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Effectively Reducing CK-MB Utilization Using Computer Order Entry in the Emergency Department

To the Editor: Money spent on health care in the United States is expected to consume 20.3% of gross domestic product by 2018 and reach $4.4 trillion by 2020. Physicians, whose medical decisions are highly dependent on laboratory results, delegate the majority of the health care costs when making testing decisions. Historically, elevated cardiac biomarkers have aided in the diagnosis of acute myocardial infarction (AMI) and are accepted by the American College of Cardiology and the European Society of Cardiology. Although the cardiac biomarkers creatine kinase-muscle and brain type isoenzyme (CK-MB) and troponin both increase following AMI, troponin is currently recommended as the biomarker for diagnosis because of enhanced sensitivity and specificity to myocardial injury. Physicians commonly order multiple cardiac biomarker laboratory tests, potentially contributing to enhanced health care costs. A team of physicians and medical personnel at the authors’ institution recommended that CK-MB offered little added value as preselected testing in our computerized provider order entry (CPOE) system for AMI and elected to unselect CK-MB from the routine order set; nonetheless, CK-MB could be selected if needed. Baseline measurements of CK-MB testing were measured from January to March 2014 using the institution’s Cerner Discern Analytics Program. Post intervention, CK-MB testing was measured from January to March 2015. Mortality metrics were analyzed before and after the CPOE changes. Direct cost to perform CK-MB testing was calculated from the institution’s Laboratory Quality and Safety Cost Accounting System. The rate of CK-MB orders was reduced significantly from 43.7 to 6.8 CK-MB tests per day post intervention, a decline in utilization of 84%. Extrapolating testing cost to a per day rate, a decline of costs, specifically institutional cost avoidance, from pre to post intervention decreased from $546 per day to $85 per day. The savings can reasonably be annualized to approximately $168 000. A guiding principle for health care operations and processes is “first do no harm.” Using the Advisory Board’s Crimson Continuum of Care benchmarking tool, we reviewed 2 mortality metrics before and after intervention. There were no adverse effects in mortality ratio: observed/expected or mortality rate percent with exclusion; rather, a slight decrease was observed. These mortality metrics should not be interpreted to represent a correlation between reductions in CK-MB utilization with a reduction in mortality—only that the intervention did no apparent harm. By simply removing the check from the CK-MB prepopulated CPOE order set, our institution reduced unnecessary, non–value-added testing. With a cost of $12.49 per test, this small change reduced patient gross charges and an estimated $168 220 in cost to the system annually. Although fewer cardiac biomarker tests were performed, patient quality of care was maintained, supported by mortality trends. Small productive changes contribute to a reduction in the ever-increasing financial burden of health care costs. If institutions and physicians make a conscious effort to pinpoint unnecessary health care costs, including redundant CK-MB testing, collaborations through CPOE order sets offer a unique opportunity to reduce financial burdens while maintaining high-quality patient care.