Cost consequences of point-of-care troponin T testing in a Swedish primary health care setting

Abstract

Objective. To evaluate the safety and cost-effectiveness of point-of-care troponin T testing (POCT-TnT) for the management of patients with chest pain in primary care. Design. Prospective observational study with follow-up. Setting. Three primary health care (PHC) centres using POCT-TnT and four PHC centres not using POCT-TnT in south-east Sweden. Patients. All patients ≥ 35 years of age, contacting one of the PHC centres for chest pain, dyspnoea on exertion, unexplained weakness and/or fatigue, with no other probable cause than cardiac, were included. Symptoms must have commenced or worsened during the previous seven days. Main outcome measures. Emergency referral rates, diagnoses of acute myocardial infarction (AMI) or unstable angina (UA), and costs were collected for 30 days after the patient sought care at the PHC centre. Results. A total of 196 patients with chest pain were included: 128 in PHC centres with POCT-TnT and 68 in PHC centres without POCT-TnT. Fewer patients from the PHC centres with POCT-TnT (n = 32, 25%) were emergently referred to hospital than from centres without POCT-TnT (n = 29, 43%; p = 0.011). Eight patients (6.2%) from PHC centres with POCT-TnT were diagnosed with AMI or UA compared with six patients (8.8%) from centres without POCT-TnT (p = 0.565). Two patients with AMI or UA were classified as missed cases from PHC centres with POCT-TnT and there were no missed cases from PHC centres without POCT-TnT. SKr290 000 was saved per missed case of AMI or UA. Conclusion. The use of POCT-TnT in primary care may be cost saving but at the expense of missed cases.

Asia-Pacific consensus statement on the optimal use of high-sensitivity troponin assays in acute coronary syndromes diagnosis: focus on hs-TnI

“…53 As POC troponin testing systems have good specificity but low sensitivity, a result that is low or undetectable does not preclude the possibility of ACS. 54 It is recommended that a sample is sent to the laboratory for hs-Tn evaluation. If this is impossible, the POC troponin test should be repeated at 6 hours to assess changes.…”

Troponin Testing in the Emergency Department: Real world experience

“…[2][3][4] In these circumstances, a troponin test should only be performed if there is strong suspicion of an ACS-such as prior chest pain or ECG changes-as a positive result can be misleading. 5,6 Interestingly, although 97 patients in the current study had a final cardiac-related diagnosis, only eight of these patients (8.2%) were diagnosed with an ACS. This number is relatively low and might reflect the short study period.…”

“…8 Although troponin tests are widely available, not all hospitals have clear guidelines or protocols as to when a troponin test should be requested, which can inadvertently lead to the inappropriate use of this diagnostic investigation. 5,6,9 While troponin tests are mainly used to diagnose an ACS, troponin levels can also be elevated in other cardiac conditions such as heart failure, tachyarrhythmias and post-cardiac arrest and direct current cardioversion as well as noncardiac conditions such as cerebrovascular accidents, head injuries, sepsis and pulmonary emboli. [2][3][4] In these circumstances, a troponin test should only be performed if there is strong suspicion of an ACS-such as prior chest pain or ECG changes-as a positive result can be misleading.…”

“…11,20,21 For economic reasons, it is prudent to limit such requests for unnecessary tests, in turn reducing unnecessary hospital stays and admissions. 6 This study was subject to certain limitations due to its retrospective nature and the method of data collection using patient records. The cTn-I tests were requested by various ED doctors or triage nurses without standard protocols to guide requests for troponin testing or to screen for an ACS or myocardial injuries or infarctions.…”

“…4 As the main reason for testing cardiac troponin is to rule out an acute coronary syndrome (ACS), it is thus essential that troponin is only checked in circumstances where the probability of ischaemic heart disease is high and an ACS is suspected, especially as indiscriminate troponin testing can lead to unnecessary investigations or a misdiagnosis. 5,6 This study therefore aimed to review patterns of troponin testing among patients attending the ED of the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman, and to examine whether initial troponin test results had an effect on patient management, especially length of hospital stay (LOS).…”