Practice pattern of use of high sensitivity troponin in the outpatient settings
Enrico G Ferro1, Ankeet S Bhatt1, Guohai Zhou2
1Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Insights
High-sensitivity troponin T (hs-TnT) testing in outpatient settings significantly decreased after implementation. While hs-TnT aids in triaging acute coronary syndrome, some providers inappropriately manage patients with elevated hs-TnT levels.
Area of Science:
- Cardiology
- Clinical Chemistry
- Health Services Research
Background:
- High-sensitivity troponin assays (hs-Tn) offer improved detection of cardiac troponin levels compared to older methods.
- Hs-Tn assays are crucial for evaluating acute coronary syndrome (ACS) in emergency departments.
- The utilization patterns of hs-Tn assays in outpatient settings remain under-described.
Purpose of the Study:
- To evaluate the utilization trends of outpatient troponin testing before and after the implementation of high-sensitivity troponin T (hs-TnT).
- To analyze how outpatient providers use hs-TnT for triaging patients with suspected ACS.
- To compare adverse events in patients discharged home based on hs-TnT levels.
Main Methods:
- A comparative analysis of outpatient troponin test volumes was conducted, comparing the pre-hsTn (January 2015-March 2018) and post-hsTn (April 2018-January 2020) periods.
- Triage patterns were assessed by comparing patients with hs-TnT levels at or above the 99th percentile versus those below.
- Adverse events in patients discharged home were compared between hs-TnT groups using log-rank tests.
Main Results:
- Outpatient troponin testing volume decreased significantly post-hs-TnT implementation (80 prior-generation tests/month vs. 12 hs-TnT tests/month).
- Orders for hs-TnT were primarily placed by cardiologists (54%) and primary care providers (32%), with dyspnea and chest pain as common symptoms.
- Symptomatic patients with hs-TnT ≥ 99th percentile were more likely to be sent to the ED (RR, 3.36). Patients discharged home with high hs-TnT had more adverse events (22.2% vs. 3.3%).
Conclusions:
- Outpatient troponin utilization substantially declined following hs-TnT implementation in this healthcare system.
- Hs-TnT is used by some outpatient providers for ACS triage to the ED.
- Concerns exist regarding the testing of asymptomatic patients and the discharge of patients with elevated hs-TnT levels.
Background:
High-sensitivity troponin assays (hs-Tn) detect lower serum concentrations than prior-generation assays and help guide acute coronary syndrome (ACS) evaluation in emergency departments. Outpatient hs-Tn utilization is not well described.
Hypothesis:
Outpatient providers use hs-TnT to triage patients with suspected ACS.
Methods:
We compared the volume of outpatient prior-generation troponin tests in the pre-hsTn implementation period (January 2015-March 2018) with outpatient hs-TnT volume in the post-implementation period (April 2018-January 2020). Triage patterns were compared between patients with hs-TnT≥99th vs <99th percentile, using two-sample t tests. In patients triaged home, adverse events were compared between patients with hs-TnT≥99th vs <99th percentile, using log-rank tests.
Results:
Across a large tertiary healthcare system, a mean of 80 prior-generation tests/month were ordered during the pre-hsTn implementation period compared with 12 hs-TnT tests/month in the post-implementation period. Prior-generation orders rose by 1.72 tests/month during pre-implementation, vs a decline of 2.74 hs-TnT tests/month during post-implementation (P < .001). Among 129 hs-TnT orders, most were placed by cardiologists (54%) and primary care providers (32%). Patient symptoms at the time of troponin ordering included dyspnea (34%) and chest pain (33%), although 25% were asymptomatic. Among symptomatic patients (n = 74), those with hs-TnT > 99th percentile were more likely to be sent to the ED (RR, 3.36; 95% CI, 1.22-9.25; P = .002). Among patients sent home (n = 66), those with hs-TnT > 99th percentile had more adverse events by 6 months (3.3% vs 22.2% RR, 6.67; 95% CI, 1.04-42.9; P = .026).
Conclusions:
In this healthcare system, outpatient troponin utilization significantly declined since hs-TnT implementation. Some providers use hs-TnT to triage patients with suspected ACS to the ED; others test asymptomatic patients and some send patients home despite high hs-TnT values.
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