90 Economic Impact: A Cluster Randomized Trial of a Rapid, High-Sensitivity Cardiac Troponin I Protocol

Document Type

Conference Proceeding

Publication Date

10-1-2022

Publication Title

Ann Emerg Med

Abstract

Background: Economic data on the use of new rapid rule-out protocols using high sensitivity cardiac troponin I (hs-cTnI) for acute coronary syndrome (ACS) in the US is lacking. The RACE-IT stepped-wedge randomized controlled trial compared an accelerated hs-cTn protocol for evaluating ACS to standard of care (SoC) in 9 EDs serving Detroit, MI. Study Objective: We investigated the economic impact of the RACE-IT protocol on cost of care and length of stay (LOS) for patients suspected and evaluated for ACS. Methods: The trial took place from 7/2020 - 3/2021 in 9 EDs in an integrated health system serving Detroit, MI. The trial arms included a new 0/1-hour rapid protocol using hs-cTnI and SoC using a 0/3-hour protocol without hs-cTnI results. Randomization occurred by ED site. We included all adult ED patients for whom the treating clinician ordered an ECG and cardiac troponin. We excluded patients with STEMI, any hs-cTnI >18 ng/L in the ED, or a traumatic cause of symptoms. In the rapid protocol, MI was excluded, and ED discharge advised if hs-cTnI <4 ng/L at time 0, or =4 ng/L at time 0 with 1 hour <8 ng/L. For this analysis, the cost of care and length of stay for subjects enrolled in the rapid protocol was compared to SoC. Three measures were used for cost of care: total cost as estimated by the hospital, total payments received by hospital from insurance and patient, and total payment received from patient. The cost of care was considered for the initial visit, as well as at 30 days. The analysis adjusted for demographics, payer type (Medicare, Medicaid, commercial, other), and patient socioeconomic status as approximated by the first three digits of the zip code of the patient’s residence. Results: There were 32,609 patients, of whom 13,505 were in the standard care and 19,104 in the rapid protocol arms. The mean age was 59 years and 57.4% were female. Before adjustments, participants in the intervention arm had ED LoS 43 minutes longer than SoC, and hospital admissions that were approximately 0.14 days longer. The increase in LoS corresponds with an additional $500 cost incurred, on average, by patients in the intervention arm when compared to SoC patients. Patients in the intervention group paid an average of $251 more for the encounter. In the adjusted analysis, participants in the intervention group incurred modest increases in cost (+$64.06), greater hospital revenue (+286.71), and paid slightly less (-$12.48) when compared to patients in the SoC group. Adjusted analysis of length of stay demonstrated an increased ED LOS (+46.05 min) and hospital LOS (+0.11 days) for the intervention group compared to SoC. These results did not meet statistical significance. Conclusion: Implementation of a rapid 0/1-hour hs-cTnI protocol to evaluate ACS in the ED was associated with modest increases in the cost of care and length of stay, but these differences did not reach statistical significance. No, authors do not have interests to disclose

Volume

80

Issue

4

First Page

S45

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