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Published on: January 27, 2023
The use of quality improvement interventions in reducing rarely appropriate echocardiograms: A systematic review and
Michael Tao1, Mohammed Al-Sadawi1, Navid Ahmed1
1Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, New York, USA.
Insights
Quality improvement interventions significantly reduce rarely appropriate cardiac imaging tests. These interventions, including education and decision support tools, show lasting effectiveness over time.
Area of Science:
- Cardiology
- Health Services Research
- Medical Imaging
Background:
- Increasing volume of cardiac imaging tests, often for rarely appropriate indications.
- Development of Appropriate Use Criteria (AUC) by professional societies.
- Need to assess the effectiveness of quality improvement (QI) interventions on cardiac imaging test utilization.
Approach:
- Systematic literature search across multiple databases (MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, CINAHL).
- Inclusion of studies evaluating QI interventions aimed at reducing rarely appropriate echocardiograms.
- Primary endpoint focused on the reduction of rarely appropriate testing.
Key Points:
- Nine studies involving 22,070 patients demonstrated QI interventions significantly reduced rarely appropriate echocardiograms (OR 0.52).
- Effectiveness persisted in both short-term (OR 0.62) and long-term (OR 0.47) follow-up periods.
- Both education tools (OR 0.54) and decision support tools (OR 0.47) were effective; feedback tools did not add benefit.
Conclusions:
- Quality improvement interventions are effective in reducing rarely appropriate echocardiography.
- The positive effects of QI interventions are sustained over time.
- Education and decision support tools are key components for optimizing cardiac imaging test ordering.
Background:
The volume of cardiac imaging continues to increase, with many tests performed for rarely appropriate indications. Appropriate use criteria (AUC) documents were published by the American Society of Echocardiography and American College of Cardiology, with quality improvement (QI) interventions developed in various institutions. However, the effectiveness of these interventions has not been assessed in a systematic fashion.
Methods:
We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL for studies reporting association between cardiac imaging, AUC and QI. The search was not restricted to time or publication status. We selected studies assessing the effect of QI interventions on performance of rarely appropriate echocardiograms. The primary endpoint was reduction of rarely appropriate testing.
Results:
Nine studies with 22,070 patients met inclusion criteria. Mean follow up was 15 months (1-60 months). QI interventions resulted in statistically significant reduction in rarely appropriate tests (OR 0.52, 95% CI: .41-.66; p < .01). The effects of QI interventions were analyzed over both the short (<3 months) and long-term (>3 months) post intervention (OR 0.62, 95% CI: .49-.79; p < .01 in the short term, and OR 0.47, 95% CI: .35-.62; p < .01 in the long term). Subgroup analysis of the type of intervention, classified as education tools or decision support tools showed both significantly reduced rarely appropriate testing (OR 0.54, 95% CI: .41-.73; p < .01; OR .47, 95% CI: .36-.61; p < .01). Adding a feedback tool did not change the effect compared to not using a feedback tool (OR 0.49 vs. 0.57, 95% CI: .36-.68 vs. 39-.84; p > .05).
Conclusion:
QI interventions are associated with a significant reduction in performance of rarely appropriate echocardiography testing, the effects of which persist over time. Both education and decision support tools were effective, while adding feedback tools did not result in further reduction of ordering rarely appropriate studies.
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