than 100 in the International Classification of Diseases, Ninth Revision and the International Classification of Diseases, Tenth Revision) and because the variation in their use across institutions within the dataset limited the utility of using these codes to consistently and accurately identify patients with myocardial ischemia. Moreover, the diagnosis of AMI encompasses the subcategories of myocardial ischemia.8
Hospital rates of ordering cardiac biomarkers (troponin-only or troponin and myoglobin/CK-MB) were determined overall for the entire study period and for each quarter of the study period based on the total patients with a discharge diagnosis of AMI. For each quarter of the 12 study quarters, all the hospitals were divided into tertiles based on their rate of troponin-only testing per discharge diagnosis of AMI. Hospitals were then classified into 3 groups based on their tertile ranking over the full 12 study quarters. The first group included hospitals whose rate of troponin-only testing placed them in the top tertile for each and all quarters throughout the study period. The second group included hospitals whose troponin-only testing rate placed them in the bottom tertile for each and all quarters throughout the study period. The third group included hospitals whose troponin-only testing rate each quarter led to either an increase or decrease in their tertile ranking throughout the study period. χ2 tests were used to test for bivariate associations among hospitals based on their rate of troponin-only testing and hospital size (number of beds), their regional geographic location, the volume of AMI patients seen at the hospital, whether the primary physician during the hospitalization was a cardiologist or other provider, and the hospitals’ quality ratings. Quality rating was based on an internal Vizient rating and the “Best Hospitals for Cardiology and Heart Surgery Rankings” as published in the US News & World Report.9 The Vizient quality rating is based on a composite score that combines scores from the domains of quality (hospital quality incentive scores), safety (patient safety indicators), patient-centeredness (Hospital Consumer Assessment of Healthcare Providers and Systems Hospital Survey), and equity (distribution of care by race/ethnicity, gender, and age). Simple slopes were calculated to determine the rate of change in troponin-only testing for each study quarter, and Student t tests were used to compare the rates of change of these simple slopes across study quarters.
Pattern of Troponin-Only Testing by Hospital Size
Pattern of Troponin-Only Testing by Geographic Region
The rate of troponin-only testing also varied and was statistically significantly different when comparing the 3 groups of hospitals across geographic regions of the country (P < 0.0001). Of the hospitals in the top tertile of troponin-only testing throughout the study period, the majority were in the Midwest (n = 6) and Mid-Atlantic (n = 5) regions. However, the rate of troponin-only testing for AMI in this group was highest in hospitals in the West (86/100 patients) and/or Southeast (75/100 patients) regions, although this rate was based on a small number of hospitals in these geographic areas (n = 1 in the West, n = 2 in the Southeast). Of hospitals in the bottom tertile of troponin-only testing throughout the study period, the majority were in the Mid-Atlantic region (n = 10). Hospitals that increased their troponin-only testing during the study period were predominantly in the Midwest (n = 12) and Mid-Atlantic regions (n = 11; Table), with the hospitals in the Midwest having the highest rate of troponin-only testing in this group.
Pattern of Troponin-Only Testing by Volume of AMI Patients
Of the hospitals in the top tertile of troponin-only testing during the study period, the majority cared for ≥1500 AMI patients (n = 9), but interestingly, among these hospitals, those caring for a smaller volume of AMI patients all had higher rates of troponin-only testing per 100 patients (P < 0.0001; Table). There was no other obvious pattern of troponin-only testing based on the volume of AMI patients cared for in hospitals in either the bottom tertile of troponin-only testing or hospitals that improved troponin-only testing during the study period.
Pattern of Troponin-Only Testing by Physician Type
Of the hospitals in the top tertile of troponin-only testing throughout the study period, those where a cardiologist cared for patients with AMI had higher rates of troponin-only testing (71/100 patients) than did hospitals where patients were cared for by a noncardiologist (60/100 patients). However, of the hospitals that improved their troponin-only testing during the study period, higher rates of troponin-only testing were seen in hospitals where patients were cared for by a noncardiologist (48/100 patients) compared with patients cared for by a cardiologist (34/100 patients; Table). These differences in hospital rates of troponin-only testing during the study period based on physician type were statistically significant (P < 0.0001; Table).
Pattern of Troponin-Only Testing by Quality Rating
Hospitals that were in the top tertile of troponin-only testing and were rated highly by Vizient’s quality rating or recognized as a top hospital by the US News & World Report had higher rates of troponin-only testing per 100 patients than did hospitals in the top tertile that were not ranked highly by Vizient’s quality rating or recognized as a top hospital by the US News & World Report. However, the majority of hospitals in the top tertile of troponin-only testing were not rated highly by Vizient (n = 15) or recognized as a top hospital by the US News & World Report (n = 16). The large majority of hospitals in the bottom tertile of troponin-only testing were not recognized as high-quality hospitals by Vizient (n = 32) or the US News & World Report (n = 31). Of the hospitals that improved their troponin-only testing during the study period, the majority were not recognized as high-quality hospitals by Vizient (n = 33) or the US News & World Report (n = 36), but among this group, those hospitals recognized by Vizient as high quality (n = 5) had the highest rate of troponin-only testing (57/100 patients). The differences in the rate of troponin-only testing across the different groups of hospitals and quality ratings were statistically significant (P < 0.0001; Table).
The Effect of Choosing Wisely® on Troponin-Only Testing
In the hospitals that demonstrated increasing adoption of troponin-only testing, there are several interesting patterns. First, among these hospitals, smaller hospitals tended to have higher overall rates of troponin-only testing per 100 patients than larger hospitals. Additionally, the hospitals with the highest rates were located in the Midwest region. These hospitals may be learning from and following the high-performing institutions observed in our data that are also located in the Midwest. Additionally, among the hospitals that significantly increased their rate of troponin-only testing, we see that the Choosing Wisely® recommendation appeared to facilitate accelerated adoption of troponin-only testing. In these institutions, it is likely that the impact of Choosing Wisely® was significant because there was attention to high-value care and already an existing movement underway to institute such high-value practices. For example, natural champions, leadership, infrastructure, and a supportive culture may all be prerequisites for Choosing Wisely® recommendations to become institutionally adopted.
Lastly, in the hospitals that have continued to order myoglobin and CK-MB, future work is needed to understand and overcome barriers to adopting high-value care practices.
There are several limitations to this study. First, because this was an observational study, we cannot prove a causal relationship between the Choosing Wisely® recommendation and the increased rates of troponin-only testing. Additionally, the Vizient CDB/RM contains reporting data for a limited number of academic medical centers only, and therefore, these results may not represent practices at nonacademic or even other academic medical centers. Our study only included patients with a principal discharge diagnosis of AMI because the Choosing Wisely® recommendation to order troponin-only is specific for diagnosing patients with AMI. However, it is possible that the Choosing Wisely® recommendation also has affected provider ordering in patients with diagnoses such as chest pain or angina, and these affects would not be captured in our study. Lastly, because instituting high-value care practices take time, our follow-up time may not have been long enough to capture improvement in troponin-only testing at institutions responding to and attempting to adhere to the Choosing Wisely® recommendation to order troponin-only testing for patients with AMI.
No other individuals besides the authors contributed to this work. This project was not funded or supported by any external grant or agency. Dr. Prochaska’s institute received funding from the Agency for Research Healthcare and Quality for a K12 Career Development Grant (AHRQ K12 HS023007) outside the submitted work. Dr. Hohmann and Dr Modes have nothing to disclose. Dr. Arora receives financial compensation as a member of the Board of Directors for the American Board of Internal Medicine and has received grant funding from the ABIM Foundation. She also receives royalties from McGraw Hill.