CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Dr. Rakesh Engineer at the Cleveland Clinic. Early adoption of the next-generation troponin had a downside: He and colleagues could not turn to data from other U.S. institutions to guide them. But creating something fresh allowed them to be responsive to the needs of their colleagues—a bottom-up approach.
The first was what to do with an intermediate value (12 to 52 ng/L). Generally, says Dr. Engineer, patients who fall into this category will be observed. But there’s a wrinkle: What if a nurse orders a troponin at triage (without the benefit of taking a more detailed history), or a physician’s assistant orders the test on a patient who normally would not need to be ruled out? If those results fall into the intermediate range, went the worry, would those patients be kept unnecessarily, and would it lead to increased testing?
Cleveland Clinic decided to implement physician-only ordering at Hillcrest Hospital while allowing nurses and PAs to order it at the main campus. With this approach, the overall discharge rate was much higher at the main campus. The Hillcrest physicians mainly ordered the test on patients they thought could be sent home; at the main campus, the test was ordered on the majority of patients. “Sometimes we were surprised—we had patients we would have thought needed observation who, lo and behold, could actually go home” based on a non-high-risk history, nonischemic ECG, and the serial high-sensitivity troponin, Dr. Engineer says.
He also had to clear up early confusion regarding decision support. His colleagues found the criteria from the Mokhtari trial somewhat befuddling, so Dr. Engineer developed a decision tree. “Almost like a flow chart,” he says. “That helped a lot.” Then there was the matter of revising a “clumsy” computer clinical decision support tool, as well as removing an awkward decision note within the algorithm that called for using 14 as a rule-in for patients with either a high-risk history or an ischemic ECG, since those patients would be admitted anyway.
Non-MI patients—those with renal disease, cardiomyopathy, CHF—are treated according to the same algorithm. “If your numbers are really, really low, and you meet the low-risk criteria, you’re going home,” says Dr. Engineer. “But that doesn’t happen very often. Most will be observed and undergo the extended rule-out, like they had previously.”
Dr. Engineer saw two main objectives for adopting the assay. No. 1, he says, was to give emergency physicians a tool to discharge patients when they weren’t 100 percent certain. “Say you’re 95 percent sure—but five percent is too much to miss,” Dr. Engineer says. The new approach gets those patients home. “That’s how most people see this test.”
A second objective—though this one is less talked about—addresses the variability in clinicians’ practices. Dr. Engineer concedes that he might discharge a patient whom another ED colleague would just as easily admit. “If we can reduce that variability, both between providers as well as between facilities, then you’re going to have more happy patients as well as lower costs in delivering that care. So that’s the long-term goal, but it’s going to take a little while to get there.”
Dr. Engineer’s focus, understandably, has been on the needs of his clinical colleagues, both within and outside the ED. But he goes out of his way to praise the role of the laboratory in making the troponin transition. “Our interactions have been fantastic,” he says. If he sounds a bit surprised, well, he is. “The lab has a lot to offer, but as clinicians, we just don’t run into each other very much, the way we do with cardiologists who come down to our department.”
In Philadelphia, Dr. Hollander has long been interested in a higher sensitivity troponin and plans to launch it at Jefferson University Hospitals in the next few months. “Unless somebody stamps up and down and screams too much,” he says.
Does he anticipate a stop-the-wedding moment? “We do,” he says. “But we expect to educate enough that they jump on board.”
Dr. Hollander
Dr. Hollander takes a deep breath and a step back to try to settle physicians’ concerns. “What everyone should get grounded in is the fact that it really is just better for patients. When you play the math, with these higher-sensitivity assays, you should be able to discharge about twice as many patients from the emergency department” versus the older assays, “and you should be able to do it considerably faster, with a lower miss rate and a high negative predictive value.”
There’s no doubt in his mind of the value to patients. “Being able to tell twice as many patients they don’t have a condition that could kill them—because that’s what they’re worried about—and in fact they have nothing wrong, and to send them back home to their families in a couple of hours, is a huge benefit.”
The resistance to higher-sensitivity assays, he says, stems from providers who don’t understand how to use them and haven’t for years. In the early days of troponin use, he notes, education rested on a swift maxim: If a patient’s troponin is elevated, they’re having a heart attack. “That never was true, and it’s not true now. But if you’re a doctor who still believes troponin equals MI, you’ve missed the boat for a long time.” He marvels at the mental fog that continues to envelop the test. “Every time I give the same lecture to the same group of people, it’s like they never heard it before. I can’t dumb it down any more.”
Historically, he notes, troponin was the answer to specificity, which has turned out to be one of medicine’s Lost Cause myths. And 20 years ago, he continues, 24-hour rule-outs were the norm. Eventually providers became comfortable with six to 12 hours. Given that context, the Twitter-like shift to one to three hours should not be highly discomfiting.
To counter ongoing myths, he and his colleagues plan to ratchet up their educational efforts before the rollout. He anticipates using two non-sex-specific cutpoints (rule in and rule out), with a two-hour second measurement when needed to look for a rising delta.
The new approach will likely boost from 10 percent to 30 percent the number of patients requiring additional care. “If you give them all to the cardiologists, they’re going to hate the ER docs,” Dr. Hollander says, since the majority won’t have coronary disease requiring intervention. “The ER docs are going to have to be smarter, or the cardiologists are going to be miserable”—unless they’re fee-for-service, he jokes.
To prepare his colleagues and to nip confusion in the bud, “We’re going to have more stuff written on the lab slips than we normally do, and we’re going to do town halls, which we never do when we roll out a new assay, and offer to go in-service people on their grand rounds and departmental meetings,” he says. “Even though doctors are reasonably smart people, they’re not really good at thinking about any one lab test that’s not their area of expertise.” The goal, at heart, is to educate those who call the cardiologists. The laboratory has been quite involved, he says. “I give them an enormous amount of credit.”
The added effort will pay off, Dr. Hollander predicts. “Higher sensitivity troponins are great for patients.”
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Karen Titus is CAP TODAY contributing editor and co-managing editor.