Eliminating Creatine Kinase–Myocardial Band Testing Saves Money, Improves Quality

Creatine kinase–myocardial band (CK-MB) testing provides no incremental value to patient care, and if hospitals and emergency rooms would eliminate its use for evaluating suspected acute coronary syndrome, it could lead to millions of health care dollars saved without adversely affecting patient care, according to a special communication published online Aug. 14 in JAMA Internal Medicine.

Since 2000, the American College of Cardiology and the European Society of Cardiology have recognized cardiac troponin (cTn) as the preferred biomarker for assessing myocardial infarctions due to its "nearly absolute" specificity for myocardial tissue and high sensitivity for myocardial injury. CK-MB has higher rates of false positives because, as it can be elevated with skeletal muscle damage.

Despite considerable evidence supporting cTn use over CK-MB and institutional efforts to improve testing orders (e.g., institutional guidelines, clinician education efforts, removal of CK-MB from routine order sets, and alerts within the computerized provider order entry system), CK-MB has not yet been eliminated from clinical practice. The College of American Pathologists' 2013 proficiency survey found that more than three-quarters of U.S. laboratories still use CK-MB. A 2010 study that used National Hospital Ambulatory Medical Care Survey data found that cardiac biomarker testing (both cTn and CK-MB) occurred in nearly 17 percent of all emergency department visits, translating to an estimated 28.6 million visits nationwide annually.

Its high use also makes cardiac biomarker testing costly. Based upon Medicare's 2016 Clinical Diagnostic Laboratory Fee Schedule national payment for cTn testing was $13.40 and CK-MB was $15.73, accounting for approximately $416 million in spending annually.

"Eliminating a simple laboratory test that provides no incremental value to patient care can lead to millions of health care dollars saved without adversely affecting patient care quality, and in this case potentially improving patient care," write the authors led by Matthew D. Alvin, M.D., from Johns Hopkins in Baltimore, Md., and colleagues from the High Value Practice Academic Alliance. "Successful deimplementation of CK-MB requires leadership support, education, and reassurance that diagnostic efficacy will not be compromised."

Takeaway: Laboratories have an opportunity to work with clinicians to improve test ordering, save unnecessary spending, and improve patient care through the elimination of CK-MB testing in cases of suspected acute coronary syndrome.