Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation
Ishani Ganguli1, Jinghan Cui2, Nitya Thakore3
1Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Insights
Implementing high-sensitivity cardiac troponin (hs-cTn) assays increased upfront testing for chest pain patients but led to fewer downstream cardiac interventions and hospitalizations. This shift impacts diagnostic cascades and resource utilization.
Area of Science:
- Cardiology
- Clinical Diagnostics
- Health Services Research
Background:
- Troponin testing is crucial for diagnosing acute myocardial infarction in patients presenting with chest pain.
- Downstream diagnostic services (cascades) following troponin testing often have uncertain clinical value.
- The implementation of high-sensitivity cardiac troponin (hs-cTn) assays may alter these cascade patterns.
Purpose of the Study:
- To evaluate the association between the implementation of high-sensitivity cardiac troponin (hs-cTn) assays and the occurrence of cascade events in patients with chest pain.
- To compare changes in diagnostic and treatment pathways after hs-cTn assay adoption.
Main Methods:
- A difference-in-differences analysis was conducted using electronic health record and billing data from 5 emergency departments.
- Patient visits for chest pain (n=7,564) were compared to visits for other symptoms (n=100,415) before and after hs-cTn assay implementation.
- Outcomes included the presence of cascade events, length of stay, and spending on cardiac services.
Main Results:
- Hs-cTn assay implementation was associated with a 2.8% net increase in cascade events for chest pain patients.
- Patients experienced more troponin tests and electrocardiograms but fewer CT scans, stress tests, and percutaneous coronary interventions (PCI).
- There was a net decrease in cardiology evaluations and hospital admissions, along with a shorter length of stay, but no change in spending.
Conclusions:
- Hs-cTn assay implementation led to more initial tests but fewer downstream interventions like stress tests and PCI for chest pain patients.
- The study observed a reduction in cardiology evaluations and hospital admissions relative to other symptom presentations.
- The findings suggest a shift in the diagnostic cascade following hs-cTn assay adoption, with implications for patient management and healthcare resource allocation.
Background:
Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value.
Objectives:
This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events.
Methods:
Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services.
Results:
Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending.
Conclusions:
Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.
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