Improving Appropriate Use of Transthoracic Echocardiography

Study Questions:

What is the impact of an Appropriate Use Criteria (AUC) intervention on the rate of ordering transthoracic echocardiograms (TTEs) that would be considered rarely appropriate (rA)?


The Echo WISELY study was conducted in eight hospitals over a 17-month period. TTE ordering characteristics were tabulated for outpatient-based activity for both cardiologists and primary care physicians. Physicians were randomized to a control group who did not receive additional training regarding Appropriate Use Criteria and an intervention group who received video and written instructions regarding AUC as well as monthly updates detailing their ordering patterns. After exclusions, 179 physicians were included in the analysis: 91 in the control group and 88 in the intervention group. During the study, 14,697 TTEs were assessed for AUC classification using the 2011 AUC for echocardiography.


TTE ordering volumes were similar between the intervention and control groups (77.7 ± 89.3 vs. 85.4 ± 111.4; p = 0.83). For the entire group, the proportion of rA TTE was 8.6% in the intervention group versus 11.1% in the control group (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.57-0.99; p = 0.039). When considering only physicians who ordered at least one TTE per month, there also was a lower proportion of rA TTE in the intervention versus the control group (8.6% vs. 11.1%; OR, 0.76; 95% CI, 0.57-0.99; p = 0.047).


The rate of ordering TTEs considered rA by the current AUC guidelines can be diminished with an active educational intervention aimed at ordering physicians.


This study builds on several previous retrospective and prospective reports of the impact of published AUC on the rate of ordering echocardiograms generally considered to be rA. The authors demonstrate a statistically significant, but very modest reduction in the rate of ordering of rA echocardiograms in the intervention group. The study was designed anticipating a 25% rate of ordering of rA echocardiograms, which would be in line with earlier data. The actual rate of ordering rA echocardiograms was less than half the anticipated rate, and as such, the room for improvement in the intervention group significantly lessened. The reason for the low rate of rA echocardiograms in the control group may relate to the sophisticated audience understudy as well as the fact that AUC had been in publication and generally available to ordering physicians for well over 5 years in advance of this study. The degree to which the control group had already adapted to AUC and thus modified ordering patterns is uncertain.

Clinical Topics: Noninvasive Imaging, Echocardiography/Ultrasound

Keywords: Cardiac Imaging Techniques, Echocardiography, Outpatients, Physicians, Primary Care, Quality Improvement

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