Education Effect on Appropriateness of Outpatient Echo

Study Questions:

Do appropriate use criteria (AUC)-based educational initiatives improve outpatient transthoracic echocardiography (TTE) ordering practices of attending cardiologists?


In a prospective, randomized clinical trial of an educational intervention designed to reduce the number of outpatient TTEs deemed to be rarely appropriate by published AUC, blinded investigators classified outpatient TTEs ordered by 66 cardiologists at the Massachusetts General Hospital. All cardiologists received a lecture reviewing AUC. Cardiologists randomly assigned to the intervention arm also received monthly individual physician feedback via email describing the percentage of rarely appropriate TTEs and the AUC rationale for classifying studies as rarely appropriate; cardiologists in the control arm received no monthly feedback. The primary outcome was the rate of rarely appropriate TTEs.


Of 66 cardiologists enrolled in the study, 65 were included in the analysis (one intervention cardiologist retired from practice during the study). The participants’ mean age was 50.6 ± 10.5 years; 48 (73%) were men. Following intervention, the proportion of rarely appropriate TTEs was significantly lower in the intervention versus control group (143 of 1,359 [10.5%] vs. 285 of 1,728 [16.5%]; odds ratio [OR], 0.59; 95% confidence interval [CI], 0.39-0.88; p = 0.01), and there was a nonsignificant increase in the proportion of appropriate TTEs in the intervention versus control group (1,054 [77.6%] vs. 1,244 [72.0%]; OR, 1.38; 95% CI, 0.93-2.05; p = 0.11). The most common of the 428 rarely appropriate indications were routine surveillance within 3 years after prosthetic valve insertion (73 [17.1%]), routine surveillance within 1 year for moderate or severe valvular stenosis (64 [15.0%]), and routine surveillance of cardiomyopathy (45 [10.5%]) or ventricular function (36 [8.4%]).


An AUC-based educational and feedback intervention reduced the number of rarely appropriate TTEs ordered by attending academic cardiologists. The authors concluded that this strategy may be feasible to improve TTE utilization among cardiologists, and that this type of intervention warrants study in other practice environments.


The Hawthorne effect describes the reactivity of human behavior such that individuals modify or improve their behavior in response to awareness of being observed ( In this study, the effect of a lecture alone was not assessed, but showing attending cardiologists that their use of outpatient TTE was being scrutinized for adherence to AUC proved more effective in modifying their behavior than not providing evidence of ongoing scrutiny. The upside is that monitoring and frequent feedback affects behavior; the downside is that ‘flag fatigue’ and physician burnout are not addressed. There appear to be fewer total TTEs ordered by the intervention/feedback group than the control group (1,359 vs. 1,728), not accounted for by the reduction in rarely appropriate TTEs (143 vs. 285, ∆ 1,216 vs. 1,443 appropriate or may be appropriate TTEs). This study used isolated AUC adherence as an endpoint, and does not address whether monitoring-for-inappropriateness can lead to untoward consequences including failure to use appropriate testing, or compromise in clinical outcomes.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Academic Medical Centers, Aortic Valve Stenosis, Cardiomyopathies, Constriction, Pathologic, Diagnostic Imaging, Education, Echocardiography, Heart Failure, Heart Valve Diseases, Unnecessary Procedures, Ventricular Function

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