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Rameh V, Kossaify A. Appropriate Use Criteria in Echocardiography: An Observational Institutional Study with the Perspective of a Quality Improvement Project. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:23-8. [PMID: 26917982 PMCID: PMC4756858 DOI: 10.4137/cmc.s36504] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/16/2015] [Accepted: 01/04/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Appropriate use criteria (AUC) in echocardiography are essential tools for aligning the indications of echocardiography with the best clinical standards, improving clinical outcome, restraining abuse, and preserving health-care resources. OBJECTIVES The aim of this study was to ascertain the AUC for transthoracic echocardiography in a university hospital and create a quality improvement project (QIP). METHODS The assessment of 501 inpatients who received transthoracic cardiac echo was conducted according to the 2011 AUC report. Indications were classified as appropriate, uncertain, or inappropriate, and patients not matching any of the abovementioned divisions were grouped in the nonfitting category. RESULTS Of the 501 eligible patients, 374 patients (74.66%) were in the appropriate group, 85 patients (16.96%) in the inappropriate group, 20 patients (3.99%) in the uncertain group, and 22 patients (4.39%) in the nonfitting category. DISCUSSION Interpretation and analysis of the obtained results are presented, along with the results of many comparable studies; moreover, a QIP was set up accordingly. CONCLUSION AUC are useful to assess local practice, preserve health-care resources, and improve clinical outcome.
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Affiliation(s)
- Vanessa Rameh
- Echocardiography Unit, Cardiology division, University Hospital Notre Dame des Secours, Byblos, Lebanon
| | - Antoine Kossaify
- Echocardiography Unit, Cardiology division, University Hospital Notre Dame des Secours, Byblos, Lebanon
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Bhatia RS, Alabousi M, Dudzinski DM, Weiner RB. Appropriate use criteria: a review of need, development and applications. Expert Rev Cardiovasc Ther 2016; 14:281-90. [DOI: 10.1586/14779072.2016.1131125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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53
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Chaudhuri D, Montgomery A, Gulenchyn K, Mitchell M, Joseph P. Effectiveness of Quality Improvement Interventions at Reducing Inappropriate Cardiac Imaging. Circ Cardiovasc Qual Outcomes 2016; 9:7-13. [DOI: 10.1161/circoutcomes.115.001836] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 10/23/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Dipayan Chaudhuri
- Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada
| | - Alison Montgomery
- Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada
| | - Karen Gulenchyn
- Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada
| | - Morgan Mitchell
- Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada
| | - Philip Joseph
- Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada
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Sachdeva R, Douglas PS. Quality Improvement Interventions to Improve Appropriateness of Imaging Studies. Circ Cardiovasc Qual Outcomes 2016; 9:2-4. [DOI: 10.1161/circoutcomes.115.002510] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ritu Sachdeva
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (R.S.); and Department of Medicine, Duke University, Durham, NC (P.S.D.)
| | - Pamela S. Douglas
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (R.S.); and Department of Medicine, Duke University, Durham, NC (P.S.D.)
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Appropriate use criteria for transthoracic echocardiography at a tertiary care centerAppropriate use criteria for transthoracic echocardiography. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.repce.2015.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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56
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Fonseca P, Sampaio F, Ribeiro J, Gonçalves H, Gama V. Appropriate use criteria for transthoracic echocardiography at a tertiary care center. Rev Port Cardiol 2015; 34:713-8. [DOI: 10.1016/j.repc.2015.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 06/12/2015] [Indexed: 11/24/2022] Open
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57
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Comentário a «Critérios de adequação para ecocardiografia transtorácica num centro terciário». Rev Port Cardiol 2015; 34:719-22. [DOI: 10.1016/j.repc.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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58
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Galrinho A. Comment on “Appropriate use criteria for transthoracic echocardiography at a tertiary care center”Comment on “Appropriate use criteria for transthoracic echocardiography at a tertiary care center”. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.repce.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Development of an Educational Strategy and Decision Support Tool to Enhance Appropriate Use of Stress Echocardiography at a Large Academic Medical Center: A Prospective, Pre- and Postintervention Analysis. J Am Soc Echocardiogr 2015; 28:1401-9. [DOI: 10.1016/j.echo.2015.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 11/23/2022]
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61
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Al-Kaisey A, Jones E, Nadurata V, Farouque O, De Silva D, Ramchand J. Appropriate use of echocardiography in an Australian regional centre. Intern Med J 2015; 45:1128-33. [DOI: 10.1111/imj.12824] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/26/2015] [Indexed: 11/30/2022]
Affiliation(s)
- A. Al-Kaisey
- Department of Cardiology; Bendigo Health; Bendigo Australia
| | - E. Jones
- Department of Cardiology; Austin Health; Melbourne Victoria Australia
| | - V. Nadurata
- Department of Cardiology; Bendigo Health; Bendigo Australia
| | - O. Farouque
- Department of Cardiology; Austin Health; Melbourne Victoria Australia
| | - D. De Silva
- Department of Cardiology; Bendigo Health; Bendigo Australia
| | - J. Ramchand
- Department of Cardiology; Bendigo Health; Bendigo Australia
- Department of Cardiology; Austin Health; Melbourne Victoria Australia
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Levitt K, Shojania KG, Bhatia RS. Point-of-care decision support for reducing inappropriate test use: easier said than done. BMJ Qual Saf 2015; 25:6-8. [PMID: 26424763 DOI: 10.1136/bmjqs-2015-004785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Kevin Levitt
- Toronto East General Hospital, University of Toronto, Toronto, Ontario, Canada Women's College Hospital, University of Toronto, Toronto, Ontario, Canada Division of Cardiology, University of Toronto, Toronto, Ontario, Canada Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kaveh G Shojania
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Hospital, University of Toronto, Toronto, Ontario, Canada Division of Cardiology, University of Toronto, Toronto, Ontario, Canada Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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63
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Affiliation(s)
- Xiaoyan Huang
- From Providence Heart Clinic, Portland, OR (X.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (M.B.R.).
| | - Meredith B Rosenthal
- From Providence Heart Clinic, Portland, OR (X.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (M.B.R.)
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64
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Boggan JC, Schulteis RD, Donahue M, Simel DL. Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency. BMJ Qual Saf 2015; 25:57-62. [DOI: 10.1136/bmjqs-2015-004284] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/01/2015] [Indexed: 11/04/2022]
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65
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Sachdeva R, Allen J, Benavidez OJ, Campbell RM, Douglas PS, Eidem BW, Gold L, Kelleman MS, Lopez L, McCracken CE, Stern KW, Weiner RB, Welch E, Lai WW. Pediatric Appropriate Use Criteria Implementation Project. J Am Coll Cardiol 2015; 66:1132-40. [DOI: 10.1016/j.jacc.2015.06.1327] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 11/30/2022]
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66
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Bhatia RS, Ivers N, Yin CX, Myers D, Nesbitt G, Edwards J, Yared K, Wadhera R, Wu JC, Wong B, Hansen M, Weinerman A, Shadowitz S, Johri A, Farkouh M, Thavendiranathan P, Udell JA, Rambihar S, Chow CM, Hall J, Thorpe KE, Rakowski H, Weiner RB. Design and methods of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen SignificantlY) study: An investigator-blinded randomized controlled trial of education and feedback intervention to reduce inappropriate echocardiograms. Am Heart J 2015; 170:202-9. [PMID: 26299215 DOI: 10.1016/j.ahj.2015.04.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 04/25/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Appropriate use criteria (AUC) for transthoracic echocardiography (TTE) were developed to address concerns regarding inappropriate use of TTE. A previous pilot study suggests that an educational and feedback intervention can reduce inappropriate TTEs ordered by physicians in training. It is unknown if this type of intervention will be effective when targeted at attending level physicians in a variety of clinical settings. AIMS The aim of this international, multicenter study is to evaluate the hypothesis that an AUC-based educational and feedback intervention will reduce the proportion of inappropriate echocardiograms ordered by attending physicians in the ambulatory environment. METHODS In an ongoing multicentered, investigator-blinded, randomized controlled trial across Canada and the United States, cardiologists and primary care physicians practicing in the ambulatory setting will be enrolled. The intervention arm will receive (1) a lecture outlining the AUC and most recent available evidence highlighting appropriate use of TTE, (2) access to the American Society of Echocardiography mobile phone app, and (3) individualized feedback reports e-mailed monthly summarizing TTE ordering behavior including information on inappropriate TTEs and brief explanations of the inappropriate designation. The control group will receive no education on TTE appropriate use and order TTEs as usual practice. CONCLUSIONS The Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly in an education RCT) study is the first multicenter randomized trial of an AUC-based educational intervention. The study will examine whether an education and feedback intervention will reduce the rate of outpatient inappropriate TTEs ordered by attending level cardiologists and primary care physicians (www.clinicaltrials.gov identifier NCT02038101).
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Affiliation(s)
- R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre of the University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Noah Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; Department of Family and Community Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Cindy X Yin
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Dorothy Myers
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada
| | - Gillian Nesbitt
- Cardiology Division, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jeremy Edwards
- Echocardiogram and Vascular Lab, St Michael's Hospital, Toronto, Ontario, Canada
| | - Kibar Yared
- The Scarborough Hospital, Toronto, Ontario, Canada
| | - Rishi Wadhera
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Justina C Wu
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Brian Wong
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Mark Hansen
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | | | | | - Amer Johri
- Queen's University, Kingston, Ontario, Canada
| | - Michael Farkouh
- Peter Munk Cardiac Centre of the University Health Network, University of Toronto, Toronto, Ontario, Canada; Cardiology Division, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Jacob A Udell
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; Department of Family and Community Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Sherryn Rambihar
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Chi-Ming Chow
- Echocardiogram and Vascular Lab, St Michael's Hospital, Toronto, Ontario, Canada
| | - Judith Hall
- Cardiology Division, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Cardiology Division, Mount Sinai Hospital, Toronto, Ontario, Canada; Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada
| | - Harry Rakowski
- Peter Munk Cardiac Centre of the University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rory B Weiner
- Cardiology Division, Massachusetts General Hospital, Boston, MA
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67
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Fonseca R, Negishi K, Otahal P, Marwick TH. Temporal changes in appropriateness of cardiac imaging. J Am Coll Cardiol 2015; 65:763-773. [PMID: 25720619 DOI: 10.1016/j.jacc.2014.11.057] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 11/23/2014] [Accepted: 11/24/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Appropriate use criteria (AUC) for cardiac imaging have been available for almost 10 years. The extent to which there has been a reported improvement in appropriate use is undefined. OBJECTIVES This study systematically reviewed published evidence to identify whether the promulgation of AUC has led to an improvement in the proportion of appropriate cardiac imaging requests. METHODS Electronic databases were systematically searched for English-language papers related to AUC and cardiovascular imaging. We found 59 reports involving 103,567 tests that were published from 2000 to 2012. The rate of appropriate testing over time was analyzed in a meta-regression. RESULTS New AUC were associated with apparent improvements in appropriateness for transthoracic echocardiography (TTE) (80% [95% confidence interval (CI): 0.75 to 0.84] vs. 85% [95% CI: 0.81 to 0.89]), transesophageal echocardiography (TEE) (89% [95% CI: 0.81 to 0.94] vs. 95% [95% CI: 0.93 to 0.96]) and computed tomography angiography (CTA) (37% [95% CI: 0.21 to 0.55] vs. 55% [95% CI: 0.44 to 0.65]) but not stress echocardiography (53% [95% CI: 0.45 to 0.61] vs. 52% [95% CI: 0.42 to 0.61]) or single-photon emission computed tomography (72% [95% CI: 0.66 to 0.77] vs. 68% [95% CI: 0.60 to 0.74]). Although there were no correlations between the proportion of appropriate TTEs and published year (p = 0.36) for 2007 AUC, there was a positive correlation between proportion of appropriateness and the year of publication (p = 0.01) for 2011 AUC. There was a significant decrease in the proportion of appropriateness over time using the 2007 TEE AUC (p = 0.03) and 2006 CT AUC (p = 0.02). There were no meaningful associations between appropriateness and publication year for stress echocardiography, CTA, or single-photon emission computed tomography. CONCLUSIONS Rates of reported appropriate use in imaging show improvements for TTE and CTA but not for stress imaging and TEE. The observed reductions in imaging studies are not matched by reported rates of appropriate use.
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Affiliation(s)
- Ricardo Fonseca
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Kazuaki Negishi
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Thomas H Marwick
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
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68
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Winchester DE, Kitchen A, Brandt JC, Dusaj RS, Virani SS, Bradley SM, Shaw LJ, Beyth RJ. Metrics of quality care in veterans: correlation between primary-care performance measures and inappropriate myocardial perfusion imaging. Clin Cardiol 2015; 38:195-9. [PMID: 25870096 DOI: 10.1002/clc.22388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/08/2014] [Accepted: 12/29/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Approximately 10% to 20% of myocardial perfusion imaging (MPI) tests are inappropriate based on professional-society recommendations. The correlation between inappropriate MPI and quality care metrics is not known. HYPOTHESIS Inappropriate MPI will be associated with low achievement of quality care metrics. METHODS We conducted a retrospective cross-sectional investigation at a single Veterans Affairs medical center. Myocardial perfusion imaging tests ordered by primary-care clinicians between December 2010 and July 2011 were assessed for appropriateness (by 2009 criteria). Using documentation of the clinical encounter where MPI was ordered, we determined how often quality care metrics were achieved. RESULTS Among 516 MPI patients, 52 (10.1%) were inappropriate and 464 (89.9%) were not inappropriate (either appropriate or uncertain). Hypertension (82.2%), diabetes mellitus (41.3%), and coronary artery disease (41.1%) were common. Glycated hemoglobin levels were lower in the inappropriate MPI cohort (6.6% vs 7.5%; P = 0.04). No difference was observed in the proportion with goal hemoglobin (62.5% vs 46.3% for appropriate/uncertain; P = 0.258). Systolic blood pressure was not different (132 mm Hg vs 135 mm Hg; P = 0.34). Achievement of several other categorical quality metrics was low in both cohorts and no differences were observed. More than 90% of clinicians documented a plan to achieve most metrics. CONCLUSIONS Inappropriate MPI is not associated with performance on metrics of quality care. If an association exists, it may be between inappropriate MPI and overly aggressive care. Most clinicians document a plan of care to address failure of quality metrics, suggesting awareness of the problem.
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Affiliation(s)
- David E Winchester
- Division of Cardiovascular Medicine, University of Florida College of Medicine
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Banihashemi B, Maftoon K, Chow BJW, Bernick J, Wells GA, Burwash IG. Limitations of free-form-text diagnostic requisitions as a tool for evaluating adherence to appropriate use criteria for transthoracic echocardiography. Cardiovasc Ultrasound 2015; 13:4. [PMID: 25592146 PMCID: PMC4326475 DOI: 10.1186/1476-7120-13-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 01/05/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Monitoring the adherence to Appropriateness Use Criteria (AUC) has been identified as an important component for the accreditation of echocardiography laboratories. Referral requisitions are a logical tool to rapidly determine the appropriateness of transthoracic echocardiography (TTE) referrals, however data is lacking. We investigated whether standard free-form-text TTE referral requisitions can be used to evaluate AUC adherence. METHODS Consecutive TTE referral requisitions to the University of Ottawa Heart Institute echocardiography laboratory were reviewed over a four-week period. Indication on the requisition was matched with the relevant indication on the 2011 American College of Cardiology Foundation (ACCF) AUC. Requisitions that did not provide sufficient information to identify the relevant AUC indication were identified as inadequate. For inadequate requisitions, reason for the referral was clarified through medical records and referring physicians. RESULTS Of the 1303 requisitions, 26.2% did not provide adequate information to determine adherence to AUC, despite a non-adherence (inappropriate) rate of only 6.1% in the referral population. Indication for referral, physician specialty, outpatient status, and prior echocardiogram were independent predictors of inadequate requisitions (p < 0.001, respectively). The most common reasons for inadequate requisitions were a failure to report: 1) change in clinical status, 2) date of a prior echocardiogram, and 3) type and/or severity of a valve lesion. Inclusion of this information would have decreased the inadequacy rate by 56%. CONCLUSION In a large, academic echocardiography laboratory, over one quarter of free-form-text TTE requisitions are inadequate to evaluate AUC adherence. Structured requisition formats requiring AUC-relevant information are needed to facilitate the practical application of AUC in the echocardiography laboratory.
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Affiliation(s)
| | | | | | | | | | - Ian G Burwash
- Department of Medicine, Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Rm 3407B, K1Y 4W7 Ottawa, Ontario, Canada.
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The First Pediatric Appropriate Use Criteria: A Step Towards Providing Quality Care in a Cost-Effective Manner. J Am Soc Echocardiogr 2014; 27:21A-22A. [DOI: 10.1016/j.echo.2014.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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71
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Marwick TH, Narula J. Teaching appropriate behavior, and what to consider if that fails. JACC Cardiovasc Imaging 2014; 7:966-7. [PMID: 25212807 DOI: 10.1016/j.jcmg.2014.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York.
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73
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Bhatia RS, Dudzinski DM, Malhotra R, Milford CE, Yoerger Sanborn DM, Picard MH, Weiner RB. Educational Intervention to Reduce Outpatient Inappropriate Echocardiograms. JACC Cardiovasc Imaging 2014; 7:857-66. [DOI: 10.1016/j.jcmg.2014.04.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 04/29/2014] [Accepted: 04/30/2014] [Indexed: 11/29/2022]
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Abstract
The goal of this review article is to highlight the appropriateness criteria programs available to clinicians, to review the current state of decision-support systems for imaging, and to briefly review the accreditation requirements currently in place in cardiothoracic imaging.
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75
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Fonseca R, Marwick TH. How I do it: judging appropriateness for TTE and TEE. Cardiovasc Ultrasound 2014; 12:22. [PMID: 24961689 PMCID: PMC4079626 DOI: 10.1186/1476-7120-12-22] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/05/2014] [Indexed: 11/10/2022] Open
Abstract
The increasing cost of healthcare is a widespread international problem to which the cost of imaging has been an important contributor. Some imaging tests are ordered inappropriately and contribute to wasted use of resources. Appropriate use criteria have been developed in the USA in order to guide test selection, but there are a number of problems, including the evidence base for these criteria and the steps that can be taken to change physician practice. A restrictive approach to test ordering is difficult to fit to the nuances of clinical presentation and may compromise patient care. We propose an alternative approach to physician guidance based on the most common markers of inappropriate testing.
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Affiliation(s)
- Ricardo Fonseca
- Menzies Research Institute Tasmania, 17 Liverpool St, Hobart, Tasmania 7000, Australia
| | - Thomas H Marwick
- Menzies Research Institute Tasmania, 17 Liverpool St, Hobart, Tasmania 7000, Australia
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76
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Winchester DE, Hymas J, Meral R, Nguyen D, Dusaj R, Shaw LJ, Beyth RJ. Clinician-dependent variations in inappropriate use of myocardial perfusion imaging: training, specialty, and location. J Nucl Cardiol 2014; 21:598-604. [PMID: 24671699 DOI: 10.1007/s12350-014-9887-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Inappropriate use of myocardial perfusion imaging (MPI) may vary depending on the training, specialty, or practice location of the clinician. METHODS We conducted a cross-sectional investigation of consecutive patients who underwent MPI at our Veterans Affairs medical center between December 2010 and July 2011. Characteristics of the MPI ordering clinicians were extracted to investigate any associations with inappropriate use. RESULTS 582 patients were included, 9.8% were inappropriate. No difference in inappropriate use was observed between cardiology and non-cardiology clinicians (n = 21, 9.5% vs n = 36, 10.0%, P = .83); no difference was noted between nurse practitioners/physician assistants, attending physicians, and housestaff (7.5% vs 11.2% vs 1.8%, P = .06). Comparing inpatient, emergency department and outpatient clinician groups, the difference was null (8.6% vs 6.3% vs 10.1%, P = .75). For most clinician groups, the most common inappropriate indication was an asymptomatic scenario; however, some groups were different: definite acute coronary syndrome for inpatient clinicians and low risk syncope for emergency medicine clinicians. CONCLUSIONS Clinician groups appear to order inappropriate MPI at similar rates, regardless of their training, specialty, or practice location. Differences in the most common type of inappropriate testing suggest that interventions to reduce inappropriate use should be tailored to specific clinician types.
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Affiliation(s)
- David E Winchester
- Malcom Randall VA Medical Center, 1601 SW Archer Rd 111D, Gainesville, FL, 32608, USA,
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Bhatia RS, Dudzinski DM, Milford CE, Picard MH, Weiner RB. Educational Intervention to Reduce Inappropriate Transthoracic Echocardiograms: The Need for Sustained Intervention. Echocardiography 2014; 31:916-23. [DOI: 10.1111/echo.12505] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Rajan Sacha Bhatia
- Division of Cardiology; Massachusetts General Hospital; Boston Massachusetts
| | - David M. Dudzinski
- Division of Cardiology; Massachusetts General Hospital; Boston Massachusetts
| | - Creagh E. Milford
- Division of Cardiology; Massachusetts General Hospital; Boston Massachusetts
| | - Michael H. Picard
- Division of Cardiology; Massachusetts General Hospital; Boston Massachusetts
| | - Rory B. Weiner
- Division of Cardiology; Massachusetts General Hospital; Boston Massachusetts
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Kossaify A, Grollier G. Echocardiography practice: insights into appropriate clinical use, technical competence and quality improvement program. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2014; 8:1-7. [PMID: 24516342 PMCID: PMC3914997 DOI: 10.4137/cmc.s13645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/09/2013] [Accepted: 12/11/2013] [Indexed: 11/24/2022]
Abstract
Echocardiography accounts for nearly half of all cardiac imaging techniques. It is a widely available and adaptable tool, as well as being a cost-effective and mainly a non-invasive test. In addition, echocardiography provides extensive clinical data, which is related to the presence or advent of different modalities (tissue Doppler imaging, speckle tracking imaging, three-dimensional mode, contrast echo, etc.), different approaches (transesophageal, intravascular, etc.), and different applications (ie, heart failure/resynchronization studies, ischemia/stress echo, etc.). In view of this, it is essential to conform to criteria of appropriate use and to keep standards of competence. In this study, we sought to review and discuss clinical practice of echocardiography in light of the criteria of appropriate clinical use, also we present an insight into echocardiographic technical competence and quality improvement project.
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Affiliation(s)
- Antoine Kossaify
- Echocardiography Unit, Cardiology Division, USEK- University Hospital N D Secours, St Charbel Street, Byblos, Lebanon
| | - Gilles Grollier
- Cardiology Division, University Hospital Caen, Av. Cote de Nacre, 14000, Caen, France
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Fonseca R, Marwick TH. Appropriateness and outcomes: is it time to adopt appropriate use criteria outside of North America? Heart 2013; 100:357-8. [PMID: 24365665 DOI: 10.1136/heartjnl-2013-305273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ricardo Fonseca
- Menzies Research Institute of Tasmania, , Hobart, Tasmania, Australia
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Quality Improvement Using the AUC: Is it This Easy?⁎⁎Editorials published in JACC: Cardiovascular Imaging reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Imaging or the American College of Cardiology. JACC Cardiovasc Imaging 2013; 6:556-8. [DOI: 10.1016/j.jcmg.2013.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 03/27/2013] [Indexed: 11/21/2022]
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