Background
Appropriate use criteria for cardiovascular imaging have been published, but compliance in practice has been incomplete, with persistent high rates of inappropriate use. The aim of this study was to show the efficacy of a continuous quality improvement (CQI) initiative to favorably influence the appropriate use of outpatient transthoracic echocardiography and single-photon emission computed tomographic (SPECT) myocardial perfusion imaging (MPI) in a large cardiovascular practice.
Methods
In this prospective study, a multiphase CQI initiative was implemented, and its impact on ordering patterns for outpatient transthoracic echocardiography and SPECT MPI was assessed. Between November and December 2010, a baseline analysis of the application of appropriate use criteria to indications for outpatient transthoracic echocardiographic studies ( n = 203) and SPECT MPI studies ( n = 205) was performed, with studies categorized as “appropriate,” “inappropriate,” “uncertain,” or “unclassified.” The CQI initiative was then begun, with (1) clinician education, including didactic lectures and case-based presentations with audience participation; (2) system changes in ordering processes, with redesigned image ordering forms; and (3) peer review and feedback. A follow-up analysis was then performed between June and August 2012, with categorization of indications for transthoracic echocardiographic studies ( n = 206) and SPECT MPI studies ( n = 206).
Results
At baseline, 73.9% of echocardiographic studies were categorized as appropriate, 16.7% as inappropriate, 5.9% as uncertain, and 3.4% as unclassified. Similarly, for SPECT MPI studies 71.7% were categorized as appropriate, 18.5% as inappropriate, 7.8% as uncertain, and 1.9% as unclassified. Separate analysis of the two most important categories, appropriate and inappropriate, demonstrated a significant improvement after the CQI initiative, with a 63% reduction in inappropriate echocardiographic studies (18.5% vs 6.9%, P = .0010) and a 46% reduction in inappropriate SPECT MPI studies (20.5% vs 11.1%, P = .010).
Conclusions
This study demonstrates the effective and persistent positive impact of a CQI initiative to reduce inappropriate ordering of cardiovascular imaging.
Ensuring appropriate use of cardiovascular (CV) imaging is an increasingly important aspect of medical decision making and care delivery. Given the continuing escalation of US health care expenditures, choosing “the right test for the right patient at the right time” has never been more relevant. In 2010, Medicare Part B spending on outpatient imaging was $10.9 billion. As this amount of spending pertains to CV imaging, it is estimated that 15% to 20% of echocardiographic and stress nuclear myocardial perfusion imaging (MPI) studies are best classified as inappropriate, on the basis of the application of published appropriate use criteria (AUC). With the intent of improving the appropriate use of CV imaging, the American College of Cardiology launched the FOCUS initiative in 2009 to help CV professionals identify best practices for implementing AUC. In this report, as part of the FOCUS initiative, we describe a continuous quality improvement (CQI) initiative that sought to improve adherence to CV AUC within a large cardiology group, practicing at multiple sites over a wide geographic area.
Methods
The Adult Cardiology Division of the Sanger Heart & Vascular Institute (SHVI) comprises >65 cardiologists in 15 offices in the 31-county region encircling Charlotte, North Carolina. SHVI has a multisite echocardiography laboratory and a multisite cardiac nuclear imaging laboratory, both accredited by the Intersocietal Accreditation Commission, at which an average of 60,000 echocardiographic studies and 15,000 stress MPI studies are performed annually. This study was performed prospectively to evaluate the effect of the implementation of a multifaceted CQI initiative on appropriate use rates for outpatient transthoracic echocardiography and single-photon emission computed tomographic (SPECT) MPI. The study involved only SHVI cardiologists and did not include advanced care providers or noncardiology providers.
Baseline
To establish baseline patterns of test ordering for echocardiography and MPI, we retrospectively applied the AUC for echocardiography and SPECT MPI to studies ordered by SHVI providers. We analyzed 30 consecutive outpatient transthoracic echocardiographic and SPECT MPI studies ordered by SHVI providers located at the seven highest volume sites between November 1, 2010, and December 31, 2010. Clinical information was obtained by chart review. For MPI, a hierarchical determination of appropriateness was used, as has been previously outlined. Because appropriateness criteria for echocardiography and stress echocardiography were revised in 2011, all echocardiographic testing was retrospectively reclassified on the basis of the updated criteria. All testing indications were classified by a single reviewer (T.V.J.). Test indications were classified into one of four categories on the basis of the guidelines: appropriate, inappropriate, uncertain, or unclassified. Unclassified studies were those for which no matching scenario could be identified in the guidelines.
CQI Initiative
After baseline data evaluation, a multifaceted quality improvement protocol was initiated, incorporating clinician education; process change, with redesigned order entry forms; and peer review and feedback.
Clinician Education
Education of staff members was provided by a series of teleconferences on AUC in CV imaging. The educational curriculum included not only didactic lectures but also embedded case-based, audience participation sessions to provide contextualized learning. The program was structured as follows.
A core curriculum was developed that highlighted the importance of appropriate imaging, including cost-effectiveness, reducing radiation exposure, and decreasing rates of false-positive results on imaging. The fundamental principles behind appropriate use guidelines were reviewed.
Next, the results of the baseline data analysis, including rates of appropriate and inappropriate imaging, were reviewed. A frequency analysis of the most common inappropriate indications was highlighted.
Finally, a focused program of education was initiated, targeting those clinical scenarios associated with the highest rates of inappropriate use. For example, one such area identified was stress testing in patients with low or intermediate CV risk being evaluated for noncardiac surgery. A detailed presentation of the methodology for the assessment of CV risk, including the Diamond-Forester method and the Framingham risk score, was presented. Components of perioperative CV evaluation, including clinical risk markers, surgery risk stratification, and functional capacity, were also reviewed.
Process Change
After the educational program, system changes were enacted in the ordering process for outpatient CV imaging. Separate order forms were created for transthoracic echocardiographic and stress nuclear MPI studies (see Figures 1 and 2 A ).
Order Form Design
Each form is a single page and is organized by category of test indications for easy navigation. All appropriate indications as classified by the AUC are listed on the form, with check-box options for ordering. Several of the indications classified as uncertain are also included. All indications incorporate pertinent criteria for appropriateness (e.g., chest pain in a patient with intermediate or high risk for CV disease) and include the specific references within the published AUC guidelines. On the reverse side of the stress echocardiography and MPI form (see Figure 2 B), tools for clinician use at the point of care are included. The Diamond-Forester table, criteria for classifying angina, and the Adult Treatment Panel III clinical conditions associated with high risk for cardiac disease are provided to facilitate assessment of pretest probability of CV disease. Key elements of CV perioperative risk evaluation, including risk stratification by operation and five clinical markers associated with increased cardiac risk, are listed.
Implementation of Order Form
Instructions for the use of these forms were included at the end of the educational series. Through coordination with individual office site managers, the new forms were integrated into the clinical practice. Forms were collected and entered into a database created for this study.
Peer Review and Feedback
The final CQI phase was peer review and feedback. The indications for imaging for five consecutive studies for each clinician were analyzed and categorized according to the AUC. Clinicians received individualized reports of their results benchmarked to the performance of the group as a whole. All inappropriate studies were listed by patient record and indication on the scorecard so that clinicians could individually identify areas for improvement.
Follow-Up
A follow-up survey was performed consisting of 30 consecutive outpatient transthoracic echocardiographic and 30 MPI studies ordered by SHVI clinicians from each of the seven sites between June 1, 2012, and August 31, 2012.
Data Analysis
To test the accuracy of the order form in reflecting the documented reason for testing ordering, chart review was performed on 208 consecutive forms in the database for correlative purposes. The indication on the form was checked against the supporting data in the medical record. Results were considered discordant if the indication on the form did not accurately reflect the clinical scenario.
Because use of the order entry form was not mandatory, this allowed comparison of outcomes not only before and after the CQI initiative but also with or without the use of the clinical ordering tool. Echocardiographic and MPI data were analyzed separately. In addition, analysis of reclassification of the 2011 AUC for echocardiography compared with the 2007 AUC was also performed. The χ 2 test was used to compare the distribution of assessment categories. SAS version 9.3 (SAS Institute Inc, Cary, NC) was used for all analyses. Two-tailed P values < .05 were considered statistically significant.
Data Analysis
To test the accuracy of the order form in reflecting the documented reason for testing ordering, chart review was performed on 208 consecutive forms in the database for correlative purposes. The indication on the form was checked against the supporting data in the medical record. Results were considered discordant if the indication on the form did not accurately reflect the clinical scenario.
Because use of the order entry form was not mandatory, this allowed comparison of outcomes not only before and after the CQI initiative but also with or without the use of the clinical ordering tool. Echocardiographic and MPI data were analyzed separately. In addition, analysis of reclassification of the 2011 AUC for echocardiography compared with the 2007 AUC was also performed. The χ 2 test was used to compare the distribution of assessment categories. SAS version 9.3 (SAS Institute Inc, Cary, NC) was used for all analyses. Two-tailed P values < .05 were considered statistically significant.
Results
Baseline Survey
Echocardiography
A total of 210 consecutive transthoracic echocardiographic studies were screened at baseline. Seven studies (3%) could not be characterized, because of incomplete clinical information, leaving 203 studies for analysis. At baseline, 73.9% of studies were categorized as appropriate, 16.7% as inappropriate, 5.9% as uncertain, and 3.4% as unclassified. The most common inappropriate indications for testing were (1) infrequent premature atrial contractions or infrequent premature ventricular contractions without other evidence of heart disease and (2) routine surveillance of ventricular function with known coronary artery disease (CAD) and no change in clinical status or cardiac examination (see Figure 3 , top panel ).
SPECT MPI
Of the 210 studies comprising the baseline SPECT MPI group, five studies (2%) could not be characterized, because of incomplete information, leaving 205 studies for analysis. At baseline, 71.7% of studies were categorized as appropriate, 18.5% as inappropriate, 7.8% as uncertain, and 1.9% as unclassified. The most common inappropriate indications (90% of all inappropriate studies) were (1) low-risk symptomatic patients, (2) post–percutaneous intervention in patients with stable symptoms or asymptomatic <2 years after intervention, and (3) perioperative evaluation for noncardiac surgery (see Figure 3 , bottom panel ).
Follow-Up Survey
Echocardiography
On follow-up, 210 transthoracic echocardiographic studies were reviewed, four of which (2%) could not be characterized because of incomplete information, leaving 206 studies for analysis. The change across all four categories is listed in Table 1 . Separate analysis of the two most important categories, appropriate and inappropriate, is listed in Table 2 . There was a 63% reduction in the percentage of inappropriate studies (18.5% vs 6.9%, P = .001). The percentage of studies ordered for appropriate indications increased from 81.5% to 93.1% ( P = .0001). There was a significantly larger number of echocardiographic studies classified as uncertain (12.1% vs 5.9%, P = .0013) on the follow-up examination (see Table 1 ). The number of studies ordered for infrequent premature atrial contractions and infrequent premature ventricular contractions without other evidence of heart disease decreased from six (3% of all baseline echocardiographic studies) to one (0.5% of all follow-up echocardiographic studies). No studies in the follow-up survey were ordered for routine surveillance of ventricular function with known CAD without change in clinical status.
