After implementation of the Choosing Wisely campaign recommendation to order only troponin (cTn) testing for the work-up of acute myocardial infarction (AMI), nearly 50% of 91 academic medical centers (AMC) still were ordering tests for creatine kinase-MB (CK-MB) or myoglobin in addition to cTn (J Hosp Med 2017; doi 10.12788/jhm.2846). These findings “should be used as a burning platform to those who wish to ‘test wisely’ in cardiac biomarker use,” according to an accompanying editorial (J Hosp Med 2017; doi 10.12788/jhm.2851).
The authors accessed ordering information on all inpatients with a principal diagnosis of AMI from Vizient’s (formerly the University HealthSystem Consortium) database. They included data from all AMCs that reported for all 36 months of the study period, which covered approximately 1 year before and 18 months after the Choosing Wisely campaign recommended using only cTn I or T but not myoglobin or CK-MB to diagnose AMI (4th quarter 2013 to 3rd quarter 2016). In all, 106,954 discharges were included.
Across all AMCs the mean rate of cTn-only testing was 29.2% at the start of the study, rising to 53.5% at the end. The authors analyzed AMI-related ordering practices based on several characteristics of the AMCs, such as hospital size, geographic region, and volume of AMI patients. They also found that 21% of AMCs had high rates of cTn testing throughout the study period, while 37% continued to order cTn, myoglobin, and CK-MB and were in the bottom tertile of all.
While a majority of hospitals with consistent cTn-only ordering saw ≥1,500 AMI patients, those with smaller patient volumes had higher rates of cTn-only testing per 100 patients. Hospitals in the Midwest and mid-Atlantic also had higher rates. Release of the Choosing Wisely recommendation was associated with a significant increase in cTn-only testing among AMCs that were in the bottom tertile at the study’s onset.