Evaluation of a protocol to control utilization of B-type natriuretic peptide testing

The Veterans Affairs (VA) Boston Healthcare System, Boston, MA, instituted a protocol limiting the number of B-type natriuretic peptide (BNP) assays to 1 per hospitalization or outpatient visit and requiring approval of the cardiology service for more than 1 because of a 3-fold monthly increase in BNP testing. Effectiveness of this protocol was assessed by studying BNP utilization for 6-month periods before and after institution of the protocol. Before: 1,886 assays in 752 patients; mean BNP assays per patient, 2.5; direct reagent cost, $33,948; 1 BNP assay in 57.3% (431) of patients; 321 patients with multiple and 204 patients with serial BNP requests. After: 782 assays (-58.5%) in 593 patients (-21.1%); mean BNP assays per patient, 1.3 (-48.0%); direct reagent cost, $14,076 (-58.5%); 1 BNP assay in 81.1% (481) of patients; 112 patients with multiple and 24 patients with serial BNP requests (-88.2%). The emergency department was the source of BNP assays in 15.4% of requests before compared with 58.1% after introduction of the protocol. The protocol with slight modifications has been adopted by other VA medical centers in New England and may serve as a model for other medical facilities seeking to control BNP utilization.