UC Irvine Medical Center
Department of Internal Medicine
DSR2 Cost-Conscious Project
4/6/15

• Hormone initially identified in the brain but released primarily from the heart, particularly the ventricles
• Cleavage of the pro-hormone proBNP produces biologically active BNP as well as biologically inert N-terminal pro-BNP (NT-proBNP)

• Available commercial assays for plasma BNP or NTproBNP actually measure mixtures of peptides
• Plasma BNP assays appear to detect various degradation products of BNP as well as proBNP
• Assays for NT-proBNP likely also detect proBNP
• The relative contribution of individual natriuretic peptides has not yet been elucidated

1.
Cardiac conditions:
• Left or right ventricular heart failure
• Valvular disease
• Left ventricular hypertrophy
• Myocarditis
• Coronary artery disease
• Myocardial trauma (contusion, cardiac surgery, cardioversion)
• Atrial fibrillation
• Pericardial disease

2.
Pulmonary disease:
 Acute pulmonary embolism (i.e. RV failure)
 Pulmonary hypertension
 Obstructive sleep apnea
 Infection
 Chronic obstructive lung disease

3.
Neurologic disorders: CVA (ischemic or hemorrhagic)
4.
Critical illness:
 Sepsis
 Burns
 Transfusion associated circulatory overload (TACO)
5.
Toxins:
 Chemotherapy
 Snake bites

6.
Renal insufficiency
7.
Anemia
8.
Cirrhosis
9.
Hyperaldosteronism
10.
Hypertension

• To support clinical decision-making regarding the diagnosis of HF in the setting of dyspnea
• To support clinical judgment for the diagnosis of acutely decompensated HF
• Establishing prognosis or disease severity in both acutely decompensated and chronic HF

As a guide to achieve optimal dosing of HF therapy in select euvolemic patients followed in a well-structured HF disease management program

• Study population: 21 UCI inpatients
• Teams: Medicine ward teams, CCU, MICU
• Time period: 1 week in March 2015

Indication
Decompensated heart failure
Atrial fibrillation
Sepsis
CKD
Pneumonia
Pulmonary embolism
Cor pulmonale
Cardiac arrest
Anemia
Altered mental status
Pancreatitis
Pleural effusion
Vascular insufficiency
Number Ordered
5
1
1
1
2
2
2
2
1
1
1
1
1

Test Indicated
Test Not Indicated
Potentially Indicated
Number
7
3
11
Diagnoses
Decompensated HF, A-Fib
Pancreatitis, cardiac arrest,
AMS
CKD, PNA, PE, cor pulmonale, sepsis, anemia, pleural effusion, vascular insufficiency

• Average cost of BNP assay alone = $32
• Estimated cost per test (including cost of phlebotomy, technician, reagent, calibration, equipment rental) = $100
• Cost of ordering tests not indicated or only potentially indicated = $1400 per week
• Extrapolated to cost per year = $72,800

• Physicians should be educated about the indications for
BNP ordering
• However, indications can be construed as vague
• Clinical impact of ordering BNPs is unclear
• Medical personnel should be made aware of the cumulative cost of ordering BNPs as every extraneous order increases our overall high cost of healthcare

• Snap shot of 1 week (variability of providers, symptoms, diagnoses)
• Extrapolation is not really a valid representation
• Small sample size
• Patients limited to medicine services though it was not clear whether ER or Medicine physician ordered BNP
• Poor/inadequate documentation?

Colucci WS, Chen HH. Natriuretic peptide measurement in heart failure. In: UpToDate,
Post TW (Ed), UpToDate, Waltham, MA. (Accessed in April 2015.)
Heidenreich PA, Gubens MA, Fonarow GC, et al. Cost-effectiveness of screening with Btype natriuretic peptide to identify patients with reduced left ventricular ejection fraction. J Am Coll Cardiol. 2004;43(6):1019-1026.
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary. A report of the American college of cardiology foundation/American heart association task force on practice guidelines. J Am Coll
Cardiol. 2013;62(16): 1495-1539.