April 18th, 2013

Educating House Staff on Appropriate Use of Echoes

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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.

4 Responses to “Educating House Staff on Appropriate Use of Echoes”

  1. Edgar Abovich, MD says:

    I don’t quite understand what the fuss is all about. Sure, there are inappropriate echoes, but there’s also inappropriate invasive procedures, surgeries, etc. I haven’t seen too many complications, ER visits and, god forbid, readmissions due to inappropriate echoes. If someone wants to improve care of the hospitalized patients, it should be on the bottom of a long list. Yes, it’s a concern, but it’s a very very small one compared to everything else that happens in the hospitals. Ultimately, the house staff is there to learn all aspects of patient care, including when to order echoes. Sorry for being old-fashioned, but I believe that the best way to take care of our patients is to think about each case thoroughly instead of blindly following guidelines and protocols.

  2. David Powell , MD, FACC says:

    The overall reduction in inappropriate studies seems slim, notwithstanding statistical significance. I suspect a more robust result with perfusion stress tests. For me, the fact that an echo would have been appropriate for the majority of heart failure patients who did not get an echo in the hospital is a bigger and concerning issue. Please correct me if I did not interpret the study well in this regard.
    As for the whole AUC issue….the interpretation is quite subjective and the bulk of the volume is within the “may be appropriate” or 2a/2b territory.

  3. Rajan Sacha Bhatia, MD/MBA says:

    We would like to thank everyone for their interest in our study and comments.

    Dr. Abovich is correct that echocardiography is a non-invasive procedure, and the risk of any procedural harm is very small. Inappropriate echocardiograms do, however, significantly increase the cost of delivering healthcare services and incidental findings from these tests may lead to further testing which could be harmful. Furthermore, increased volume of echocardiogram orders may reduce the capacity of a lab or hospital to provide echocardiograms in a timely manner to those who need them most .

    The purpose of this study was to develop an intervention, using feedback and education, that would reduce inappropriate utilization of this important imaging modality, without compromising physician ordering autonomy or the principles of physician self regulation. In this time of constrained budgets, alternative approaches such as radiology benefits managers or pre-authorization do directly impact the autonomy of health care providers to order individual echocardiograms on their patients. The methodology in our study does not. In fact, our study allows physicians to do exactly what Dr. Abovich suggests, which is use clinical judgment to decide the best clinical plan for patients , while still achieving the objective of reducing inappropriate utilization through education.

    Finally, we agree that there are many other areas of cardiac testing and interventions where inappropriate ordering may be a concern. Our approach is not necessarily restricted to echocardiography, but could be used in these areas as well.

    With respect to Dr. Powell’s comments, we agree that the reduction of inappropriate echocardiograms may seem small (13% to 5%), however when one considers the volume of echocardiograms ordered at a large institution like ours (about 30 000/year), this small reduction has a significant impact on overall TTE volumes. In addition, our study was focused on inpatient care, where the inappropriate rates of TTE ordering are modest. In the outpatient setting, work we have previously published shows inappropriate TTE ordering rates up to 30%. We are currently conducting a study examining the effect of this intervention in the outpatient environment.

    Finally, one point of clarification to Dr. Powell’s comments. Our study did not suggest that the majority of HF patients in hospital did not get an echocardiogram. Rather, when we looked at HF patients in control versus the intervention period there was no difference in the rates of appropriate TTE ordering in these patients. The point being that our intervention did not appear to deter clinicians from ordering appropriate TTEs.

    R. Sacha Bhatia and Rory B. Weiner
    Massachusetts General Hospital

  4. David Powell , MD, FACC says:

    I appreciate the response. The last sentence before the “Discussion” section of the manuscript states that of those hospitalized HF patents who did not get a TTE, most would have satisfied appropriateness criteria. I understand that there was no significant difference between the intervention and control groups in this regard. But I think this finding is intriguing. Perhaps we underorder echoes in this respect, a practice which may be more deleterious to patient care. Why not focus on a problem of not ordering appropriate tests, as well as ordering inappropriate ones? The literature on changing utilization on the basis of AUC seems to preferentially focus on inappropriate testing. Why? Just because it is easier to study?