An Educational Intervention Reduces the Rate of Inappropriate Echocardiograms on an Inpatient Medical Service

Study Questions:

Can the rate of appropriate and inappropriate transthoracic echocardiograms (TTEs) be altered by an educational intervention directed at a general medicine service in a major teaching hospital?


All TTEs ordered from a general medicine inpatient teaching service from February 23 to June 24, 2012, were reviewed and classified as according to the 2011 Appropriate Use Criteria (AUC). Each echocardiogram was classified appropriate, inappropriate, or uncertain from review of the electronic medical records. At the beginning of the study period, a lecture was provided to all medical house staff on the basics of AUC, highlighting common clinical scenarios as well as appropriate and inappropriate indications. A laminated pocket card regarding tips for classification of appropriate and inappropriate TTE was provided, and at 2-week intervals, the inpatient teams were provided with email feedback regarding their ordering patterns. The rates for appropriate and inappropriate TTE were compared to a 10-month period in 2011, for which similar data regarding appropriate and inappropriate ordering patterns were available.


During the baseline period, 5,623 patients were admitted to the teaching medical service, and during the 4-month intervention period, 1,711 patients were admitted. The average number of admissions per day was 16.8 in the preintervention period and 13.9 in the intervention period. During both periods, there was a relatively low prevalence of primary cardiovascular disease, and no clinically relevant discrepancies in the patient populations. During the preintervention period, 23 TTEs/100 admissions were ordered compared to 20 TTEs/100 admissions in the intervention period. In the preintervention and intervention periods, 99% and 98% of TTEs were classifiable, 84% and 93% were appropriate, and 13% and 5% were inappropriate (p < 0.001). Comparing month-to-month ordering patterns, there was a greater than fourfold variation in the rate of inappropriate TTEs ordered during the baseline period. The most common inappropriate indications in the preintervention period were for transient fever without evidence of bacteremia, or a new murmur or transient bacteremia with a known source, or nonpathogenic organism. Other common inappropriate indications included evaluation of LV function for routine surveillance, or when function was known to be normal from a prior examination. There was no statistically significant decrease in the rate of any single inappropriate AUC; however, when inappropriate TTEs for suspicion of endocarditis were pooled, there was a significant decrease in the inappropriate TTE rate from 7% to 3% (p = 0.002), and a similar pattern seen when inappropriate indications for routine assessment of LV function were pooled (2.2% vs. 0.5%, p = 0.05).


An educational intervention targeting house officers with respect to appropriate and inappropriate TTE indications is effective at reducing the rate of inappropriate TTEs in an inpatient general medicine teaching service.


The AUC for echocardiography were developed as a guideline for identification of clinical scenarios in which an echocardiogram would be appropriate and likely to assist in diagnosis or alter clinical management, or inappropriate, in which case little or no change in a specific diagnosis or patient management would be expected. Multiple surveillance studies have demonstrated rates of inappropriate TTE of 10% to 15% depending on practice situations. In this study, the authors described a fairly simple and straightforward educational initiative directed at house staff on an inpatient academic general medicine teaching service consisting of lectures, pocket cards, and feedback regarding ordering patterns. They then compared the rate of inappropriate and appropriate TTE to a prior 10-month period on the same inpatient service, although obviously with different teams of physicians. At first glance, there was an immediate impact on ordering patterns with a significant reduction in the rate of inappropriate TTEs being ordered, which would be a commendable result, and likely to result in reduced inappropriate expenditures. As a side evaluation, the authors also evaluated 50 patients with congestive heart failure during each time period and determined that there was no difference in the rate of appropriate and inappropriate TTE for the 50 patients, suggesting that their intervention was not reducing utilization in appropriate settings. While the intervention in all likelihood was responsible for a substantial reduction in the inappropriate TTE ordering rate, other factors clearly are at play. First, the study period in 2012 occurred after publication of multiple manuscripts on AUC and heightened awareness of appropriate and inappropriate medical utilization both in the medical literature and often in the lay press. As such, the house staff and medical teams under evaluation in 2012 may have already been more well educated regarding appropriate utilization of medical resources than their colleagues were in 2011. Additionally, the number of admissions per day fell from 16.8 in the preintervention period to 13.9 in the intervention period, suggesting the possibility of a shift in either patient acuity or an enhanced pattern of ‘appropriate’ admissions versus more marginal indications for hospital admission. This would have the effect of providing the house staff with a larger proportion of patients appropriately admitted for whom TTE may be an appropriate tool compared to the preintervention period, which may have represented a different patient population. As such, while the intervention described here is commendable for its straight-forward nature and simplicity, which renders it applicable to virtually any institution, it may be only part of the story with respect to improved rates of inappropriate and appropriate TTE.

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

Keywords: Physicians, Heart Diseases, Electronic Health Records, Endocarditis, Education, Medical, Graduate, General Practice, Heart Failure, Awareness, Medical Staff, Hospitals, Teaching, Echocardiography

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