April 18th, 2013
Educating House Staff on Appropriate Use of Echoes
CardioExchange invited R. Sacha Bhatia and Rory B. Weiner to discuss their paper in JACC: Cardiac Imaging (free full text) on an educational intervention to reduce the rate of inappropriate transthoracic echocardiography (TTE) ordered by house staff at Massachusetts General Hospital. They found that a program consisting of (1) a lecture based on the 2011 appropriate use criteria, (2) a pocket card that described the criteria in the context of common clinical scenarios, and (3) twice-monthly e-mail feedback on the appropriateness of orders resulted in a 26% reduction in TTEs compared with the control period. During the intervention period, the proportion of TTEs deemed inappropriate dropped from 13% to 5%. The appropriate use criteria for echoes were updated just this week.
Dr. Ryan: Why did you develop this educational intervention?
Drs. Bhatia and Weiner: This intervention was developed as an effort to improve utilization of echocardiography at our institution. Analysis of TTE utilization patterns at our hospital showed patterns similar to national trends, with an inappropriate rate of ~15% on the inpatient medical service. In addition to aiming to reduce the inappropriate rate, the goal was to generally educate house staff on the Appropriate Use Criteria (AUC).
Dr. Ryan: How did you develop the intervention?
Drs. Bhatia and Weiner: A key step prior to developing the intervention was analysis of ordering patterns for TTE at MGH. We identified several clinical situations which accounted for the majority of inappropriate TTEs on the medical service. The 2 most common situations included TTEs that related to endocarditis and lightheadedness. These clinical situations are therefore the focus of the pocket card (Figure 1 in the paper) that was distributed to the medical residents. Valve disease and heart failure, also common indications for inappropriate TTE, were highlighted on the back of the pocket card. The AUC is a large, comprehensive document and we believed that focusing on the most common inappropriate clinical situations would be more likely to make a difference than would trying to be exhaustive.
We feel that the feedback was a key component of our intervention, and indeed, previous studies support the concept that feedback can facilitate the success of interventions aimed at improving physician ordering.
Dr. Ryan: Do you think what you did is scalable and can be replicated throughout an entire hospital or health care system?
Drs. Bhatia and Weiner: We believe that the educational and feedback intervention utilized in our study can be used as a template for other institutions seeking to incorporate appropriate use criteria (for echocardiography or for other cardiovascular technologies) into their daily ordering practices. Knowledge of baseline local ordering patterns is essential to developing such interventions. However, the components of the intervention (lecture, pocket card, and email feedback) can be easily adopted by others. The classification of TTEs and subsequent generation of the feedback can be time-consuming when done manually, but if the process were automated through integration of ordering software with the electronic medical record, this type of intervention could be done on a large scale.
Dr. Ryan: Should we integrate this approach into every institution?
Drs. Bhatia and Weiner: Tracking appropriateness of orders is now a requirement for accreditation for echo labs. The next logical step is using this information to improve ordering practices. Further study is required to analyze the impact of approaches such as ours on patient outcomes and healthcare spending. In addition, the use of this kind of program in other settings (i.e., community clinics or with attending level physicians) requires study. Intuitively, however, such interventions empower physicians to take responsibility for improving utilization of diagnostic testing and preserve the privilege of physician self-regulation.