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Facility Variation in Troponin Ordering Within the Veterans Health Administration
Philip W Chui1, Denise Esserman2, Lori A Bastian3
1Section of Cardiovascular Medicine, Department of Internal Medicine.
Insights
Troponin testing for acute coronary syndrome varies widely across Veterans Health Administration facilities. Higher troponin ordering rates correlate with increased downstream healthcare use, indicating potential for improved efficiency.
Area of Science:
- Cardiology
- Health Services Research
- Biomarker Utilization
Background:
- Current US guidelines endorse troponin for acute coronary syndrome (ACS) assessment.
- Guidelines lack specificity on patient selection for troponin testing.
- Variations in troponin ordering may impact healthcare resource utilization.
Purpose of the Study:
- To analyze variations in troponin ordering across Veterans Health Administration (VA) facilities.
- To determine the extent to which case mix and facility characteristics explain these variations.
- To assess the association between troponin ordering rates and downstream healthcare resource utilization.
Main Methods:
- Cross-sectional analysis of 3,308,131 emergency department (ED) visits from 2015-2017 in 121 VA acute care facilities.
- Quantified variation in troponin ordering rates.
- Assessed association between facility quartiles of risk-adjusted troponin ordering and downstream resource utilization (admissions, noninvasive/invasive procedures).
Main Results:
- Troponin order proportion varied from 2.2% to 64.5% (median 37.1%).
- Case mix explained 9.5% of variation; case mix and facility characteristics explained 34.6%.
- Facilities with highest troponin ordering showed significantly higher rates of inpatient admissions and cardiac procedures.
Conclusions:
- Significant, unexplained variation in troponin utilization exists across VA facilities.
- Higher troponin ordering rates are linked to increased downstream resource utilization.
- Opportunities may exist to optimize troponin testing protocols and resource allocation.
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.
