Cardiac injury markers and a failed algorithm: can accurate assessment of acute myocardial infarction be cost
1Department of Pathology, Madigan Army Medical Center, Fort Lewis, WA 98431, USA.
Insights
Cardiac troponin I (cTnI) is the most specific marker for diagnosing acute myocardial infarction (AMI). This study found that using only cTnI for AMI assessment is more accurate and cost-effective, saving lives and resources.
Area of Science:
- Clinical Chemistry
- Cardiology
- Health Economics
Background:
- Cardiac injury markers like cardiac troponin I (cTnI), total creatine kinase (CK Total), and CK-MB are used to diagnose acute myocardial infarction (AMI).
- Existing literature shows inconsistencies in assay-ordering criteria, leading to non-specific, ambiguous, and costly testing patterns for acute chest pain evaluation.
- High expenditure on cardiac marker assays, consuming a significant portion of the supply budget despite representing a small percentage of total tests, highlights the need for optimized strategies.
Purpose of the Study:
- To design a cost-effective strategy for ordering cardiac injury marker assays.
- To establish clear criteria for ordering cardiac injury marker assays.
- To compare Madigan Army Medical Center's (MAMC) testing patterns with published guidelines to identify areas for improvement.
Main Methods:
- Retrospective analysis of 34,412 cardiac marker assays from 4,861 patients during 1999-2000 at MAMC.
- Inclusion of data from the first six months of 2001, comprising 5,850 assays from 1,223 patients.
- Evaluation of MAMC's cardiac marker assay expenditure and ordering patterns.
Main Results:
- MAMC spent over $100,000 on cardiac injury marker assays in 1999, with similar spending in 2000 after implementing an ordering algorithm.
- Cardiac marker testing (CK Total, CK-MB, cTnI) constituted 3.5% of chemistry tests but consumed approximately 20% of the supply budget.
- Disproportionate costs were linked to numerous, varied, and high-volume ordering patterns.
Conclusions:
- Optimized use of cardiac marker assays can facilitate rapid and accurate diagnosis of AMI, potentially saving lives.
- Cardiac troponin I (cTnI) is identified as the sole marker necessary for accurate and cost-effective AMI assessment.
- Implementing standardized ordering criteria for cTnI can reduce costs and improve diagnostic efficiency.
Context:
Most studies assessing the use of cardiac injury markers, such as cardiac troponin I (cTnI), total creatine kinase (CK Total), and the cardiac isoenzyme of CK (CK-MB), agree that cTnI is the most specific test for diagnosing acute myocardial infarction (AMI). However, throughout the literature, there are ambiguities and contradictions on assay-ordering criteria. Inconsistent ways of viewing biochemical assessment of acute chest pain leads to cardiac injury marker assay-ordering patterns that can be nonspecific, ambiguous, and costly.
Objective:
This study set out to design a cost-effective strategy and to outline criteria for ordering cardiac injury marker assays. This is accomplished by comparing Madigan Army Medical Center (MAMC) testing patterns to guidelines described in recently published prospective hospital studies investigating the markers.
Design:
This was a retrospective study analyzing the patterns of 34,412 cardiac marker assays performed on 4,861 patients during 1999 and 2000 at MAMC. A total of 5,850 assays were run from 1,223 patients during the first 6 months of 2001.
Results:
The MAMC chemistry section spent more than $100,000 during 1999 for the measurement of cardiac injury markers. During 2000, an algorithm was implemented to place controls on ordering; however, the same dollar amount was spent. CK Total, CK-MB, and cTnI testing represent 3.5% of the tests performed in the chemistry section, but they consumed about 20% of the supply budget. This disproportionate expenditure is attributable to numerous, dissimilar, and voluminous ordering patterns.
Conclusions:
Proper use of cardiac marker assays can lead to rapid and accurate diagnosis of AMI and subsequently save lives. This study demonstrates that cTnI is the only marker needed for accurate and more cost-effective assessment of AMI.
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