Research Design: We carried out a retrospective cohort evaluation consisting of sufferers with suspected ACS present process both standard troponin I (n = 14,631) or hsTnT (n = 7237) testing between January 2016 and February 2019.
Strategies: Log-binomial regression with interrupted time sequence modeled analysis patterns, and logistic regression with segmented time traits modeled stress testing charges. Noticed traits had been in contrast with anticipated traits utilizing common marginal impact (AME).
Outcomes: Charges of acute myocardial infarction–associated diagnoses had been comparable within the post-hsTnT interval (AME, –0.6%; P = .065). Publish hsTnT introduction, sufferers had been extra prone to obtain a analysis of coronary heart failure (2.1%; P < .001) or atrial fibrillation/flutter (0.9%; P < .001) and fewer prone to obtain a analysis of hypertensive coronary heart illness (–10.2%; P < .01) or hypertensive coronary heart illness with persistent kidney illness (–3.7%; P < .001). Probability of receiving stress testing elevated after hsTnT implementation (2.3%; P < .001).
Conclusions: Variations in discharge analysis patterns and will increase in stress check utilization had been noticed following hsTnT implementation. Hospitals can count on comparable adjustments, which can have long-term implications on well being care utilization, price, and hospital reimbursement.
Am J Manag Care. 2021;27(9):In Press
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Takeaway Factors
This research demonstrated that switching from a traditional troponin assay to a high-sensitivity troponin assay resulted in adjustments to analysis patterns—particularly, elevated charges of coronary heart failure and atrial fibrillation and decreased charges of hypertensive coronary heart illness with and with out persistent kidney illness.
- Switching to a high-sensitivity troponin assay was additionally related to elevated utilization of electrocardiogram stress testing and echocardiographic stress testing.
- Modifications noticed on this research might have an effect on establishments and well being care techniques by affecting useful resource utilization, well being care price, and reimbursement fashions.
- Moreover, applications and insurance policies which might be tied to particular diagnoses (eg, Hospital Readmissions Discount Program) could also be influenced by such adjustments seen with switching to a high-sensitivity troponin assay; subsequently, additional research are warranted to guage the long-term affect of such adjustments.
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Excessive-sensitivity troponin testing is more and more getting used internationally as a approach to higher rule out acute coronary syndrome (ACS). Its utilization has resulted in as much as a 33% discount in emergency division (ED) size of keep1-5 and has helped facilitate decision-making within the ED, with decreases in inpatient admissions for chest ache and elevated disposition to residence.6-8 Nevertheless, in contrast with sufferers who obtain standard troponin I testing, the next proportion of sufferers who obtain high-sensitivity troponin testing are categorized as optimistic for ACS, with greater than 25% of sufferers presenting with chest ache discovered to have an elevated troponin degree.9 Consequently, worldwide research evaluating the affect of high-sensitivity troponin testing have demonstrated elevated analysis of sort 2 non–ST-segment elevation myocardial infarctions (NSTEMIs) and elevated diagnostic testing to evaluate for ACS.10-14
In January 2017, high-sensitivity troponin T (hsTnT) testing was accepted to be used in the US.15 Though sturdy literature describes the affect of high-sensitivity troponin testing inside the worldwide well being care group, main research highlighting its results on solely the US well being care system are missing. Moreover, given the implications {that a} extra delicate check might need on affected person care, well being care utilization, and price, it is very important perceive its affect on the US well being care system and on well being care supply, thus informing future insurance policies, care pathways, and fee fashions. As such, we sought to grasp the affect of hsTnT testing on discharge analysis patterns and diagnostic stress testing utilization at a significant US medical middle.
METHODS
We carried out a retrospective cohort evaluation at Michigan Drugs, a big, tutorial, quaternary care middle in Ann Arbor, Michigan, with 1000 licensed beds and greater than 100,000 ED visits yearly. Our cohort included grownup sufferers (≥ 18 years) presenting with a medical suspicion of ACS (ie, presenting to the ED with a chief grievance of both “chest ache” or “shortness of breath” per preliminary triage documentation) who had troponin testing both previous to or after implementation of hsTnT testing (Determine 1). Sufferers who acquired standard troponin I (January 2016-December 2017) or hsTnT (March 2018-February 2019) testing had been included for evaluation. Information had been excluded throughout our washout interval (January 2018-February 2018) to permit suppliers time to change into acquainted with the brand new troponin assay.
Diagnoses had been recognized utilizing the first Worldwide Classification of Illnesses, Tenth Revision (ICD-10) coded discipline within the hospital’s digital well being document system. Stress testing (together with electrocardiogram stress testing and echocardiographic stress testing) was recognized by the ordered process identify utilizing the digital well being document, and it included any testing carried out within the ED or inpatient setting.
To establish adjustments following implementation of hsTnT, we used log-binomial regression fashions with an interrupted time sequence (ITS) design to mannequin the proportion of sufferers with every closing discharge analysis within the pre- and post-hsTnT durations. Interplay phrases had been used to stratify the intercept, level-change, and pre- and post-hsTnT traits by chief grievance so as to assess for variations based mostly on affected person presentation. The saturated mannequin underneath this ITS design permits for distinct intercepts and time traits for every time interval and chief grievance as impartial variables. We seek advice from this saturated mannequin as a various traits mannequin, however we additionally thought of much less advanced submodels utilizing Akaike’s data criterion (AIC) for mannequin choice.16 Particularly, we thought of submodels with solely a single fixed pattern or no traits in any respect. The fixed pattern mannequin permits for less than a single time pattern (per chief grievance) that doesn’t range between pre- and postintervention durations, whereas the no-trend mannequin omits traits altogether and reduces to a typical adjusted pre-post comparability.
Noticed postimplementation percentages had been in contrast with anticipated percentages extrapolated from prior traits (when current) utilizing common marginal results (AMEs).17 The AME represents the patient-level distinction between the chance of a given analysis predicted by the ITS mannequin much less the chance anticipated underneath prior traits, averaged over all sufferers within the post-hsTnT interval. The worth is transformed to proportion scale for straightforward interpretation. For diagnoses for which fashions with traits had been chosen, we additional summarized these fashions by evaluating noticed postimplementation percentages with the ultimate pre-hsTnT degree, referring to this amount as an “common marginal impact with fixed counterfactual,” or AME-c. Fashions additionally managed for affected person gender, day of the week (grouped empirically as Saturday/Sunday, Monday/Friday, and Tuesday/Wednesday/Thursday) on which an ED go to occurred, and seasonality utilizing a round smoothing spline foundation growth for day in yr. We omitted seasonality, day of the week, and/or interactions between chief grievance and the level-change when justified by AIC. We targeted our 12-month postintervention evaluation on adjustments in acute myocardial infarction (AMI)–associated analysis based mostly on an interim evaluation to cut back a number of statistical comparability testing to 16 analysis teams.
Stress check utilization was in contrast utilizing logistic regression with segmented time traits to match noticed charges with anticipated charges within the post-hsTnT durations, summarized utilizing AME. The stress check mannequin managed for chief grievance, gender, and age, and it included interactions between chief grievance and all phrases besides gender.
A nominal P worth of < .05 was thought of statistically important when describing outcomes. To regulate the family-wise error charge at 0.05 throughout all 48 main comparisons utilizing the Bonferroni methodology, the reader can contemplate P values of 0.05 / 48 = .001 important. There are 48 (= 16 × 3) main comparisons as a result of we examined adjustments in 16 analysis teams and made 3 comparisons inside every group—general and individually for every of two chief complaints. Statistical evaluation was executed in R model 3.6.1 (R Basis for Statistical Computing) utilizing the mgcv bundle18 for regression modeling. This evaluation was carried out as a part of a top quality enchancment venture designated as “not regulated” by the College of Michigan Medical Faculty Institutional Evaluation Board (HUM00145002).
RESULTS
A complete of 14,631 and 7237 sufferers had been included within the pre- and postimplementation durations, respectively. Of those, 9023 (61.7%) sufferers within the pre-hsTnT interval and 4455 (61.6%) sufferers within the post-hsTnT interval offered with a chief grievance of chest ache. An extra 5608 (38.3%) sufferers within the pre-hsTnT interval and 2782 (38.4%) sufferers within the post-hsTnT interval offered with a chief grievance of shortness of breath. Every cohort had a median age of 59 years and a median physique mass index of 29 kg/m2. Different affected person traits had been comparable between teams, though there have been small will increase in frequency of hypertension (42.7% vs 40.1%; P < .001) and diabetes (20.9% vs 19.4%; P = .013) and a small lower in smoking historical past (52.4% vs 54.8%; P < .001) when evaluating the post-hsTnT cohort with the pre-hsTnT cohort (Desk 1).
Following implementation of hsTnT testing, sufferers who offered with concern for ACS and acquired troponin testing had comparable chance of AMI-related diagnoses in contrast with extrapolated traits from the preimplementation interval (AME, –0.6%; 95% CI, –1.3% to 0.04%; P = .065) (Determine 2). Charges of AMI-related diagnoses pre- and submit hsTnT had been comparable if the presenting chief grievance was shortness of breath (–0.1%; 95% CI, –0.8% to 0.7%; P = .88). Nevertheless, AMI-related diagnoses decreased submit hsTnT if the presenting chief grievance was chest ache (–1.0%; 95% CI, –1.9% to 0.0%; P = .049).
Sufferers who acquired hsTnT testing had been extra prone to obtain a closing analysis of coronary heart failure (2.1%; 95% CI, 1.7%-2.6%; P < .001) when put next with anticipated traits from previous months. Probability of coronary heart failure analysis was elevated by 0.7% (95% CI, 0.3%-1.0%; P < .001) if chief grievance was chest ache and elevated by 4.5% (95% CI, 3.4%-5.5%; P < .001) if chief grievance was shortness of breath. After hsTnT implementation, sufferers had been additionally extra prone to obtain a closing analysis of atrial fibrillation/flutter (0.9%; 95% CI, 0.3%-1.6%; P < .001). When stratified by presenting grievance, sufferers had been extra prone to obtain a analysis of atrial fibrillation/flutter if the preliminary chief grievance was shortness of breath (1.6%; 95% CI, 0.9%-2.4%; P < .001). Nevertheless, the rise noticed with chest ache (0.4%; 95% CI, –0.4% to 1.2%; P = .36) was not statistically important.
Publish hsTnT, sufferers had a lower-than-expected chance of receiving a analysis of hypertensive coronary heart illness (–10.2%; 95% CI, –16.4% to –3.9%; P = .001). Sufferers presenting with shortness of breath had a 21.4% decrease chance (95% CI, –35.9% to –6.9%; P = .004) of this analysis, however the decreased danger was not statistically important for sufferers who offered with chest ache (–3.2%; 95% CI, –7.1% to 0.7%; P = .10). When noticed traits had been in contrast with the ultimate analysis charge previous to hsTnT implementation, sufferers nonetheless had an general decrease chance of receiving a analysis of hypertensive coronary heart illness (–1.6%; 95% CI, –2.8% to –0.5%; P = .007), which additionally held true for sufferers presenting with a chief grievance of shortness of breath (–3.3%; 95% CI, –5.9% to –0.6%; P = .017). Nevertheless, the lower was nonetheless not statistically important for sufferers presenting with chest ache.
Sufferers had been additionally much less prone to obtain a analysis of hypertensive coronary heart illness with persistent kidney illness (CKD; –3.7%; 95% CI, –5.9% to –1.5%; P < .001) after the implementation of hsTnT. The distinction on this closing analysis for sufferers whose chief grievance was shortness of breath was –9.7% (95% CI, –15.1% to –4.3%; P < .001). Nevertheless, a big distinction was not seen in sufferers who offered with chest ache (–0.02%; 95% CI, –1.1% to 1.1%; P = .975). When evaluating noticed analysis charges with the ultimate pre-hsTnT charge, the decreased chance in analysis was not statistically important (P = .096), besides when sufferers offered with chief grievance of shortness of breath (–2.8%; 95% CI, –5.2% to –0.5%; P = .021).
Lastly, 2 different ICD-10 diagnoses had been famous to have statistically important adjustments after the implementation of hsTnT. “Abnormalities in heartbeat” was famous to have elevated (0.7%; 95% CI, 0.3%-1.1%; P = .001), with postimplementation change largely pushed by sufferers who offered with chest ache (0.94%; 95% CI, 0.4%-1.5%; P < .001) versus shortness of breath (0.2%; 95% CI, –0.3% to 0.7%; P = .47). “Different” diagnoses, which represents the combination of diagnoses with fewer than 200 occurrences throughout our research interval, exhibited decreased frequency submit hsTnT (–1.9%; 95% CI, –3.1% to –0.7%; P = .002), which was largely because of decreased analysis in sufferers presenting with shortness of breath (–3.9%; 95% CI, –5.9% to –1.8%; P < .001). No different diagnoses inside our evaluation had statistically important adjustments when put next with anticipated postimplementation traits (Desk 2).
Publish hsTnT, sufferers who offered with concern for ACS had been extra prone to have a diagnostic stress check carried out (2.3%; 95% CI, 1.5%-3.1%; P < .001). When stratified by chief grievance, stress testing elevated by 3.4% (95% CI, 2.2%-4.7%) if sufferers offered with chest ache, versus no important change (0.6%; 95% CI, –0.1% to 1.3%) if sufferers offered with shortness of breath (Determine 3).
DISCUSSION
We describe the affect of switching to a high-sensitivity troponin assay on discharge analysis patterns and on frequency of diagnostic stress testing. In sufferers presenting with concern for ACS, charges of AMI-related diagnoses didn’t expertise a statistically important change after implementation of hsTnT. Nevertheless, there was an elevated danger of receiving a analysis of coronary heart failure or atrial fibrillation/flutter and a decreased danger of receiving a analysis of hypertensive coronary heart illness with or with out CKD. Sufferers had been additionally discovered to have an elevated chance of receiving stress testing throughout their index encounter, which held true in the event that they offered with chief grievance of chest ache however not in the event that they offered with chief grievance of shortness of breath.
Though no statistically important change in AMI-related diagnoses occurred for our mixed cohort, a statistically important lower was noticed in sufferers presenting with chest ache (95% CI, –1.9 to 0.0; P = .049). Though the mixed cohort of AMI-related diagnoses didn’t attain statistical significance, it is very important observe that charges of AMI-related diagnoses didn’t enhance as would have been anticipated with a extra delicate check. That is opposite to worldwide literature noting a rise in AMI-related diagnoses, resembling sort 2 NSTEMI, after implementing high-sensitivity troponin testing.14,19 You will need to observe that these research utilized a special high-sensitivity troponin assay14 and had a decrease 99th percentile higher reference restrict,19 which can have contributed to their findings. Moreover, the Fourth Common Definition of Myocardial Infarction was launched in August 2018 to accommodate the usage of higher-sensitivity troponin testing.20 It launched the definition of myocardial harm as “detection of an elevated cardiac troponin worth above the 99th percentile higher reference restrict.” This new emphasis on delineating myocardial infarction from myocardial harm might have mitigated any potential uptick in sort 2 NSTEMI diagnoses and any adjustments in general charges of AMI-related diagnoses.
Moreover, implementation of hsTnT was related to elevated chance of receiving a analysis of coronary heart failure or atrial fibrillation/flutter and a decreased chance of receiving a analysis of hypertensive coronary heart illness with or with out CKD. Modifications in frequency of those diagnoses had been probably additionally associated to elevated sensitivity of the check and up to date emphasis on distinguishing myocardial ischemia/infarction from myocardial harm. As no ICD-10 code particularly identifies myocardial harm, discharge diagnoses usually tend to replicate the underlying causes of the myocardial harm, which embody diagnoses resembling coronary heart failure, hypertension, or arrhythmias, amongst others.21-24 Nevertheless, we notably noticed a lower in analysis of hypertensive coronary heart illness with or with out CKD, with adjustments largely seen in sufferers presenting with a chief grievance of shortness of breath. It’s unclear what led to the lower in these diagnoses, because it was anticipated that they might enhance because of the causes beforehand listed. Though it could stand to purpose that the decreased analysis of hypertensive coronary heart illness with or with out CKD might have been counterbalanced by will increase in pulmonary-related diagnoses, we didn’t observe any statistically important will increase inside our evaluation. Regardless of these noticed adjustments, we anticipate that medical administration of sufferers who obtain hsTnT testing for analysis of ACS won’t drastically differ in contrast with the pre-hsTnT cohort, as administration ought to largely stay targeted on addressing underlying comorbidities.
Understanding the systematic affect of hsTnT testing in the US is vitally vital, particularly as extra well being techniques start utilizing it to facilitate ACS rule-out. Postimplementation adjustments can have important affect on not solely affected person care but additionally hospital reimbursements, significantly as they relate to the Hospital Readmissions Discount Program.25 CMS has included 4 medical circumstances (AMI, persistent obstructive pulmonary illness [COPD], coronary heart failure, and pneumonia) for which 30-day unplanned readmissions are tracked and factored into the reimbursements that acute care hospitals obtain. Hospitals that have elevated or decreased analysis of those circumstances may additionally see adjustments within the related 30-day readmission charges because of adjustments within the variety of at-risk sufferers. Variations in readmission charges would subsequently have an effect on future reimbursements as a result of they’re based mostly upon hospital readmission efficiency from the previous 3 years. Moreover, adjustments in readmission charges may additionally have an effect on reimbursements regarding bundled funds by growing the expenditure related to an admission episode. In our evaluation, solely coronary heart failure diagnoses elevated after hsTnT implementation, whereas AMI, COPD, and pneumonia diagnoses didn’t display statistically important adjustments. Hospitals experiencing elevated diagnoses of those circumstances chosen by CMS ought to subsequently commit extra focus to discharge coordination and follow-up to assist mitigate potential danger of elevated readmissions. Moreover, as analysis patterns change, CMS might have to reevaluate insurance policies and reimbursement fashions that extra precisely replicate and appropriately have an effect on the altering affected person inhabitants.
Along with the adjustments in analysis patterns outlined earlier, our evaluation additionally revealed important adjustments to diagnostic stress testing charges submit hsTnT. We discovered that sufferers who offered with concern for ACS and acquired hsTnT testing had elevated chance of getting inpatient diagnostic stress testing carried out. That is in step with findings of earlier worldwide research, which demonstrated a rise in downstream analysis methods resembling echocardiography, stress testing, and invasive angiography.10-13 Nevertheless, this enhance in stress testing might signify normal supplier uncertainty with decoding hsTnT and will signify a transient rise, with subsequent stabilization of stress check ordering, as suppliers change into extra acquainted with decoding hsTnT outcomes.
Limitations
Our research has a number of potential limitations. Though this research was carried out at a quaternary care middle with a high-volume ED, it represents the analysis and follow patterns at solely a single establishment. Moreover, our research timeframe was restricted to the 12 months after implementation of hsTnT, which gives insights into solely the quick postimplementation interval with out perspective into the long-term implications. Moreover, as a result of our evaluation relied on present registries and algorithms to gather baseline variables, we’re unable to increase our adjusted analyses past what we’ve reported. You will need to observe that solely ED and inpatient stress check utilization was in a position to be reliably captured. Subsequently, we’re unable to touch upon the affect of hsTnT implementation on outpatient follow-up check utilization. Lastly, though ITS might help consider the connection between particular occasions and adjustments in traits, it shouldn’t be interpreted as rigorously establishing causal relationships. Regardless of these limitations, we imagine that our research gives helpful insights into how hsTnT testing impacts analysis patterns and stress check utilization inside a big US hospital, significantly in an period through which elevated focus is positioned on distinguishing myocardial harm from myocardial infarction. Improved understanding of those adjustments will assist hospitals and well being techniques adapt to shifts in useful resource utilization and might have important affect on how future insurance policies and fee constructions are designed in relation to the diagnoses assessed.
CONCLUSIONS
Sufferers who offered with concern for ACS and acquired hsTnT analysis had comparable chance of AMI-related diagnoses in contrast with prior traits. Publish-hsTnT sufferers had been extra prone to obtain a discharge analysis of coronary heart failure or atrial fibrillation and fewer prone to obtain a analysis of hypertensive coronary heart illness with or with out CKD. Implementation of hsTnT testing was related to elevated downstream utilization of stress testing in each the ED and inpatient settings. As US hospitals contemplate switching to extremely delicate troponin testing, postimplementation adjustments might have an effect on long-term well being care utilization, price, and reimbursement.
Acknowledgments
The authors thank Ms Hannah Lahti for her help with manuscript preparation.
Writer Affiliations: Division of Cardiovascular Drugs (RYY, HH, JF, GDB) and Division of Hospital Drugs (AG, SAF), Division of Inside Drugs (KG, AG, SAF), Division of Pathology (DG), and Division of Emergency Drugs (DS), Michigan Drugs, Ann Arbor, MI; Consulting for Statistics, Computing, and Analytics Analysis, College of Michigan (JH), Ann Arbor, MI; Michigan Program on Worth Enhancement (JH, ERD, DS, SAF, GDB), Institute for Healthcare Coverage and Innovation (JF, SAF, GDB), College of Michigan, Ann Arbor, MI; Course of Redesign Division, Sparrow Well being System (MJ), Lansing, MI; Drugs Service, Veterans Affairs Ann Arbor Healthcare System (AG), Ann Arbor, MI.
Supply of Funding: None.
Writer Disclosures: Dr Froehlich has consulted for or suggested Pfizer, Merck, Janssen, and Boehringer Ingelheim relating to anticoagulant use. The remaining authors report no relationship or monetary curiosity with any entity that will pose a battle of curiosity with the subject material of this text.
Authorship Info: Idea and design (RYY, JH, KG, MJ, ERD, AG, DG, DS, SAF, GDB); acquisition of knowledge (RYY, KG, MJ, DS); evaluation and interpretation of knowledge (RYY, HH, JH, AG, SAF, GDB); drafting of the manuscript (RYY, HH, JH, DG); crucial revision of the manuscript for vital mental content material (RYY, HH, JH, KG, ERD, AG, DG, JF, DS, SAF, GDB); statistical evaluation (RYY, JH); provision of sufferers or research supplies (RYY, JF); administrative, technical, or logistic help (RYY, KG, MJ, ERD, JF); and supervision (SAF, GDB).
Deal with Correspondence to: Raymond Y. Yeow, MD, Michigan Drugs, 1500 E Medical Heart Dr, Ann Arbor, MI 48109. E-mail: yeowr@med.umich.edu.
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