Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis

A systematic review of existing appropriate use criteria in cardiovascular disease from the last 15 years

Appropriate use criteria (AUC) aim to impact the provision of high-value care. This scoping review identified AUC regarding the procedural and operative treatment of cardiovascular disease and described the evolution of AUC in this space over time, including changes in the focus, strategy, and language of AUC. The summative presentation of these AUC identifies elements of AUC that may lead to successes in, and barriers to, implementation across disease processes, specialties, and societies. AUC topics include coronary artery disease, peripheral artery disease, valvular disease, venous disease, renal artery stenosis, and mesenteric ischemia, among others.

The Medicare Appropriate Use Criteria Program: A Review of Recommendations for Testing in Coronary Artery Disease

BACKGROUND

Congress established the Appropriate Use Criteria (AUC) Program to reduce unnecessary advanced imaging studies. Organizations that wish to develop AUC can apply to the Centers for Medicare & Medicaid Services (CMS) to qualify as provider-led entities (PLEs) under this program. Variable methods, content, and formatting of PLE-generated AUC could lead to clinician uncertainty about whether an advanced imaging test is appropriate or not.

PURPOSE

To review AUC published by CMS-qualified PLEs focused on advanced imaging tests for coronary artery disease (CAD), a "priority clinical area" identified by CMS.

DATA SOURCES

Publicly available data from the worldwide web searched on 29 August 2022.

STUDY SELECTION

Approved AUC with recommendations related to testing for CAD.

DATA EXTRACTION

Manual review of published AUC by all authors.

DATA SYNTHESIS

Among the 17 CMS-qualified PLEs, only 7 had published AUC related to CAD. Substantial variation in the methods and formatting of these AUCs was observed. The number of clinical scenarios covered ranged from 6 to 210, and the number of advanced imaging methods covered ranged from 1 to 25. When specifically applied to clinical scenarios, many AUC offered no guidance on appropriateness; those that did conflicted with respect to appropriateness.

LIMITATION

Other CMS-identified priority clinical areas were not evaluated.

CONCLUSION

CMS-qualified AUC for imaging of CAD are heterogeneous and sometimes discrepant, creating substantial potential for uncertainty among clinicians seeking to provide their patients with appropriate imaging tests.

PRIMARY FUNDING SOURCE

No funding was received for this study.

Implementation effort: Reducing the ordering of inappropriate echocardiograms through a point-of-care decision support tool

Study objective

Reduce inappropriate transthoracic echocardiograms (TTEs) using a series of Plan-Do-Study-Act (PDSA) quality improvement cycles.

Design

Three PDSA cycles were designed with the first integrating a previously published decision support tool (DST) into the electronic TTE order, the second tailoring the DST to reflect the most common inappropriately ordered TTEs at our institution, and the third integrating direct clinician education.

Setting

Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, USA.

Participants

Consecutive patients were studied using the database of all TTEs performed at our institution without regard for specific patient characteristics.

Interventions

Three PDSA Cycles as described above.

Main outcome measure

Reduction in inappropriate TTEs at our institution.

Results

After implementing our DST during the first cycle, no difference in inappropriate TTEs was observed (relative risk [RR] 0.71, p = 0.12, 95 % confidence interval [CI] 0.46-1.09). After the second cycle, we observed a reduction in the proportion of inappropriate TTEs (RR = 0.69, p = 0.014, 95 % CI 0.5-0.94), however two of the four inappropriate TTEs targeted by the DST increased. Feedback gathered from clinicians in the third cycle showed significant knowledge gaps regarding appropriate use criteria for TTE.

Conclusions

At our facility, implementation of a DST failed to substantially reduce inappropriate TTEs, even when adapted to facility-specific ordering patterns. Gaps in clinician knowledge about TTEs may have contributed to the inefficacy of our DST.

OUP accepted manuscript

The increasing volume and richness of healthcare data collected during routine clinical practice have not yet translated into significant numbers of actionable insights that have systematically improved patient outcomes. An evidence-practice gap continues to exist in healthcare. We contest that this gap can be reduced by assessing the use of nudge theory as part of clinical decision support systems (CDSS). Deploying nudges to modify clinician behaviour and improve adherence to guideline-directed therapy represents an underused tool in bridging the evidence-practice gap. In conjunction with electronic health records (EHRs) and newer devices including artificial intelligence algorithms that are increasingly integrated within learning health systems, nudges such as CDSS alerts should be iteratively tested for all stakeholders involved in health decision-making: clinicians, researchers, and patients alike. Not only could they improve the implementation of known evidence, but the true value of nudging could lie in areas where traditional randomized controlled trials are lacking, and where clinical equipoise and variation dominate. The opportunity to test CDSS nudge alerts and their ability to standardize behaviour in the face of uncertainty may generate novel insights and improve patient outcomes in areas of clinical practice currently without a robust evidence base.

The Paediatric AirWay Suction (PAWS) appropriateness guide for endotracheal suction interventions

BACKGROUND/OBJECTIVE

Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations.

METHODS

The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation.

RESULTS

Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population 'patients with highly infectious respiratory disease'. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances.

CONCLUSION

Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Appropriateness and subsequent management of inpatient echocardiograms: An evaluation of low value care

Study objective

Transthoracic echocardiograms (TTE) are perceived to be overused and multiple TTEs are often ordered within one inpatient visit with unclear utility. This study identified inpatients who received multiple TTEs to determine the appropriateness, results, and subsequent management of repeat TTEs.

Design

Retrospective Cohort Study.

Setting

Single academic medical center.

Participants

Subjects over age 18 who underwent >1 TTE during hospitalization in 2020.

Interventions

N/A.

Main outcome measures

Appropriateness of TTE, TTE results, subsequent changes in management.

Results

Of the 875 subjects, the average age was 60 years old with a male predominance (57.8%). In comparing the first and second TTE results, the frequency of new abnormal findings decreased significantly from 44.7% to 15.1% (p < .0001). Changes in clinical management in relation to the TTEs decreased from 47.1% to 32.5% (p < .0001), of which medication changes were most common. The majority of tests were appropriate, with a slight increase of inappropriate TTEs from 0.6% to 1.8% (p < .0001) between first and second TTEs.

Conclusions

While the rate of inappropriate TTE use increased after the initial TTE, the overall rate of inappropriate use was very small indicating that stricter adherence to AUC would not appreciably reduce duplication of inpatient TTEs. The non-negligible frequency of new abnormal findings for the repeat TTEs at 15% cannot be ignored. Our data suggests that the assumption that repeat TTEs are in large part unnecessary is more complicated than originally thought.

Adherence to Best Practice Advice for Diagnosis of Pulmonary Embolism

PURPOSE

This study evaluated clinician adherence to the American College of Physicians Best Practice Advice for diagnosis of pulmonary embolism.

DESIGN

A prospective, single-center, descriptive design was utilized.

METHODS

A heterogeneous sample of 111 hemodynamically stable adult inpatients with a computed tomography pulmonary angiogram ordered was consented. Electronic medical records were reviewed for demographic and clinical variables to determine adherence. The 6 individual best practice statements and the overall adherence were evaluated by taking the sum of "yes" answers divided by the sample size.

RESULTS

Overall adherence was 0%. Partial adherence was observed with clinician-recorded clinical decisions rules and obtaining d-dimer (3.6% [4/111] and 10.2% [9/88], respectively) of low/intermediate probability scorers. Age adjustment of d-dimer was not recorded. Computed tomography pulmonary angiogram was the first diagnostic test in 89.7% (79/88) in low/intermediate probability patients.

CONCLUSION

In hemodynamically stable, hospitalized adults, adherence to best practice guidelines for diagnosis of pulmonary embolism was minimal. Clinical utility of the guidelines in hospitalized adults needs further evaluation. Systems problems (eg, lack of standardized orders, age-adjusted d-dimer values, information technology support) likely contributed to poor guideline adherence.