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Ashraf H, Rambarat CA, Setteducato ML, Winchester DE. Implementation effort: Reducing the ordering of inappropriate echocardiograms through a point-of-care decision support tool. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 18:100185. [PMID: 38559418 PMCID: PMC10978316 DOI: 10.1016/j.ahjo.2022.100185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/01/2022] [Accepted: 07/15/2022] [Indexed: 04/04/2024]
Abstract
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.
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Affiliation(s)
- Hassan Ashraf
- Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
| | - Cecil A. Rambarat
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
| | - Michael L. Setteducato
- Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
| | - David E. Winchester
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
- Cardiology Section, Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, United States of America
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Madan K, Khor L, Pathan F, Negishi K. Revisiting Appropriate Use Principles for Transthoracic Echocardiography in the COVID-19 Pandemic Era. Heart Lung Circ 2021; 31:e22-e23. [PMID: 34756530 PMCID: PMC8552817 DOI: 10.1016/j.hlc.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/14/2021] [Accepted: 10/02/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Kedar Madan
- Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia; Nepean Clinical School, The University of Sydney, Sydney, NSW, Australia.
| | - Lynn Khor
- Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia; Nepean Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia; Nepean Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Kazuaki Negishi
- Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia; Nepean Clinical School, The University of Sydney, Sydney, NSW, Australia
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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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Hackett I, Ward RP. Appropriate Use Criteria for Echocardiography in the Era of Value-Based Care: Mission Accomplished or Future Mandates? Curr Cardiol Rep 2020; 22:69. [PMID: 32561996 PMCID: PMC7303569 DOI: 10.1007/s11886-020-01310-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of Review The purpose of this review is to highlight the past impact and current role of the Appropriate Use Criteria (AUC) for echocardiography in value-based healthcare, and to address future implications in light of the recent mandate from the Centers for Medicare and Medicaid Services to incorporate AUC for other imaging modalities. Recent Findings Several studies have proven that the AUC effectively stratify the clinical practice of echocardiography as they predict important echo abnormalities and impact optimal patient care. Recent investigations have tested new technologies and demonstrated the feasibility and scalability of the application of the AUC for echocardiography at the point of care. Summary The AUC for echocardiography has accomplished their core mission, as utilization has moderated over the last decade and mandatory implementation at the point of care for echocardiography remains rare. While a new mandate signals another wave of focus on appropriate utilization, echocardiography stands ready.
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Affiliation(s)
- Ian Hackett
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, DCAM Rm 5726, Chicago, IL, 60637, USA
| | - R Parker Ward
- Section of Cardiology, University of Chicago Medicine, 5841 S. Maryland Ave, DCAM Rm 5726, Chicago, IL, 60637, USA.
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5
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Affiliation(s)
- David E Winchester
- Malcom Randall VA Medical Center, University of Florida College of Medicine, Gainesville, Florida.
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Haji K, Wong C, Neil C, Cox N, Mulligan A, Wright L, Vogrin S, Marwick TH. Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE). Echo Res Pract 2019; 6:91-96. [PMID: 31516721 PMCID: PMC6733360 DOI: 10.1530/erp-19-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/07/2019] [Indexed: 11/08/2022] Open
Abstract
Background Handheld ultrasound could provide sufficient information to satisfy the clinical questions underlying 'rarely appropriate' echo requests, but there are limited data about its use as a gatekeeper to standard echocardiography. We sought to determine whether the use of handheld ultrasound could improve the appropriate use of echocardiography. Method A prospective study comparing handheld ultrasound strategy to standard echocardiography for studies deemed rarely appropriate, using a questionnaire based on appropriate use criteria was conducted across two hospitals, from October 2017 to April 2018. Results Groups undergoing Handheld ultrasound (n = 76, 58 (46.5-72.5) years, 53 males, 78% outpatients) and standard echocardiography (n = 72, 61 (49.0-71.5) years, 42 males, 76% outpatients) were comparable. There was a significant decrease in the time to scan from just over 1 month in standard group to a median of 12 days in handheld ultrasound group (P < 0.001). This difference was small for inpatients (from 1 day to a median of 10 min in handheld ultrasound, P = 0.014), but prominent in outpatients (from 1.5 months in the standard group to median of 2 weeks in the handheld ultrasound group, P < 0.001). There was no increase in the need for follow-up scan within 6 months and no significant differences in length of hospital stay for inpatients. Conclusion Handheld ultrasound can be an effective gatekeeper to standard echocardiography for requests deemed rarely appropriate, reducing time to echocardiography significantly and potentially decreasing the need for standard echocardiography by up to 20%.
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Affiliation(s)
- Kawa Haji
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Chiew Wong
- Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Christopher Neil
- Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Nicholas Cox
- Cardiology Department, Western Health, Melbourne, Australia
| | | | - Leah Wright
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Cardiology Department, Western Health, Melbourne, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Cardiology Department, Western Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
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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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