Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation

Clinical question: How is high-sensitivity cardiac troponin (hs-cTn) assay implementation associated with cascade events?

What is known: Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing,which may prompt downstream services (cascades) of uncertain value.

Methods: Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments. 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 service.

Results/Implications: 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 and electrocardiograms but received fewer computed tomography scans, stress tests  and percutaneous coronary intervention (PCI) and were less likely to receive cardiac medications, undergo cardiology evaluation or be hospitalized. Patients with chest pain had lower net mean length of stay  but no net change in spending.

Bottom-line: 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.