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Badejo O, Saleeb M, Hall A, Furlong B, Logan GS, Gao Z, Barrett B, Alcock L, Aubrey-Bassler K. Audit and feedback to change diagnostic image ordering practices: A systematic review and meta-analysis. PLoS One 2024; 19:e0300001. [PMID: 38837994 DOI: 10.1371/journal.pone.0300001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/19/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Up to 30% of diagnostic imaging (DI) tests may be unnecessary, leading to increased healthcare costs and the possibility of patient harm. The primary objective of this systematic review was to assess the effect of audit and feedback (AF) interventions directed at healthcare providers on reducing image ordering. The secondary objective was to examine the effect of AF on the appropriateness of DI ordering. METHODS Studies were identified using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov registry on December 22nd, 2022. Studies were included if they were randomized control trials (RCTs), targeted healthcare professionals, and studied AF as the sole intervention or as the core component of a multi-faceted intervention. Risk of bias for each study was evaluated using the Cochrane risk of bias tool. Meta-analyses were completed using RevMan software and results were displayed in forest plots. RESULTS Eleven RCTs enrolling 4311 clinicians or practices were included. AF interventions resulted in 1.5 fewer image test orders per 1000 patients seen than control interventions (95% confidence interval (CI) for the difference -2.6 to -0.4, p-value = 0.009). The effect of AF on appropriateness was not statistically significant, with a 3.2% (95% CI -1.5 to 7.7%, p-value = 0.18) greater likelihood of test orders being considered appropriate with AF vs control interventions. The strength of evidence was rated as moderate for the primary objective but was very low for the appropriateness outcome because of risk of bias, inconsistency in findings, indirectness, and imprecision. CONCLUSION AF interventions are associated with a modest reduction in total DI ordering with moderate certainty, suggesting some benefit of AF. Individual studies document effects of AF on image order appropriateness ranging from a non-significant trend toward worsening to a highly significant improvement, but the weighted average effect size from the meta-analysis is not statistically significant with very low certainty.
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Affiliation(s)
- Oluwatosin Badejo
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Maria Saleeb
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
- Population Health and Applied Health Sciences, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Bradley Furlong
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Gabrielle S Logan
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Zhiwei Gao
- Population Health and Applied Health Sciences, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Brendan Barrett
- Population Health and Applied Health Sciences, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
- Discipline of Medicine, Faculty of Medicine, Memorial University of Newfoundland, Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Lindsay Alcock
- Health Sciences Library, Memorial University of Newfoundland and Labrador, Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
- Population Health and Applied Health Sciences, Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
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Wardle G, Sanfilippo AJ, Narula A, Kolos A, Chan K, Leong-Poi H, Sasson Z, Woodward G. Variations and inequities in access to cardiac diagnostic services in Ontario Canada. Health Policy 2024; 143:105033. [PMID: 38564973 DOI: 10.1016/j.healthpol.2024.105033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Echocardiography is an essential diagnostic modality known to have wide regional utilization variations. This study's objectives were to quantify regional variations and to examine the extent to which they are explained by differences in population age, sex, cardiac disease prevalence (CDP), and social determinants of health (SDH) risk. METHODS This is an observational study of all echocardiography exams performed in Ontario in 2019/20 (n = 695,622). We measured regional variations in echocardiography crude rates and progressively standardized rates for population age, sex, CDP, and SDH risk. RESULTS After controlling for differences in population age, sex, and CDP, Ontario's highest rate regions had echocardiography rates 57% higher than its lowest rate regions. Forty eight percent of total variation was not explained by differences in age, sex, and CDP. CDP increased with SDH risk. Access to most cardiac diagnostics was negatively correlated with SDH risk, while cardiac catheterization rates were positively correlated with SDH risk. CONCLUSION Variations analysis that adjusts for age and sex only without including clinical measures of need are likely to overestimate the unwarranted portion of total variation. Substantial variations persisted despite a mandatory provider accreditation policy aimed at curtailing them. The associations between variations and SDH risks imply a need to redress access and outcome inequities.
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Affiliation(s)
- Gavin Wardle
- Preyra Solutions Group, 172 Palmerston Ave. Toronto ON M6J 2J4 Canada.
| | | | - Ashrut Narula
- Preyra Solutions Group, 172 Palmerston Ave. Toronto ON M6J 2J4 Canada
| | | | - Kwan Chan
- Ottawa Heart Institute, 40 Ruskin Street K1Y 4W7 Ottawa, Ontario Canada
| | - Howard Leong-Poi
- University of Toronto, Temerty Faculty of Medicine, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada
| | - Zion Sasson
- University of Toronto, Temerty Faculty of Medicine, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada
| | - Graham Woodward
- Ontario Health, 500 - 525 University Ave, Toronto, ON M5G 2L3, Canada
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Kling SMR, Kalwani NM, Winget M, Gupta K, Saliba-Gustafsson EA, Baratta J, Garvert DW, Veruttipong D, Brown-Johnson CG, Vilendrer S, Gaspar C, Levin E, Tsai S. An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation. J Eval Clin Pract 2024; 30:107-118. [PMID: 37459156 DOI: 10.1111/jep.13896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 03/01/2024]
Abstract
OBJECTIVES Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics. METHODS Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2. RESULTS Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001). CONCLUSIONS This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.
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Affiliation(s)
- Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Neil M Kalwani
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Marcy Winget
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kush Gupta
- Stanford University School of Medicine, Stanford, California, USA
| | - Erika A Saliba-Gustafsson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Juliana Baratta
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donn W Garvert
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Darlene Veruttipong
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Cati G Brown-Johnson
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stacie Vilendrer
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | | | - Eleanor Levin
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
| | - Sandra Tsai
- Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Stanford Health Care, Stanford, California, USA
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Al-Sadawi M, Tao M, Frye J, Dianati-Maleki N, Mann N. The Use of Quality Improvement Interventions in Reducing Rarely Appropriate Cardiac Imaging. Am J Cardiol 2023; 207:349-355. [PMID: 37774477 DOI: 10.1016/j.amjcard.2023.08.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023]
Abstract
The use of cardiac imaging has become increasingly prevalent over the last decade. Approximately 10% to 15% of noninvasive cardiac imaging is ordered for rarely appropriate indications. The appropriate use criteria (AUC) for cardiac imaging were issued to decrease unnecessary testing and reduce health care costs. However, it remains unclear whether these efforts have been successful. This meta-analysis evaluates whether AUC quality improvement (QI) interventions effectively reduce inappropriate cardiac imaging. Databases were searched for studies reporting QI intervention effect aiming to reduce rarely appropriate noninvasive cardiac imaging based on AUC. Imaging modalities assessed include transthoracic echocardiography, stress echocardiography, and myocardial perfusion imaging. We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL. The primary end point was a decrease of rarely appropriate testing. The search was not restricted to time or publication status. The literature search identified 2,391 possible studies, 13 studies and 26,557 patients were included. Mean follow-up was 12 months (1 to 60 months). QI interventions were statistically significant in reducing rarely appropriate tests after the intervention compared with the control group (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.41 to 0.64, p <0.01). The QI interventions were also assessed for persistence based on short-term (<3 months) and long-term (>3 months) efficacy. Both the short-term effect and long-term effect were persistent (OR 0.6, 95% CI 0.47 to 0.77, p <0.01 and OR 0.47, 95% CI 0.37 to 0.61, p <0.01, respectively). AUC QI interventions are associated with the successful decrease of inappropriate noninvasive cardiac testing with these effects persisting over time.
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Affiliation(s)
- Mohammed Al-Sadawi
- Department of Cardiovascular Medicine, University of Michigan Hospital, Ann Arbor, Michigan.
| | - Michael Tao
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, New York
| | - Jesse Frye
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, New York
| | - Neda Dianati-Maleki
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, New York
| | - Noelle Mann
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, New York
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5
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Tao M, Al-Sadawi M, Ahmed N, Dianati-Maleki N, Mann N, Kort S. The use of quality improvement interventions in reducing rarely appropriate echocardiograms: A systematic review and meta-analysis. Echocardiography 2023; 40:916-924. [PMID: 37464949 DOI: 10.1111/echo.15653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/18/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The volume of cardiac imaging continues to increase, with many tests performed for rarely appropriate indications. Appropriate use criteria (AUC) documents were published by the American Society of Echocardiography and American College of Cardiology, with quality improvement (QI) interventions developed in various institutions. However, the effectiveness of these interventions has not been assessed in a systematic fashion. METHODS We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL for studies reporting association between cardiac imaging, AUC and QI. The search was not restricted to time or publication status. We selected studies assessing the effect of QI interventions on performance of rarely appropriate echocardiograms. The primary endpoint was reduction of rarely appropriate testing. RESULTS Nine studies with 22,070 patients met inclusion criteria. Mean follow up was 15 months (1-60 months). QI interventions resulted in statistically significant reduction in rarely appropriate tests (OR 0.52, 95% CI: .41-.66; p < .01). The effects of QI interventions were analyzed over both the short (<3 months) and long-term (>3 months) post intervention (OR 0.62, 95% CI: .49-.79; p < .01 in the short term, and OR 0.47, 95% CI: .35-.62; p < .01 in the long term). Subgroup analysis of the type of intervention, classified as education tools or decision support tools showed both significantly reduced rarely appropriate testing (OR 0.54, 95% CI: .41-.73; p < .01; OR .47, 95% CI: .36-.61; p < .01). Adding a feedback tool did not change the effect compared to not using a feedback tool (OR 0.49 vs. 0.57, 95% CI: .36-.68 vs. 39-.84; p > .05). CONCLUSION QI interventions are associated with a significant reduction in performance of rarely appropriate echocardiography testing, the effects of which persist over time. Both education and decision support tools were effective, while adding feedback tools did not result in further reduction of ordering rarely appropriate studies.
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Affiliation(s)
- Michael Tao
- Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, New York, USA
| | - Mohammed Al-Sadawi
- Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, New York, USA
| | - Navid Ahmed
- Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, New York, USA
| | - Neda Dianati-Maleki
- Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, New York, USA
| | - Noelle Mann
- Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, New York, USA
| | - Smadar Kort
- Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, New York, USA
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6
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Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. Method A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. Results The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. Conclusions Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01247-y.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
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7
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Sapadin J, Campbell L, Bajaj K, Moskovitz JB. Reducing thoracic and lumbar radiographs in an urban emergency department through a clinical champion led quality improvement intervention. BMC Emerg Med 2022; 22:69. [PMID: 35488199 PMCID: PMC9052451 DOI: 10.1186/s12873-022-00611-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Low back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number. Methods A multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months. Results The percent of appropriately ordered radiographs increased from 5.8 to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frame. Conclusion A multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.
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Affiliation(s)
- Joshua Sapadin
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, USA
| | - Linelle Campbell
- Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY, 10461, USA
| | - Komal Bajaj
- Department of Obstetrics and Gynecology, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY, 10461, USA
| | - Joshua B Moskovitz
- Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY, 10461, USA. .,Department of Public Health, Hofstra University School of Health Sciences, Hempstead NY 11549 College of Medicine, 1400 Pelham Parkway South, Bronx, NY, 10461, USA.
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, Alberta T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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9
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Kossaify A. Quality Assurance and Improvement Project in Echocardiography Laboratory: The Pivotal Importance of Organizational and Managerial Processes. Heart Views 2021; 22:35-44. [PMID: 34276887 PMCID: PMC8254161 DOI: 10.4103/heartviews.heartviews_112_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 02/04/2021] [Indexed: 11/04/2022] Open
Abstract
Echocardiography plays a vital role in the diagnosis and management of cardiovascular conditions. Echocardiography use is progressively increasing nowadays, and this is correlated to the evolving echo indications, to the relatively new available echocardiography modes (tissue Doppler imaging, speckle tracking imaging, three-dimensional mode, etc.) and modalities (transthoracic, transesophageal, and intracardiac) along with the various available clinical approaches (point of care echo, portable echo, etc.). Quality assurance in echocardiography is correlated to appropriate use criteria, adequate equipment, standardization of performance and reporting, along with timely storage and archiving. Quality improvement plan must target strategic planning, with metrics and timeline for assessment and re-assessment of results. Improvement project aims to ensure and enhance conformity with appropriate use criteria and standardization, timely completion of exams and reports, detection of discrepancies, and continuous improvement of knowledge and skills. Strategic planning is essential in this context in order to develop organizational and managerial processes, with regular auditing for a highly professional and advanced level of echocardiography, while ensuring teamwork and standards of ethical values.
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Affiliation(s)
- Antoine Kossaify
- Division of Cardiology, University Hospital Notre Dame Des Secours, Byblos, Lebanon.,School of Medicine and Medical Sciences (SMMS), USEK University, Kaslik, Lebanon
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10
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Ellenbogen MI, Prichett L, Johnson PT, Brotman DJ. Development of a Simple Index to Measure Overuse of Diagnostic Testing at the Hospital Level Using Administrative Data. J Hosp Med 2021; 16:77-83. [PMID: 33496661 PMCID: PMC7850599 DOI: 10.12788/jhm.3547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We developed a diagnostic overuse index that identifies hospitals with high levels of diagnostic intensity by comparing negative diagnostic testing rates for common diagnoses. METHODS We prospectively identified candidate overuse metrics, each defined by the percentage of patients with a particular diagnosis who underwent a potentially unnecessary diagnostic test. We used data from seven states participating in the State Inpatient Databases. Candidate metrics were tested for temporal stability and internal consistency. Using mixed-effects ordinal regression and adjusting for regional and hospital characteristics, we compared results of our index with three Dartmouth health service area-level utilization metrics and three Medicare county-level cost metrics. RESULTS The index was comprised of five metrics with good temporal stability and internal consistency. It correlated with five of the six prespecified overuse measures. Among the Dartmouth metrics, our index correlated most closely with physician reimbursement, with an odds ratio of 2.02 (95% CI, 1.11-3.66) of being in a higher tertile of the overuse index when comparing tertiles 3 and 1 of this Dartmouth metric. Among the Medicare county-level metrics, our index correlated most closely with standardized costs of procedures per capita, with an odds ratio of 2.03 (95% CI, 1.21-3.39) of being in a higher overuse index tertile when comparing tertiles 3 and 1 of this metric. CONCLUSIONS We developed a novel overuse index that is preliminary in nature. This index is derived from readily available administrative data and shows some promise for measuring overuse of diagnostic testing at the hospital level.
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Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Corresponding Author: Michael I. Ellenbogen, MD; ; Telephone: 443-287-4362
| | - Laura Prichett
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Pamela T Johnson
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daniel J Brotman
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Winchester DE, Merritt J, Waheed N, Norton H, Manja V, Shah NR, Helfrich CD. Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:34-41. [PMID: 32232436 DOI: 10.1093/ehjqcco/qcaa029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 11/13/2022]
Abstract
AIMS The American College of Cardiology appropriate use criteria (AUC) provide clinicians with evidence-informed recommendations for cardiac care. Adopting AUC into clinical workflows may present challenges, and there may be specific implementation strategies that are effective in promoting effective use of AUC. We sought to assess the effect of implementing AUC in clinical practice. METHODS AND RESULTS We conducted a meta-analysis of studies found through a systematic search of the MEDLINE, Web of Science, Cochrane, or CINAHL databases. Peer-reviewed manuscripts published after 2005 that reported on the implementation of AUC for a cardiovascular test or procedure were included. The main outcome was to determine if AUC implementation was associated with a reduction in inappropriate/rarely appropriate care. Of the 18 included studies, the majority used pre/post-cohort designs; few (n = 3) were randomized trials. Most studies used multiple strategies (n = 12, 66.7%). Education was the most common individual intervention strategy (n = 13, 72.2%), followed by audit and feedback (n = 8, 44.4%) and computerized physician order entry (n = 6, 33.3%). No studies reported on formal use of stakeholder engagement or 'nudges'. In meta-analysis, AUC implementation was associated with a reduction in inappropriate/rarely appropriate care (odds ratio 0.62, 95% confidence interval 0.49-0.78). Funnel plot suggests the possibility of publication bias. CONCLUSION We found most published efforts to implement AUC observed reductions in inappropriate/rarely appropriate care. Studies rarely explored how or why the implementation strategy was effective. Because interventions were infrequently tested in isolation, it is difficult to make observations about their effectiveness as stand-alone strategies. STUDY REGISTRATION PROSPERO 2018 CRD42018091602. Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018091602.
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Affiliation(s)
- David E Winchester
- Cardiology Section, Malcom Randall VAMC, 1601 SW Archer Rd 111-D, Gainesville, FL, USA.,Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Justin Merritt
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Nida Waheed
- Department of Internal Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Hannah Norton
- University of Florida College of Medicine, Health Science Center Library, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Veena Manja
- Department of Surgery, University of California Davis, 2315 Stockton Blvd, Sacramento, CA 95817, USA.,VA Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA
| | - Nishant R Shah
- Department of Medicine, Providence VA Medical Center, Brown University Warren Alpert Medical School, 830 Chalkstone Ave, Providence, RI 02908, USA.,Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Christian D Helfrich
- Seattle-Denver Center for Innovation in Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way Mailstop S-152 Seattle, WA 98108, USA
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12
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Leis B, Bare I, Marshall K, Buschau E, Penner L, Keith C, De Villiers JS, Orvold J. Reducing Unnecessary Noninvasive Testing for Inpatients With Unstable Angina: The RUNIT Protocol. CJC Open 2020; 3:516-523. [PMID: 34027356 PMCID: PMC8129432 DOI: 10.1016/j.cjco.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/05/2020] [Indexed: 11/16/2022] Open
Abstract
Background Routine inpatient transthoracic echocardiography (TTE) for patients with unstable angina is common, but it anecdotally adds little value to clinical care. A practice audit at our academic hospital demonstrated that 61.5% of patients with troponin-negative chest pain (TNCP) had normal left ventriculography (LVG) during coronary angiography and normal TTE on the same admission (duplicate testing). Methods We developed the Reducing Non-Invasive Testing (RUNIT) protocol, a clinical algorithm applied by clinical nurses to patient with TNCP. We performed a prospective assessment of rate of duplicate testing before and after intervention. If patients met certain simple clinical criteria, their TTE was cancelled (RUNIT positive). Patients then proceeded to have either coronary angiography with LVG or noninvasive risk stratification. We aimed to reduce duplicate testing by 25% over a 1-year period. Balancing measures included pathology on ordered TTEs, 30-day readmission, length of stay, and number of LVG. Results Among 254 patients admitted with TNCP over 12 months, we reduced duplicate testing from 61.5% (before intervention) to 34% (P = 0.001). There was no clinical difference in 30-day readmission (0.9% vs 0.7%), and length of stay was significantly shorter in RUNIT positive (3.48 vs 4.16 days, P = 0.02). The majority of duplicate TTEs did not reveal any management-informing pathology. RUNIT-positive patients underwent more LVG than RUNIT-negative patients (78.3% vs 62.8%, P = 0.008). Conclusion We achieved a sustained reduction in reflexive TTE ordering in patients with TNCP, and we discuss the potential of nursing-led interventions to address other areas of low value care in cardiology.
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Affiliation(s)
- Benjamin Leis
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Idris Bare
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kirsten Marshall
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Elise Buschau
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Penner
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Cassandra Keith
- Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - J S De Villiers
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Jason Orvold
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Division of Cardiology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
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13
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Lam JH, Pickles K, Stanaway FF, Bell KJL. Why clinicians overtest: development of a thematic framework. BMC Health Serv Res 2020; 20:1011. [PMID: 33148242 PMCID: PMC7643462 DOI: 10.1186/s12913-020-05844-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests. METHODS Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development. RESULTS The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: "Intrapersonal" - fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation "Interpersonal" - pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; "Environment/context" - guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology CONCLUSION: This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.
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Affiliation(s)
- Justin H Lam
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia.
| | - Kristen Pickles
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Fiona F Stanaway
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Katy J L Bell
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
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Effects of an Electronic Medical Record Intervention on Appropriateness of Transthoracic Echocardiograms: A Prospective Study. J Am Soc Echocardiogr 2020; 34:176-184. [PMID: 33139140 DOI: 10.1016/j.echo.2020.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/04/2020] [Accepted: 09/12/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders. METHODS This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography. RESULTS Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z = 0.00018) but decreased to 90.0% at late intervention (z = 0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30 days prior (odds ratio = 2.85; 95% CI, 1.18-6.31; P = .005). CONCLUSIONS The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns.
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Application of Appropriate Use Criteria for Echocardiography in Pediatric Patients with Palpitations and Arrhythmias. Pediatr Qual Saf 2020; 5:e364. [PMID: 33134762 PMCID: PMC7591125 DOI: 10.1097/pq9.0000000000000364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/14/2020] [Indexed: 11/25/2022] Open
Abstract
Before the integration of the pediatric appropriate use criteria (AUC) for initial transthoracic echocardiography (TTE) in the outpatient setting with our electronic medical record (EMR), there was a high proportion of “rarely appropriate” TTEs (17.2%) ordered for palpitations/arrhythmias. We studied appropriateness ratings and applicability of pediatric AUC on the initial outpatient evaluation of children with palpitations/arrhythmias after EMR integration and the yield of abnormal TTEs for these indications.
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16
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A Quality Initiative to Improve Appropriate Use of Initial Outpatient Echocardiography Among Pediatric Cardiologists. Pediatr Qual Saf 2020; 5:e313. [PMID: 32766488 PMCID: PMC7382553 DOI: 10.1097/pq9.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/21/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction: Methods: Results: Conclusions:
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17
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Pockros B, Balamurugan A, Radparvar J, Chilingerian JA, Cohen M. System-Wide Echocardiography Accreditation: Physician Perceptions and Concerns. J Am Soc Echocardiogr 2020; 33:255-256. [DOI: 10.1016/j.echo.2019.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/09/2019] [Accepted: 09/09/2019] [Indexed: 02/05/2023]
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18
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Tharmaratnam T, Bouck Z, Sivaswamy A, Wijeysundera HC, Chu C, Yin CX, Nesbitt GC, Edwards J, Yared K, Wong B, Weinerman A, Thavendiranathan P, Rakowski H, Dorian P, Anderson G, Austin PC, Dudzinski DM, Ko DT, Weiner RB, Bhatia RS. Association Between Physicians' Appropriate Use of Echocardiography and Subsequent Healthcare Use and Outcomes in Patients With Heart Failure. J Am Heart Assoc 2020; 9:e013360. [PMID: 31870231 PMCID: PMC6988149 DOI: 10.1161/jaha.119.013360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background There is little understanding of whether a physician's tendency to order an inappropriate cardiac service is associated with the use of other cardiac services and clinical outcomes in their patients with heart failure (HF). Methods and Results We conducted a secondary analysis of 35 Ontario‐based cardiologists who participated in the control arm of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial. Transthoracic echocardiograms, ordered during the trial, were classified as rarely appropriate (rA), appropriate, or maybe appropriate on the basis of the 2011 appropriate use criteria. Cardiologists were grouped into tertiles of rA transthoracic echocardiogram ordering frequency: low ordering (bottom tertile), n=11; moderate ordering, n=12; or high ordering (top tertile), n=12. The main outcomes were measures of cardiac service use, including cardiology‐related physician visits, tests, and medications. Among 1677 patients with heart failure and an outpatient visit to 1 of 35 cardiologists, we found no significant association between rA transthoracic echocardiogram ordering frequency (by tertile) and cardiac testing use, although patients of cardiologists in the high ordering group had fewer physician visits, on average, than patients seen by low ordering cardiologists. In addition, patients of cardiologists in the highest rA ordering tertile had significantly lower odds of receiving potentially effective interventions, such as β blockers (odds ratio, 0.62; 95% CI, 0.43–0.89), than the low ordering group. Conclusions Although patients of cardiologists who frequently order rA transthoracic echocardiograms do not appear more (or less) likely to have subsequent cardiac tests, these patients have fewer follow‐up visits and lower odds of receiving evidence‐based medications. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02038101.
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Affiliation(s)
- Tharmegan Tharmaratnam
- School of Medicine Royal College of Surgeons Ireland Dublin Ireland.,Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,Dalla Lana School of Public Health University of Toronto Ontario Canada
| | | | - Harindra C Wijeysundera
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Cherry Chu
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Cindy X Yin
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | | | - Jeremy Edwards
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Kibar Yared
- The Scarborough Hospital Toronto Ontario Canada
| | - Brian Wong
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Adina Weinerman
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | | | - Harry Rakowski
- Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
| | - Paul Dorian
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Geoff Anderson
- Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - Peter C Austin
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - David M Dudzinski
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - Dennis T Ko
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Rory B Weiner
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
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Pantoja T, Grimshaw JM, Colomer N, Castañon C, Leniz Martelli J. Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database Syst Rev 2019; 12:CD001174. [PMID: 31858588 PMCID: PMC6923326 DOI: 10.1002/14651858.cd001174.pub4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care. OBJECTIVES 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies. SELECTION CRITERIA We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions. DATA COLLECTION AND ANALYSIS Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects. AUTHORS' CONCLUSIONS Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.
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Affiliation(s)
- Tomas Pantoja
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Nathalie Colomer
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Carla Castañon
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Javiera Leniz Martelli
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
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Salik JR, Sen S, Picard MH, Weiner RB, Dudzinski DM. The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit. Echocardiography 2019; 36:631-638. [PMID: 30969477 DOI: 10.1111/echo.14314] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 01/27/2019] [Accepted: 02/18/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary-care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU. METHODS Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator. RESULTS Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%-77.9%), 12 as uncertain (1.5%, CI 0.75%-2.5%), 21 as rarely appropriate (2.5%, CI 1.6%-3.9%), and 174 were unable to be classified (21.1%, CI 18.3%-24.0%). The most common unclassifiable indication was "initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology" (n = 101). CONCLUSION Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU.
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Affiliation(s)
- Jonathan R Salik
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Sounok Sen
- Cardiology Division, Duke University, Durham, North Carolina
| | - Michael H Picard
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - David M Dudzinski
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts.,Cardiac Intensive Care Unit, Massachusetts General Hospital, Boston, Massachusetts
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Lim N, Sanchez O, Olson A. Impact on 30-d readmissions for cirrhotic patients with ascites after an educational intervention: A pilot study. World J Hepatol 2019; 11:701-709. [PMID: 31749900 PMCID: PMC6856018 DOI: 10.4254/wjh.v11.i10.701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/23/2019] [Accepted: 10/02/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement. We hypothesized that a medical educational intervention, delivered to medical residents caring for patients with cirrhosis, would improve quality of care.
AIM To determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites.
METHODS We performed a pilot prospective cohort study with time-based randomization over six months at a large teaching hospital. Residents rotating on hospital medicine teams received an educational intervention while residents rotating on hospital medicine teams on alternate months comprised the control group. The primary outcome was provision of quality care- defined as adherence to all quality-based indicators derived from evidence-based practice guidelines- in admissions for patients with cirrhosis and ascites. Patient clinical outcomes- including length of hospital stay (LOS); 30-d readmission; in-hospital mortality and overall mortality- and resident educational outcomes were also evaluated.
RESULTS Eighty-five admissions (60 unique patients) met inclusion criteria over the study period-46 admissions in the intervention group and 39 admissions in the control group. Thirty-seven admissions were female patients, and 44 admissions were for alcoholic liver disease. Mean model for end-stage liver disease (MELD)-Na score at admission was 25.8. Forty-seven (55.3%) admissions received quality care. There was no difference in the provision of quality care (56.41% vs 54.35%, P = 0.9) between the two groups. 30-d readmission was lower in the intervention group (35% vs 52.78%, P = 0.1) and after correction for age, gender and MELD-Na score [RR = 0.62 (0.39, 1.00), P = 0.05]. No significant differences were seen for LOS, complications, in-hospital mortality or overall mortality between the two groups. Resident medical knowledge and self-efficacy with paracentesis improved after the educational intervention.
CONCLUSION Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites.
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Affiliation(s)
- Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, United States
| | - Otto Sanchez
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN 55455, United States
| | - Andrew Olson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN 55455, United States
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22
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Cox K, Arunamata A, Krawczeski CD, Reddy C, Kipps AK, Long J, Roth SJ, Axelrod DM, Hanley F, Shin A, Selamet Tierney ES. "Echo pause" for postoperative transthoracic echocardiographic surveillance. Echocardiography 2019; 36:2078-2085. [PMID: 31628768 DOI: 10.1111/echo.14505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/17/2019] [Accepted: 09/25/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND No guidelines exist for inpatient postoperative transthoracic echocardiographic (TTE) surveillance in congenital heart disease. We prospectively evaluated indications for postoperative TTEs in patients with congenital heart disease to identify areas to improve upon (Phase 1) and then assessed the impact of a simple pilot intervention (Phase 2). METHODS We included patients with RACHS-1 (Risk Adjustment for Congenital Heart Surgery) scores of 2 and 3 to keep the cohort homogenous. During Phase 1, we collected data prospectively to identify postoperative TTEs for which there were no new findings and no associated clinical management decisions ("potentially redundant" TTEs). During Phase 2, prior to placement of a TTE order, an "Echo Pause" was performed during rounds to prompt review of prior TTE results and indication for the current order. The number of "potentially redundant" TTEs during Phase 1 vs. Phase 2 was compared. RESULTS During Phase 1, 98 postoperative TTEs were performed on 51 patients. Potentially "redundant" TTEs were identified in two main areas: (a) TTEs ordered to evaluate pericardial effusion and (b) TTEs ordered with the indication of "postoperative," "follow-up," or "discharge" in the setting of a prior complete postoperative TTE and no apparent change in clinical status. During Phase 2, 101 TTEs were performed on 63 patients. The number of "potentially redundant" TTEs decreased from 14/98 (14%) to 5/101 (5%) (P = .026). CONCLUSION Our results suggest that the number of "potentially redundant" TTEs during inpatient postoperative surveillance of patients with congenital heart disease can be decreased by a simple intervention during rounds such as an "Echo Pause."
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Affiliation(s)
- Kelly Cox
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Catherine D Krawczeski
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Charitha Reddy
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Alaina K Kipps
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Jin Long
- Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Stephen J Roth
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Frank Hanley
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Palo Alto, California
| | - Andrew Shin
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
| | - Elif Seda Selamet Tierney
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine, Stanford University, Palo Alto, California
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23
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Kozak PM, Trumbo SP, Christensen BW, Leverenz DL, Shotwell MS, Kingeter AJ. Addition of price transparency to an education and feedback intervention reduces utilization of inpatient echocardiography by resident physicians. Int J Cardiovasc Imaging 2019; 35:1259-1263. [DOI: 10.1007/s10554-019-01572-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/23/2019] [Indexed: 10/27/2022]
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24
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Fonseca R, Jose K, Marwick TH. Understanding decision-making in cardiac imaging: determinants of appropriate use. Eur Heart J Cardiovasc Imaging 2019; 19:262-268. [PMID: 29206942 DOI: 10.1093/ehjci/jex257] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/27/2017] [Indexed: 11/14/2022] Open
Abstract
Aims Appropriate Use Criteria (AUC) for echocardiography were developed in 2007 to facilitate decision-making, reduce variability in test utilization, and encourage rational use of imaging. However, there is little evidence that the AUC have favourably influenced ordering behaviour. This study explores the factors that contribute to clinicians requesting echocardiograms with a focus on appropriate use. Methods and results Semi-structured face-to-face interviews with cardiologists and non-cardiologists who had requested echocardiograms were conducted at an Australian tertiary hospital. The interview guide included hypothetical clinical scenarios to better understand decision-making in ordering echocardiograms and the actions they could take when receiving test reports. Interviews underwent thematic analysis. Seventeen clinicians were interviewed, ten of whom were cardiologists. All participants ordered echocardiograms to support their clinical decision-making. Awareness of the AUC was low. The categorization of tests as 'appropriate' or 'inappropriate' was considered ineffective as it failed to reflect the decision-making process. The decision to request echocardiograms was influenced by a number of personal and systemic factors as well as guidelines and protocols. Training and experience, patients' expectations, and management of uncertainty were key personal factors. Systemic factors involved the accessibility of services and health insurance status of the patient. Conclusion Factors that influenced the ordering of echocardiograms by clinicians at a tertiary care hospital did not appear to be amenable to control with AUC. Alternative approaches may be more effective than the AUC in addressing the overuse of echocardiography.
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Affiliation(s)
- Ricardo Fonseca
- Cardiovascular Imaging group, Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Kim Jose
- Cardiovascular Imaging group, Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Thomas H Marwick
- Cardiovascular Imaging group, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Victoria 3004, Australia
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25
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Anderson S, McCracken CE, Sachdeva R. Appropriateness of pediatric outpatient transthoracic echocardiogram orders following cessation of an active educational intervention. CONGENIT HEART DIS 2018; 13:1050-1057. [PMID: 30294873 DOI: 10.1111/chd.12679] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/30/2018] [Accepted: 08/28/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The educational intervention (EI) through the Pediatric Appropriate Use of Echocardiography (PAUSE) multicenter study resulted in improved appropriateness of transthoracic echocardiogram (TTE) orders at our center. The current study evaluated if this pattern persisted after cessation of EI and the potential physician characteristics influencing appropriateness. DESIGN Outpatients (≤18 years old) seen for initial evaluation during the EI (July to October, 2015) and 6-month post-EI (May to August, 2016) phases were included. Comparison was made between TTE rates and appropriateness ratings during EI and post-EI phase. Association between TTE rate and appropriateness with physician characteristics (age, experience, patient volume, and area of practice) was determined using odds ratio. RESULTS The study included 7781 patients (EI: N = 4016; post-EI: N = 3765) seen by 31 physicians. Comparison of appropriateness ratings in a randomized sample (EI: N = 1270; post-EI: N = 1325 patients) showed no significant differences between the two phases (appropriate: 75.2% vs 74.9%, P = .960; rarely appropriate 4.1% vs 6.5%, P = .065). Though there was significant variability among physicians for TTE order appropriateness (P = .044) and ordering rate (P <.001), none of their characteristics were associated with appropriateness and only a higher patient volume was associated with decreased odds of TTE ordering (OR =0.7). CONCLUSION The PAUSE study EI resulted in maintaining appropriate utilization of TTEs at our center for 6 months following its cessation. Though not statistically significant, there was a trend toward increase in the proportion of studies for indications designated rarely appropriate (R). There was significant physician variability in TTE ordering and appropriateness during both phases. Development of EI to reduce physician variability and integration of EI with provider workflow may help sustain appropriate TTE utilization.
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Affiliation(s)
- Shae Anderson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Courtney E McCracken
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
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26
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Lopes JR, Oliveira AC, Rios VG, Correia LCL. Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists and patients. ACTA ACUST UNITED AC 2018; 51:e7413. [PMID: 29846434 PMCID: PMC5999063 DOI: 10.1590/1414-431x20187413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/06/2018] [Indexed: 01/08/2023]
Abstract
Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.
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Affiliation(s)
- J R Lopes
- Escola Bahiana de Medicina e Saúde Pública, Brotas, Salvador, BA, Brasil
| | - A C Oliveira
- Escola Bahiana de Medicina e Saúde Pública, Brotas, Salvador, BA, Brasil
| | - V G Rios
- Cardioclin, Conceição do Coité, BA, Brasil
| | - L C L Correia
- Escola Bahiana de Medicina e Saúde Pública, Brotas, Salvador, BA, Brasil
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27
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Kaushal N, Wijeysundera HC, Connelly KA, Roifman I. Appropriate utilization of cardiac magnetic resonance for the assessment of heart failure and potential associated cost savings. J Magn Reson Imaging 2018; 49:e132-e138. [PMID: 29573034 DOI: 10.1002/jmri.26015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/02/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The rapid growth in cardiac imaging utilization has led to the development of appropriate use criteria (AUC) in an effort to control costs. Recently, cardiac MRI has developed into a valuable modality in the evaluation of cardiac disease. However, there are no studies examining the appropriate use of cardiac MRI in clinical practice. PURPOSE To determine the appropriate utilization of cardiac MRI in a large quaternary care institution and to compare percentages of appropriate utilization pre- and postpublication of the AUC document. We hypothesized that percentages of appropriate cardiac MRI utilization will be similar to those of other comparable cardiac imaging modalities and that there would be a significant change in appropriate use pre- and post-AUC publication. STUDY TYPE Retrospective cohort study. POPULATION In all, 2032 consecutive patients undergoing cardiac MRI for the assessment of heart failure between 2012-2016. FIELD STRENGTH 1.5T. ASSESSMENT Data were collected and an appropriateness category was assigned for each cardiac MRI. STATISTICAL TESTS Rates of major cardiac risk factors were compared between those undergoing cardiac MRIs pre- and post-AUC using the chi-square and the Mann-Whitney tests for categorical and continuous variables, respectively. Appropriateness classification was compared pre- and post-AUC publication using the chi-square test. RESULTS There were no significant differences in the prevalence of major cardiovascular risk factors before and after publication of the AUC. 95.5% of all cardiac MRIs were appropriate based on the AUC. Further, there was a significant difference when comparing the appropriateness classification before and after publication of the AUC (P = 0.0003), potentially associated with annual cost savings of ∼$14.8 million. DATA CONCLUSION We report a very high percentage of appropriate use of cardiac MRI and a significant increase in the proportion of tests classified as appropriate after AUC publication. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;49:e132-e138.
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Affiliation(s)
- Nishchay Kaushal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Idan Roifman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
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28
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Kerley RN, Thornton KP, Kelly RM, O'Flynn S. Appropriate use criteria for transthoracic echocardiography: Are they relevant to European centers? Echocardiography 2017; 35:17-23. [DOI: 10.1111/echo.13730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | | | - Siun O'Flynn
- School of Medicine; University College Cork; Cork Ireland
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29
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Romano MMD, Branco M, Moreira HT, Schmidt A, Kisslo J, Maciel BC. Appropriate use of echocardiography and relation to clinical decision making in both inpatients and outpatients in a developing country. Echocardiography 2017; 35:9-16. [PMID: 28994142 DOI: 10.1111/echo.13725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Use of echocardiography (echo) has exponentially increased in recent decades. Concerned about this scientific society developed appropriate use criteria (AUC). Clinical management still suffers geographical variations, and no objective data are available about echo AUC in developing countries. We aimed to evaluate (1) the appropriateness of referrals and (2) their relation to changes in clinical decision management. METHODS Prospective analysis of referrals from January to December 2014. Appropriateness and endpoints analyzed in different time points from medical archives. ENDPOINTS (1) change in the diagnosis, (2) indication for another method to complete the diagnosis, (3) change in clinical treatment, (4) indication for a treatment intervention, or (5) no change in management. Descriptive statistical analysis, Fisher's or chi-square tests, and Cox regression used as appropriate (significance if P < .05). RESULTS One thousand one hundred referrals were analyzed (55.5 ± 16.1 years, 44.6% male). 80.5% of referrals were appropriate (A), 11.2% "Rarely Appropriate" (RA), and 8.3% "May Be Appropriate" (MBA). Proportion of (A) did not differ between modalities (TTE-80.5% vs TEE-87.7% vs STR-81.2%, P = .67). (A) referrals were more related to clinical decision than (RA)+(MBA) (38.9% [A] vs 15% [RA]+[MBA], P < .001). The most frequent clinical indications of (RA) and (MBA) TTE were reevaluation of ventricular function without clinical change (AUC 10 and 11) and search of infectious endocarditis when low clinical probability (53). CONCLUSIONS In a developing country, appropriateness of echo was similar to the United States and Europe. However, a significant proportion of referrals were still (RA) or (MBA), with no effect in clinical management. Controlling referrals 10, 11, and 53 can optimize echo use in developing countries.
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Affiliation(s)
- Minna Moreira Dias Romano
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Marina Branco
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Henrique Turin Moreira
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - André Schmidt
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Joseph Kisslo
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Benedito Carlos Maciel
- Cardiology Center of the Medical School of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
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30
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Hua A, McCaughan V, Wright M, Zaidi A, Wright J, Azam A, Bhattacharyya S, Stock L, Lloyd G, Bhattacharyya S. Appropriateness, diagnostic value, and outcomes of repeat testing following index echocardiography. Echocardiography 2017; 35:24-29. [PMID: 28994195 DOI: 10.1111/echo.13726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIMS Emergency admission to hospital is associated with an economic burden and mortality. Echocardiography is often the first-line cardiovascular imaging investigation. Repeat testing is common; however, there are sparse data on the prevalence, appropriateness, or outcome of repeat testing. METHODS We performed an electronic database search for patients with emergency admissions to our institution in February 2015. An electronic patient record review of inpatient echocardiograms was undertaken. Indications for echocardiography were classified as appropriate, may be appropriate, or rarely appropriate. One-year follow-up for repeat testing and mortality was investigated. RESULTS A total of 409 of 2306 (17.7%) unplanned/emergency admissions underwent inpatient echocardiography. Abnormalities were identified in 165/409 (40.3%) of these patients; 154 of 409 (37.7%) had a repeat echocardiogram within the next year. Rarely appropriate indications for echocardiography occurred in 51 (33%) of repeat vs 53 (16%) of index echocardiograms, P < .0001. Repeat testing was associated with a change in findings in 17/154 (11%) patients overall. All of whom had an abnormal index echocardiogram and had an appropriate indication. There was no difference in mean survival time between patients who underwent repeat and those who only underwent a single index echocardiogram (310 days vs 327 days), P = .34. CONCLUSION Inpatient echocardiography in emergency hospital admissions identifies clinically important pathology. Repeated testing is common within 1 year of hospital admission. New diagnostic findings occurred in 11% of patients and only in patients with appropriate studies and an abnormal index echocardiogram. Identification of methods to reduce repeat testing and implement appropriateness criteria is warranted.
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Affiliation(s)
- Alina Hua
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Vincent McCaughan
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Matthew Wright
- University College London Hospital, London, United Kingdom
| | - Abbas Zaidi
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,University College London Hospital, London, United Kingdom
| | - Jessica Wright
- University College London Hospital, London, United Kingdom
| | - Aishah Azam
- University College London Hospital, London, United Kingdom
| | | | - Lisanne Stock
- University College London Hospital, London, United Kingdom
| | - Guy Lloyd
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,University College London Hospital, London, United Kingdom
| | - Sanjeev Bhattacharyya
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,University College London Hospital, London, United Kingdom
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31
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Singh A, Ward RP. Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare. Curr Cardiol Rep 2017; 18:93. [PMID: 27553788 DOI: 10.1007/s11886-016-0758-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The current climate in healthcare is increasingly emphasizing a value-based approach to diagnostic testing. Cardiac imaging, including echocardiography, has been a primary target of ongoing reforms in healthcare delivery and reimbursement. The Appropriate Use Criteria (AUC) for echocardiography is a physician-derived tool intended to guide utilization in optimal patient care. To date, the AUC have primarily been employed solely as justification for reimbursement, though evolving broader applications to guide clinical decision-making suggest a far more valuable role in the delivery of high-quality and high-value healthcare.
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Affiliation(s)
- Amita Singh
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA
| | - R Parker Ward
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA.
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32
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Hayes V, Bing-You R, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Is feedback to medical learners associated with characteristics of improved patient care? PERSPECTIVES ON MEDICAL EDUCATION 2017; 6:319-324. [PMID: 28852991 PMCID: PMC5630536 DOI: 10.1007/s40037-017-0375-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE To investigate the association of medical learner feedback with patient management and outcomes. METHODS The authors investigated 27 articles that utilized patient data or chart reviews as a subset of a prior feedback scoping review. Data extraction was completed by two authors and all authors reviewed the descriptive data analysis. RESULTS The studies were predominantly short-term investigations conducted in the US at academic teaching hospitals (89%) with one medical discipline (78%), most commonly internal medicine (56%). Patient-related outcomes primarily involved improved documentation (26%) and adherence to practice guidelines (19%) and were mostly measured through chart reviews (56%) or direct observation (15%). The primary method of feedback delivery involved a written format (30%). The majority of the studies showed a positive effect of feedback on the patient-oriented study outcomes (82%), although most involved a non-rigorous study design. CONCLUSIONS Published studies focusing on the relationship between medical learner feedback and patient care are sparse. Most involve a single discipline at a single institution and are of a non-rigorous design. Measurements of improved patient outcomes are restricted to changes in management, procedures and documentation. Well-designed studies that directly link learner feedback to patient outcomes may help to support the use of feedback in teaching clinical outcomes improvement in alignment with competency-based milestones.
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33
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Sachdeva R, Kelleman MS, McCracken CE, Campbell RM, Lai WW, Lopez L, Stern KW, Welch E, Douglas PS. Physician Attitudes toward the First Pediatric Appropriate Use Criteria and Engagement With Educational Intervention to Improve the Appropriateness of Outpatient Echocardiography. J Am Soc Echocardiogr 2017; 30:926-931.e2. [DOI: 10.1016/j.echo.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Indexed: 01/12/2023]
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34
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Improving the Appropriate Use of Transthoracic Echocardiography. J Am Coll Cardiol 2017; 70:1135-1144. [DOI: 10.1016/j.jacc.2017.06.065] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/21/2017] [Accepted: 06/29/2017] [Indexed: 01/25/2023]
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35
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Winchester DE, Schmalfuss C, Helfrich CD, Beyth RJ. A specialty-specific, multimodality educational quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging. Open Heart 2017; 4:e000589. [PMID: 28674630 PMCID: PMC5471866 DOI: 10.1136/openhrt-2017-000589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/06/2017] [Accepted: 04/11/2017] [Indexed: 01/03/2023] Open
Abstract
Objective Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI. Methods We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention. Results A total of 889 MPI were evaluated (n=287 pre, n=313 post, n=289 late-post), 95.3% were men. Chest pain was the most common symptom (n=530, 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% in the late-post cohort (p<0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p≤0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI. Conclusions In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered.
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Affiliation(s)
- David E Winchester
- Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Carsten Schmalfuss
- Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Rebecca J Beyth
- Geriatric Research Education and Clinical Centers (GRECC), Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Division of General Internal Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
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Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Chinnaiyan KM, Weiner RB. Trials of Quality Improvement in Imaging. JACC Cardiovasc Imaging 2017; 10:368-378. [PMID: 28279386 DOI: 10.1016/j.jcmg.2016.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/19/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
Cardiovascular imaging plays a central role in the diagnosis and treatment of cardiovascular disease. Recently, increased emphasis has been placed on quality in cardiovascular imaging, and it is becoming a central priority for various stakeholders, including patients, physicians, and payers. The changing health care landscape and associated challenges imposed on cardiac imagers, including reductions in reimbursement and growing need for pre-authorization, have also helped bring quality metrics to the forefront. Continuous quality improvement initiatives provide the framework for the team of physicians, technical staff members, administrators, and other health care professionals to deliver high-quality care. Efforts to improve quality in cardiac imaging have started to form the foundation for numerous research studies in this arena, and although few in number, randomized control trials have begun to emerge. This review highlights quality improvement studies focusing on appropriate use education, reporting, and radiation dose reduction in cardiovascular imaging.
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Affiliation(s)
| | - Rory B Weiner
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Fonseca R, Otahal P, Galligan J, Neilson S, Huynh Q, Saito M, Negishi K, Marwick TH. Association of survival time with transthoracic echocardiography in stable patients with heart failure: Is routine follow-up ever appropriate? Int J Cardiol 2017; 230:619-624. [PMID: 28043666 DOI: 10.1016/j.ijcard.2016.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/14/2016] [Accepted: 12/16/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The appropriateness of repeat transthoracic echocardiography (TTE) for stable heart failure (HF) is based on timing of the follow-up examination, but this lacks scientific support. We sought the association of routine follow-up TTE on survival and readmission in stable HF. METHODS Patients with HF were selected from consecutive HF admissions from 2008 to 2012. Groups were divided into: no follow-up TTE; routine <1year with no change in status ("rarely appropriate"), ≥1year follow-up with no change in status ("maybe appropriate") and TTE due to change in clinical status ("appropriate"). Survival analysis was performed for the combined endpoint of HF readmission and death, and a separate analysis was performed for HF readmission, with death as a competing risk. RESULTS Of 550 HF patients, 141 had a follow-up TTE, including 41 (29%) within 1year. The event-free time in years was similar between no TTE (1.10years [95%CI: 0.69, 1.49], routine TTE <1year (2.61years [95% CI: 1.08, 3.04], routine >1year (2.45years [95% CI: 1.37, 5.78]); all were greater than symptomatic patients (0.09years [95% CI: 0.02, 1.80]). HF readmission was independently associated with statins, renal disease, coronary angiography and NYHA class, but not follow-up TTE timing. There were no differences in the cumulative incidence for death between groups. There were no differences in change in management in routine TTE <1year and ≥1year. CONCLUSION The distinction of appropriateness of routine repeat TTE in stable HF patients, based on testing <1 or ≥1year after index admission appears unjustified.
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Affiliation(s)
| | - Petr Otahal
- Menzies Institute for Medical Research, Hobart, Australia
| | | | | | - Quan Huynh
- Menzies Institute for Medical Research, Hobart, Australia
| | - Makoto Saito
- Menzies Institute for Medical Research, Hobart, Australia
| | | | - Thomas H Marwick
- Menzies Institute for Medical Research, Hobart, Australia; Baker-IDI Heart and Diabetes Institute, Melbourne, Australia.
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Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KW, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW. Educational intervention for improving the appropriateness of transthoracic echocardiograms ordered by pediatric cardiologists. CONGENIT HEART DIS 2017; 12:373-381. [DOI: 10.1111/chd.12455] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/06/2016] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ritu Sachdeva
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | | | - Michael S. Kelleman
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Courtney E. McCracken
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Leo Lopez
- Nicklaus Children's Hospital; Miami Florida USA
| | | | | | | | - Rory B. Weiner
- Massachusetts General Hospital; Boston Massachusetts USA
| | | | - Robert M. Campbell
- Emory University School of Medicine and Children's Healthcare of Atlanta Sibley Heart Center Cardiology; Atlanta Georgia USA
| | - Wyman W. Lai
- NewYork-Presbyterian, Morgan Stanley Children's Hospital; New York New York USA
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Phelps HM, Kelleman MS, McCracken CE, Benavidez OJ, Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Stern KWD, Welch E, Sachdeva R. Application of pediatric appropriate use criteria for initial outpatient evaluation of syncope. Echocardiography 2017; 34:441-445. [PMID: 28177138 DOI: 10.1111/echo.13475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Syncope is a common reason for outpatient transthoracic echocardiography (TTE). We studied the applicability of pediatric appropriate use criteria (AUC) on initial outpatient evaluation of children (≤18 years) with syncope. METHODS Data were obtained before (Phase I, April-September 2014) and after (Phase II, January-April 2015) the release of the AUC document from six participating pediatric cardiology centers. Site investigators determined the indication for TTE and assigned appropriateness rating based on the AUC document: Appropriate (A), May Be Appropriate (M), Rarely Appropriate (R), or "unclassifiable" (U) if it did not fit any scenario in the AUC document. RESULTS Of the total 4562 TTEs, 310 (6.8%) were performed for syncope: 174/2655 (6.6%) Phase I and 136/1907 (7.1%) Phase II, P=.44. Overall, 168 (50.5%) were for indications rated A, 63 (18.9%) for M, 79 (23.7%) for R, and 23 (6.9%) for U. Release of AUC did not change the appropriateness of TTEs [A=51.6% vs 49.0%, P=.63, R=20.2% vs 28.3%, P=.09]. Overall syncope-related R indications formed 15.7% of R indications for all the echocardiograms performed in the entire Pediatric Appropriate Use (PAUSE) study (11.9% Phase I and 22.4% Phase II, P=.002). TTEs were normal in majority of the patients except 7 that had incidental findings. CONCLUSIONS In conclusion, syncope is a common reason for indications rated R and release of the AUC document did not improve appropriate utilization of TTE in syncope. Targeted educational interventions are needed to reduce unnecessary TTEs in children with syncope.
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Affiliation(s)
| | | | | | | | | | | | | | - Wyman W Lai
- Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, USA
| | - Leo Lopez
- Nicklaus Children's Hospital, Miami, FL, USA
| | | | | | - Ritu Sachdeva
- Emory University School of Medicine, Atlanta, GA, USA
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Parthiban A, Levine JC, Nathan M, Marshall JA, Shirali GS, Simon SD, Colan SD, Newburger JW, Raghuveer G. Implementation of a Quality Improvement Bundle Improves Echocardiographic Imaging after Congenital Heart Surgery in Children. J Am Soc Echocardiogr 2016; 29:1163-1170.e3. [DOI: 10.1016/j.echo.2016.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Indexed: 12/21/2022]
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Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KWD, Eidem BW, Benavidez OJ, Weiner RB, Welch E, Campbell RM, Lai WW. Effect of Release of the First Pediatric Appropriate Use Criteria on Transthoracic Echocardiogram Ordering Practice. Am J Cardiol 2016; 118:1545-1551. [PMID: 27639687 DOI: 10.1016/j.amjcard.2016.08.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 11/17/2022]
Abstract
Pediatric appropriate use criteria (AUC) were recently published for initial outpatient transthoracic echocardiography (TTE). The purpose of this study was to determine the effect of AUC publication on TTE ordering patterns of pediatric cardiologists. Data were prospectively collected on patients who had initial outpatient TTE ordered before (phase I, April to September 2014) and 3 months after (phase II, January to April 2015) AUC document publication at 6 centers. Site investigators assessed each study's indication and assigned AUC appropriateness as "appropriate" (A), "may be appropriate" (M), "rarely appropriate" (R), or "unclassifiable." One hundred three physicians ordered 4,562 TTEs (2,655 phase I and 1,907 phase II). Overall, there was no statistically significant change in the proportion of A, M, or unclassifiable, but R decreased (12.0% to 9.6%, p = 0.01). There was significant variability among the centers in the percentage of studies for indications rated R (4.9% to 34.8%). There was no significant change in any of the appropriateness ratings at 4 centers, a decrease in R and an increase in A at 1 and a decrease in R and increase in unclassifiable at another. The first pediatric AUC document had only a small impact on physician ordering behavior for initial TTEs, including a small decrease in R. There was a significant variability in appropriateness of studies among centers. These data suggest that active educational interventions are required to substantially improve the appropriate use of pediatric TTE in the outpatient setting.
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Affiliation(s)
- Ritu Sachdeva
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia.
| | - Pamela S Douglas
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Michael S Kelleman
- Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia
| | - Leo Lopez
- Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Kenan W D Stern
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital at Montefiore, New York, New York
| | - Benjamin W Eidem
- Division of Pediatric Cardiology, Department of Pediatrics, Mayo Clinic Rochester, Rochester, Minnesota
| | - Oscar J Benavidez
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rory B Weiner
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth Welch
- Division of Cardiology, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Robert M Campbell
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Wyman W Lai
- Division of Pediatric Cardiology, NewYork-Presbyterian, Morgan Stanley Children's Hospital, New York, New York
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Pathan F, Fonseca R, Marwick TH. Usefulness of Hand-Held Ultrasonography as a Gatekeeper to Standard Echocardiography for "Rarely Appropriate" Echocardiography Requests. Am J Cardiol 2016; 118:1588-1592. [PMID: 27810098 DOI: 10.1016/j.amjcard.2016.08.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/12/2016] [Accepted: 08/12/2016] [Indexed: 10/20/2022]
Abstract
Adoption of appropriate use criteria has not had a major impact on the frequency of "rarely appropriate" tests, with the rarely appropriate tests rate remaining at ∼20% in most institutions. We sought whether access to hand-held ultrasound (HHU) could be an alternative means of reducing rarely appropriate requests. We compared 2 approaches to rarely appropriate requests; "standard transthoracic echocardiography" (SE) as requested (control) and HHU as a gatekeeper (HHU). Patients were followed up for 6 months and assessed for end points including time until scan, repeat echocardiography/cost of either strategy, new major pathology, and change in management. The most common rarely appropriate requests in both groups were assessment of infective endocarditis without positive blood cultures and precordial murmur evaluation in absence of any other signs or symptoms of cardiovascular disease. The groups had comparable age, gender, requesting physician, and inpatient versus outpatient distribution. HHU led to a 59% reduction in rarely appropriate requests requiring SE. HHU significantly reduced time to decision for inpatients (0 [interquartile range 0, 1] vs 2 days [interquartile range 1, 4], p <0.001) and total cost of echocardiography (109 ± 86 vs 181 ± 37 USD, p <0.001). New major pathology was identified in 29% and 23% of HHU and SE, respectively. There was no difference with respect to change in management. In conclusion, HHU can be an effective gatekeeper to SE for rarely appropriate echocardiograms, reducing time to echocardiography and cost while satisfying the referring physician and avoiding repeat requests for SE. HHU provides a safety net that identifies potential important findings in rarely appropriate requests.
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Fonseca R, Pathan F, Marwick TH. Development and validation of a screening tool for the identification of inappropriate transthoracic echocardiograms. BMJ Open 2016; 6:e012702. [PMID: 27707833 PMCID: PMC5073583 DOI: 10.1136/bmjopen-2016-012702] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE We sought whether simple clinical markers could be used in a questionnaire for recognition of inappropriate (or rarely appropriate, RA) tests at point-of-service. Most applications of appropriateness criteria (AC) for transthoracic echocardiogram (TTE) have been at the point of order, but a simple means of identifying RA tests in an audit process would be of value. DESIGN, SETTING AND PARTICIPANTS The study was performed in 2 major hospitals in Tasmania. 2 reviewers created a questionnaire based on 4 questions most commonly associated with RA (suspected endocarditis with no positive blood cultures or new murmur, lack of cardiovascular symptoms or no change in clinical status or cardiac examination, routine surveillance and previous TTE within a year) in a derivation cohort of 814 patients. This was prospectively applied to 499 TTEs to calculate sensitivity and specificity for prediction of RA, and validated in the external group (n=880). RESULTS Of 499 prospective TTEs, the questionnaire selected 18% requests as being potentially RA. As 7.4% were actually RA (κ 89%), the sensitivity and specificity of the questionnaire were 84% and 87%, respectively. In the external validation cohort, the model found 11% requests needed to be screened for appropriateness with a sensitivity and specificity of 80% and 95%. CONCLUSIONS A questionnaire based on 4 questions detects a high proportion of RA TTE, and could be used for audit.
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Affiliation(s)
- Ricardo Fonseca
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Faraz Pathan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Thomas H Marwick
- Baker IDI Heart and Diabetes Institute, Melbourne, Tasmania, Australia
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Keller EJ, Vogelzang RL, Freed BH, Carr JC, Collins JD. Physicians' professional identities: a roadmap to understanding "value" in cardiovascular imaging. J Cardiovasc Magn Reson 2016; 18:52. [PMID: 27566058 PMCID: PMC5002193 DOI: 10.1186/s12968-016-0274-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/12/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quality improvement efforts in cardiovascular imaging have been challenged by limited adoption of initiatives and policies. In order to better understand this limitation and inform future efforts, the range clinical values related to cardiovascular imaging at a large academic hospital was characterized. MATERIALS AND METHODS 15 Northwestern Medicine physicians from internal medicine, cardiology, emergency medicine, cardiac/vascular surgery, and radiology were interviewed about their use of cardiovascular imaging and imaging guidelines. Interview transcripts were systemically analyzed according to constructivist grounded theory and combined with 56 previous interviews with interventional radiologists, interventional cardiologists, gynecologists, and vascular surgeons to develop a model describing specialty-specific values. This model was applied to the 15 pilot interviews focused on cardiovascular imaging, highlighting specialty specific differences in values and practice patterns. Transcripts were also reviewed independently by a cardiologist and 2 radiologists followed by a group discussion to assess reproducibility and achieve a consensus regarding the results. RESULTS Differences in perceived value of cardiovascular imaging and use of guidelines among physicians were well explained by three value-associated identity categories (managers, diagnosticians, and fixers) that were further differentiated along three axes (broad v. focused-thinkers, complex v. definitive-answer-seekers, and public visibility). CONCLUSIONS Quality improvement in cardiovascular imaging may be limited by a lack of understanding and incorporation of the complexity of medical culture into ongoing initiatives. Both individually and during policy development, it is important to first understand the complexity of stakeholders' diverse perceptions of "value," "quality," and "appropriateness."
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Affiliation(s)
- Eric J. Keller
- Department of Radiology, Northwestern University Feinberg School of Medicine, 737 N. Michigan Ave Suite 1600, Chicago, IL 60611 USA
| | - Robert L. Vogelzang
- Department of Radiology, Northwestern University Feinberg School of Medicine, 737 N. Michigan Ave Suite 1600, Chicago, IL 60611 USA
| | - Benjamin H. Freed
- Department of Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - James C. Carr
- Department of Radiology, Northwestern University Feinberg School of Medicine, 737 N. Michigan Ave Suite 1600, Chicago, IL 60611 USA
| | - Jeremy D. Collins
- Department of Radiology, Northwestern University Feinberg School of Medicine, 737 N. Michigan Ave Suite 1600, Chicago, IL 60611 USA
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Promislow S, Abunassar JG, Banihashemi B, Chow BJ, Dwivedi G, Maftoon K, Burwash IG. Impact of a structured referral algorithm on the ability to monitor adherence to appropriate use criteria for transthoracic echocardiography. Cardiovasc Ultrasound 2016; 14:31. [PMID: 27528386 PMCID: PMC4986360 DOI: 10.1186/s12947-016-0075-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many free-form-text referral requisitions for transthoracic echocardiography (TTE) provide insufficient information to adequately evaluate their adherence to Appropriate Use Criteria (AUC). We developed a structured referral requisition algorithm based on requisition deficiencies identified retrospectively in a derivation cohort of 1303 TTE referrals and evaluated the performance of the algorithm in a consecutive series of cardiology outpatient referrals. METHODS The validation cohort comprised 286 consecutive TTE outpatient cardiology referrals over a 2-week period. The relevant AUC indication was identified from information extracted from the free-form-text requisition. The structured referral algorithm was applied prospectively to the same cohort using information from the free-form-text requisition, electronic medical record and ordering clinicians. Referrals were classified as appropriate, uncertain, non-adherent (inappropriate) or unclassifiable based on the American College of Cardiology Foundation 2011 AUC. RESULTS Only 28.7 % of free-form-text requisitions provided adequate information to identify the relevant AUC indication, as compared to 94.4 % of referrals using the structured referral algorithm (p < 0.001). The structured algorithm improved identification in the AUC categories of general evaluation of cardiac structure/function (100 % vs. 43.0 %, p < 0.001); valvular function (100 % vs. 23.0 %, p < 0.001); hypertension, heart failure or cardiomyopathy (100 % vs. 20.3 %, p < 0.001); and adult congenital heart disease (100 % vs. 0 %, p < 0.001). By applying the algorithm, the number of identifiable non-adherent studies increased from 2.6 to 10.4 % (p <0.001). CONCLUSIONS Use of a structured TTE referral algorithm, as opposed to a free-form-text requisition, allowed the vast majority of referrals to be monitored for AUC adherence and facilitated the identification of potentially inappropriate referrals.
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Affiliation(s)
- Steven Promislow
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Joseph G Abunassar
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Behnam Banihashemi
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Benjamin J Chow
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Girish Dwivedi
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Kasra Maftoon
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ian G Burwash
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
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Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. Med Care Res Rev 2016; 74:507-550. [PMID: 27402662 DOI: 10.1177/1077558716656970] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.
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Affiliation(s)
- Carrie H Colla
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | | | - Thomas Sequist
- 2 Harvard Medical School, Boston, MA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Partners HealthCare, Boston, MA, USA
| | - Nancy Morden
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,5 Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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De Nardo A, Niranjan S. Utilisation of echocardiography and application of the appropriate use criteria at a large tertiary hospital in Queensland. Australas J Ultrasound Med 2016; 19:64-70. [DOI: 10.1002/ajum.12014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Anthony De Nardo
- Department of Medicine; Gold Coast Hospital and Health Service; Parkwood Queensland Australia
| | - Selvanayagam Niranjan
- Department of Cardiology; Gold Coast University Hospital; Parkwood Queensland Australia
- Department of Medicine; Gold Coast University Hospital; Parkwood Queensland Australia
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Byrd BF, Abraham TP, Buxton DB, Coletta AV, Cooper JHS, Douglas PS, Gillam LD, Goldstein SA, Graf TR, Horton KD, Isenberg AA, Klein AL, Kreeger J, Martin RP, Nedza SM, Navathe A, Pellikka PA, Picard MH, Pilotte JC, Ryan TJ, Rychik J, Sengupta PP, Thomas JD, Tucker L, Wallace W, Ward RP, Weissman NJ, Wiener DH, Woodruff S. A Summary of the American Society of Echocardiography Foundation Value-Based Healthcare: Summit 2014: The Role of Cardiovascular Ultrasound in the New Paradigm. J Am Soc Echocardiogr 2016; 28:755-69. [PMID: 26140937 DOI: 10.1016/j.echo.2015.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Value-Based Healthcare: Summit 2014 clearly achieved the three goals set forth at the beginning of this document. First, the live event informed and educated attendees through a discussion of the evolving value-based healthcare environment, including a collaborative effort to define the important role of cardiovascular ultrasound in that environment. Second, publication of these Summit proceedings in the Journal of the American Society of Echocardiography will inform a wider audience of the important insights gathered. Third, moving forward, the ASE will continue to build a ‘‘living resource’’ on its website, http://www.asecho.org, for clinicians, researchers, and administrators to use in advocating for the value of cardiovascular ultrasound in the new value-based healthcare environment. The ASE looks forward to incorporating many of the Summit recommendations as it works with its members, legislators, payers, hospital administrators, and researchers to demonstrate and increase the value of cardiovascular ultrasound. All Summit attendees shared in the infectious enthusiasm generated by this proactive approach to ensuring cardiovascular ultrasound’s place as ‘‘The Value Choice’’ in cardiac imaging.
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Affiliation(s)
| | | | - Denis B Buxton
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - James H S Cooper
- Vanderbilt University Owen Graduate School of Management, Nashville, Tennessee
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | | | | | | | | | | | | - Amol Navathe
- University of Pennsylvania and Navigant Consulting, Inc, Philadelphia, Pennsylvania
| | | | | | - John C Pilotte
- Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | - Thomas J Ryan
- The Ohio State University Heart Center, Columbus, Ohio
| | - Jack Rychik
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - James D Thomas
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, Illinois
| | - Leslie Tucker
- American Board of Internal Medicine and the ABIM Foundation, Philadelphia, Pennsylvania
| | | | | | - Neil J Weissman
- MedStar Health Research Institute, Washington, District of Columbia
| | | | - Sarah Woodruff
- Adult Congenital Heart Association, Philadelphia, Pennsylvania
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Eskandari M, Kramer CM, Hecht HS, Jaber WA, Marwick TH. Evidence Base for Quality Control Activities in Cardiovascular Imaging. JACC Cardiovasc Imaging 2016; 9:294-305. [DOI: 10.1016/j.jcmg.2015.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/06/2015] [Accepted: 11/11/2015] [Indexed: 11/28/2022]
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