JACC in a Flash | The ACC and other societies first published appropriate use criteria (AUC) for transthoracic echocardiography (TTE) in 2007 (and updated them in 2011) as a means of improving the quality of care and reducing inappropriate utilization of diagnostic testing. However, as R. Sacha Bhatia, MD, MBA, and colleagues point out in a recent paper in JACC: Cardiovascular Imaging, studies examining the impact of AUC on decreasing inappropriate test use have found varying degrees of success.

In their prospective study, Dr. Bhatia and investigators randomized 112 physicians-in-training (88 internal medicine residents and 24 cardiology fellows) to an AUC-based educational intervention or control group. The intervention included a lecture highlighting AUC for TTE; an electronic pocket card including "tips" on appropriate ordering of TTE; and individualized monthly feedback reports detailing the number of appropriate, inappropriate, and uncertain TTEs ordered using the 2011 AUC.

During the 9-month study period, 292 TTEs were ordered by the study physicians; a total of 1,123 patients were seen by physicians (613 in the intervention group and 600 in the control group). Notably, 27% of these patients also had a previous TTE (either inpatient or outpatient) within the previous year.

Because the majority of these echoes were ordered by cardiology fellows (10.6±5.8 TTE/physician in the intervention vs. 7.6±4.2 TTE/physician in the control group), the primary reported results are for this group. Notably, prior to study initiation, 75% of the cardiology fellows completed the AUC knowledge survey, with no difference in the correct response rate among the intervention and control arms (78% vs. 76%; p < 0.45), and no difference between the pre-study attitudes toward AUC or consideration of costs when ordering diagnostic tests.

Nearly all TTEs ordered were classifiable by the 2011 AUC; the agreement between the study investigators who reviewed the cases was 94.9%, and all discrepant TTE classifications was resolved. The proportion of inappropriate TTE was significantly lower in the intervention than in the control group throughout the 9-month study period, and the proportion of appropriate TTE ordered by the intervention group was significantly higher than that of the control group. Furthermore, the educational intervention more than doubled the likelihood of ordering an appropriate TTE (odds ratio = 2.7; 95% CI 1.5-5.1; p = 0.02).

Six clinical scenarios accounted for 75% of all inappropriate TTE, with the three most common indications being:

• routine surveillance (<1 year) of known cardiomyopathy without a change in clinical status
• routine surveillance of known small pericardial effusion
• routine surveillance of ventricular function with known coronary artery disease and no change in clinical status

"In cardiology fellows with a high rate of ordering inappropriate TTE, an AUC-based educational and feedback intervention reduced the proportion of inappropriate outpatient TTE and increased the proportion of appropriate outpatient TTE," the authors concluded, adding that the results of the study may provide a template for other researchers interested in methods to educate physicians to improve diagnostic test ordering. "A larger-scale, multicenter trial of this type of intervention directed at attending staff-level physicians and/or physician extenders is warranted to determine whether this approach will be successful in other practice environments."

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Bhatia RS, Dudzinski DM, Malhotra R, et al. JACC Cardiovasc Imaging. 2014;7:857-66.

Keywords: CardioSource WorldNews Interventions

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