Conclusions
As healthcare increasingly shifts its focus toward value-based care,
echocardiography has been a prime target for refinement as it remains a
frontline tool for the diagnosis and management of various
cardiovascular diseases.18 Given its wide availability
in all types of clinical settings as well as its safety profile,
echocardiography is at risk for being misused. Common outpatient
scenarios in which rarely appropriate echocardiograms are ordered
include routine surveillance for heart failure with recent imaging less
than one year prior, repeat assessment of left ventricular ejection
fraction in patients with coronary artery disease, monitoring trivial or
small pericardial effusions, and reassessment of valvular heart disease
at an interval more frequent than recommended by professional society
guidelines.10 Common inpatient scenarios resulting in
rarely appropriate echocardiogram orders include fevers without
bacteremia or new murmur, lightheadedness or presyncope without other
evidence of cardiovascular disease, evaluation for pulmonary embolism,
and surveillance of left ventricular ejection fraction in patients with
coronary disease or patients with prior normal ventricular function and
no change in clinical status.11,19 It is especially
important to target these rarely appropriate clinical scenarios as the
volume of echocardiography testing continues to increase.
In our search through existing literature, studies evaluating the
effectiveness of AUC-based QI interventions have demonstrated mixed
results. However, most of these studies have been single-center studies
with only the Echo WISELY trial being a multicenter
trial.12 The results of our meta-analysis help to
further clarify this topic, demonstrating that AUC QI interventions are
associated with a successful reduction in rarely appropriate
echocardiography testing. While some small studies showed that the
effects of QI interventions resulted in an initial significant change in
target behavior with eventual loss of effect over time, our results
suggest that the effects of AUC-based QI interventions are persistent
over long-term follow-up with a trend towards further reduction in
rarely appropriate testing.
It must be noted that when the initial professional societies AUC
documents were published, echocardiography studies were characterized as
“appropriate”, “uncertain”, or “inappropriate”. However, this was
subsequently revised to the categories of “appropriate”, “may be
appropriate”, and “rarely appropriate”, to acknowledge that studies
previously characterized as “inappropriate” may be appropriate in
certain specific, infrequently encountered clinical settings. In our
review of existing literature, we included both sets of nomenclature
based on time of publication. However, to be consistent with the most
updated AUC recommendations, published results utilizing the outdated
terminology of “inappropriate” were included as “rarely appropriate”
in our analysis. It is important to emphasize that for each specific
indication the inappropriate and rarely appropriate criteria are not
exchangeable, however, since we didn’t look at specific indications, but
rather investigated the effect of an intervention of clinicians’
behavior, including both terminologies in our analysis is perfectly
reasonable.
One issue that has been called into question is whether the
effectiveness of AUC QI interventions demonstrated in single-center
studies, is generalizable. Of particular interest is differences in
adaptation of QI interventions by physicians in training and more senior
physicians. It is expected to see greater degree of behavioral changes
in practice among physicians in training, who are more receptive to
changes in practice behavior and feedback. Single center studies that
are focused on trainees only, can therefore demonstrate greater degree
of effectiveness of such AUC QI interventions.10,11The advantage of our meta-analysis is that it encompasses providers of
different specialties as well as providers of differing levels of
training, and the results are therefore more generalizable.
Another important question is whether educational QI tools are effective
in changing provider behavior even when not combined with a feedback
tool. Our study demonstrate that the use of a feedback tool is not
necessary for educational tools to be effective and that the addition of
feedback tools to educational or decision support tools did not further
enhance QI intervention. Several studies have suggested that the
effectiveness of educational tools when used alone stems from the fact
that many providers are simply not aware of the existence of appropriate
use criteria for ordering echocardiograms.13,15 These
authors suggest that by simply teaching providers about AUC indications
for echocardiograms via modalities including lectures and reference
cards, there is a significant change in ordering behavior.
While we demonstrated in this meta-analysis that the addition of
feedback tools was not necessary when combined with other QI modalities,
there is limited available data to draw conclusions regarding the
effectiveness of feedback tools when used as the solitary QI
intervention. It has been seen in QI studies aimed at reducing rarely
appropriate testing done using other types of radiological imaging that
feedback tools are effective when used alone as an
intervention.20–22 To our knowledge, there have not
been any similar studies conducted for AUC-based QI interventions
targeted towards rarely appropriate echocardiogram testing. Furthermore,
it is possible that the format for feedback delivery is also important.
In the study by Bhatia et al, it was observed that when feedback was
given in both email format as well as performance reports, many
providers ignored email feedback but did access their performance
reports.12 Further studies are needed to better
clarify both the role of feedback tools and format for feedback in
AUC-based QI intervention.