Decreasing the Overuse of Troponin Testing- An Interventional Study in a Regional Hospital
1Department of Internal Medicine B, Laniado Hospital, Netanya, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
Insights
Recommendations to limit troponin testing reduced its use in hospitalized patients. However, the intervention was only partially effective, highlighting the need for improved adherence to clinical guidelines for troponin assays.
Area of Science:
- Cardiology
- Internal Medicine
- Clinical Practice Guidelines
Background:
- Troponin testing is a critical diagnostic tool for acute myocardial infarction.
- Inappropriate troponin testing can lead to increased healthcare costs and potential patient harm.
- Optimizing troponin testing protocols is essential for efficient and effective patient care.
Purpose of the Study:
- To evaluate the impact of recommendations aimed at restricting troponin testing to patients presenting with chest pain or ischemic electrocardiographic changes.
- To assess the effectiveness of an educational intervention in modifying troponin testing practices within a hospital setting.
Main Methods:
- A quasi-experimental study design was employed, comparing troponin testing rates before and after the intervention.
- Data were collected from adult patients across internal medicine, cardiology, and intensive care units.
- Statistical analysis was performed to identify factors associated with troponin test ordering and to evaluate the intervention's effectiveness.
Main Results:
- Troponin testing decreased from 51.5% to 34.6% after the intervention.
- Ideal adherence to guidelines (testing only for chest pain or ischemia) would result in a testing rate of 9.4%.
- Factors associated with increased troponin testing included older age, male sex, and specific comorbidities; auditing improved intervention effectiveness.
Conclusions:
- An educational program with clear recommendations can decrease troponin testing in hospitalized patients.
- The intervention demonstrated partial effectiveness, with notable discordance in testing for conditions like congestive heart failure.
- Further strategies are needed to enhance adherence to troponin testing guidelines and improve diagnostic stewardship.
Introduction:
The purpose of this study was to determine the effect of recommendations to limit troponin testing to patients with either chest pain or ischemic electrocardiographic changes.
Methods:
We included all adult patients hospitalized in a regional hospital in internal medicine, cardiology, and intensive care departments in 2014-2016 and in 2019 after recommending limiting troponin testing to patients with either chest pain or ischemic electrocardiographic changes.
Results:
After the intervention, testing decreased from 51.5% (11,634/22,581) to 34.6% (3417/9882). However, if only those with ischemia or chest pain were tested, the frequency would be 9.4% (924/9882) with a 95% confidence interval of 8.8%-9.9%. Variables increasing the odds of ordering a troponin test were older age, male sex, a discharge diagnosis of tachyarrhythmia, congestive heart failure, and dizziness or syncope as well as lower albumin and higher glucose, uric acid, and blood urea nitrogen test results. There were lower odds in those with nonspecific symptoms and infections of the skin, soft tissues, and the urinary tract. Auditing increased the effectiveness of the intervention in 1 internal medicine department (odds ratio 0.70, 95% confidence limit 0.60-0.82) after adjustment for other significant independent variables. The area under the curve was 0.713.
Conclusion:
We found that an educational program with clear recommendations decreased the proportion of patients with troponin testing in hospitalized internal medicine departments, but the intervention was only partially effective and did not include patients with congestive heart failure and other conditions in which expert recommendations for testing are discordant.
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