Philip W Chui1, Denise Esserman2, Lori A Bastian3, Jeptha P Curtis1,4, Parul U Gandhi1, Lindsey Rosman5, Nihar Desai1,4, Ronald G Hauser3,6. 1. Section of Cardiovascular Medicine, Department of Internal Medicine. 2. School of Public Health, Yale University School of Medicine, New Haven, CT. 3. Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven. 4. Center for Outcomes Research and Evaluation, Yale New-Haven Hospital, New Haven, CT. 5. Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC. 6. Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT.
Abstract
BACKGROUND: Current United States guidelines recommend troponin as the preferred biomarker in assessing for acute coronary syndrome, but recommendations are limited about which patients to test. Variations in troponin ordering may influence downstream health care utilization. METHODS: We performed a cross-sectional analysis of 3,308,131 emergency department (ED) visits in all 121 acute care facilities within the Veterans Health Administration from 2015 to 2017. We quantified the degree to which case mix and facility characteristics accounted for variations in facility rates in troponin ordering. We then assessed the association between facility quartiles of risk-adjusted troponin ordering and downstream resource utilization [inpatient admissions, noninvasive testing (stress tests, echocardiograms), and invasive procedures (coronary angiograms, percutaneous coronary interventions, and coronary artery bypass grafting surgeries)]. RESULTS: The proportion of ED visits with troponin orders ranged from 2.2% to 64.5%, with a median of 37.1%. Case mix accounted for 9.5% of the variation in troponin orders; case mix and differences in facility characteristics accounted for 34.6%. Facilities in the highest quartile of troponin ordering, as compared with those in the lowest quartile, had significantly higher rates of inpatient admissions, stress tests, echocardiograms, coronary angiograms, and percutaneous coronary intervention. CONCLUSIONS: Significant variation in troponin utilization exists across Veterans Health Administration facilities and that variation is not well explained by case mix alone. Facilities with higher rates of troponin ordering were associated with more downstream resource utilization.
BACKGROUND: Current United States guidelines recommend troponin as the preferred biomarker in assessing for acute coronary syndrome, but recommendations are limited about which patients to test. Variations in troponin ordering may influence downstream health care utilization. METHODS: We performed a cross-sectional analysis of 3,308,131 emergency department (ED) visits in all 121 acute care facilities within the Veterans Health Administration from 2015 to 2017. We quantified the degree to which case mix and facility characteristics accounted for variations in facility rates in troponin ordering. We then assessed the association between facility quartiles of risk-adjusted troponin ordering and downstream resource utilization [inpatient admissions, noninvasive testing (stress tests, echocardiograms), and invasive procedures (coronary angiograms, percutaneous coronary interventions, and coronary artery bypass grafting surgeries)]. RESULTS: The proportion of ED visits with troponin orders ranged from 2.2% to 64.5%, with a median of 37.1%. Case mix accounted for 9.5% of the variation in troponin orders; case mix and differences in facility characteristics accounted for 34.6%. Facilities in the highest quartile of troponin ordering, as compared with those in the lowest quartile, had significantly higher rates of inpatient admissions, stress tests, echocardiograms, coronary angiograms, and percutaneous coronary intervention. CONCLUSIONS: Significant variation in troponin utilization exists across Veterans Health Administration facilities and that variation is not well explained by case mix alone. Facilities with higher rates of troponin ordering were associated with more downstream resource utilization.
Authors: Nishant R Shah; Sarah T Ahmed; David E Winchester; David J Ramsey; Julia M Akeroyd; Wen-Chih Wu; Stephen W Waldo; Richard S Schofield; Christie M Ballantyne; Laura A Petersen; Salim S Virani Journal: JACC Cardiovasc Imaging Date: 2019-04-17
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Authors: W Frank Peacock; Brigette M Baumann; Deborah Bruton; Thomas E Davis; Beverly Handy; Christopher W Jones; Judd E Hollander; Alexander T Limkakeng; Abhi Mehrotra; Martin Than; Andre Ziegler; Carina Dinkel Journal: JAMA Cardiol Date: 2018-02-01 Impact factor: 14.676