TORONTO, ON — An intervention that featured education on appropriate-use criteria (AUC) and monthly feedback significantly reduced the number of “rarely appropriate” outpatient transthoracic echocardiograms (TTEs) in the prospective randomized Echo WISELY trial[1].
The investigators, led by Dr R Sacha Bhatia (Women’s College Hospital, Toronto, ON), say the beneficial effects of the intervention cut across countries, physician specialties, and reimbursement settings.
“We had almost no negative feedback in the intervention group to the practice report, and since the study closed we’ve actually had requests from the control physicians to get their feedback, suggesting that compared with other approaches to imaging utilization this is one that physicians really got behind,” Bhatia said in an interview.
Prior authorization programs often add to physician administrative burden and may deny up to 15% to 20% of individual medical imaging tests.
Importantly, the overall volume of echo ordering was not significantly different between the intervention and control groups (mean 77.7 vs 85.4; P=0.83).
“This is critical for providers who fear that AUC implementation might hurt the bottom line,” Dr Pamela Douglas (Duke Clinical Research Institute, Durham, NC), who was not involved in the study, told theheart.org | Medscape Cardiology in an email.
Although AUC criteria have been in existence for more than a decade, Douglas said most prior intervention studies have been small, single-center, and nonrandomized.
“Randomization is more rigorous and removes the ‘placebo’ effect of AUC dissemination vs the effect of the intervention,” she added.
Echo WISELY included 14,697 echos ordered from December 2014 to April 2016 by 179 physicians at eight US and Canadian primarily academic medical centers.
Physicians were randomized to usual care or an intervention that included a 20-minute educational video on AUC for echocardiography, instructions on how to download the American Society of Echocardiography (ASE) decision-support mobile app, and monthly feedback reports summarizing their total number of “rarely appropriate,” “may be appropriate,” and “appropriate” echos compared with other participants at their site.
Site research coordinators, blinded to physicians’ group allocation, determined echo appropriateness using the 2011 AUC.
In all, 9.5% of the 6899 echos ordered by the intervention group were deemed “rarely appropriate” compared with 12.4% of the 7798 echos ordered by controls.
After adjustment for physician specialty, the proportion of “rarely inappropriate” echos was significantly lower in the intervention group than the control group (8.8% vs 10.1%; P=0.039), the authors report in the August 29, 2017 issue of the Journal of the American College of Cardiology.
The difference between the intervention and control groups was also significant among physicians ordering at least one echo per month (8.6% vs 11.1%, P=0.047).
After further adjustment for the month in which the echo was ordered, the effect of the intervention did not wane over time (odds ratio 0.98, P=0.17). Nor did it differ significantly between US and Canadian physicians (OR 0.78, P=0.40).
The authors suggest the monthly feedback reports were one of the biggest drivers of improved echo ordering.
“I really do believe data drive performance,” Bhatia said. “I think doctors really want to do the right thing, but oftentimes they aren’t shown data about their performance that’s systematic. So I think that was a key element.
“And because this is very grassroots and physician-driven and there are no penalties. . . . it’s a lot easier to get physician buy-in to an approach like this.”
The authors write that the overall impact of the intervention was “modest” but that the results “have significant public-policy implications” that may extend beyond echocardiography to other cardiac testing and imaging modalities.
“Showing the feasibility of a [randomized controlled trial] in this space—imaging utilization—is a paradigm that that could extend to other forms of imaging and overall diagnostic care,” agreed Douglas.
She added, “Because echo is somewhat unique in having the ordering provider and the rendering provider both be clinicians (vs only the ordering provider if the rendering provider is a radiologist), this may make it a bit harder to achieve but is still an important model.”
Limitations of the study are that the durability of the effect and long-term impact on patient outcomes are unknown, Douglas said.
Dr Randolph P Martin (Emory University, Atlanta, GA) echoed those concerns in an accompanying editorial[2], which notes that once the AUC-based intervention was stopped, the number of inappropriate echos returned to preintervention levels.
“Therefore, the lesson is that some simple ways to continue to educate those who ordered echocardiography on what constituted appropriate use needs to be developed and implemented. The key words are simple and easy,” he writes.
This may include public reporting of physician audits as well as targeting educational efforts to those ordering the highest volume of echocardiograms or at the top three to five “rarely appropriate” echocardiograms being ordered.
The top three “rarely appropriate” culprits in Echo WISELY were: routine surveillance of prosthetic heart valves in place for <3 years, if there was no known or suspected dysfunction (AUC indication #48); routine surveillance of ventricular function in patients with known CAD and no change in clinical status or cardiac exam (AUC indication #11); and routine surveillance within 1 year in patients with moderate to severe valvular stenosis with no change in clinical status or cardiac exam (AUC indication #40).
Finally, Martin suggests incorporating natural-language processing and automated analytical software in electronic-medical-records ordering systems.
“If companies such as Amazon can know what your online ordering history and preferences are, why can’t similar [artificial intelligence] AI machine-learning algorithms be applied to the ordering of echocardiograms by individual physicians or healthcare providers?”
Funding was provided by the Peter Munk Cardiac Centre (Toronto, ON), the Ontario Ministry of Health and Long-term Care, and the Cardiac Care Network of Ontario. Bhatia reported no relevant financial relationships. Disclosures for the coauthors are listed in the paper. Martin reported no relevant financial relationships.
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