Editorial Quality Improvement Interventions to Improve Appropriateness of Imaging Studies Necessary, But Are They Sufficient? Ritu Sachdeva, MBBS; Pamela S. Douglas, MD
S
ince 2005, the American College of Cardiology Foundation, in conjunction with other societies, has released Appropriate Use Criteria (AUC) for various procedures and imaging modalities. The AUC are being increasingly recognized as an important link in the chain of quality improvement processes in cardiovascular patient care.
Article see p 10 Implementation studies evaluating AUC in usual clinical care have been instrumental in benchmarking the appropriateness and inappropriateness rates. A recent meta-analysis summarizing ≈60 published reports in >100 000 imaging tests found the rate of both appropriateness and rarely or inappropriate imaging test to vary widely by modality, as well as by iteration of the AUC document (Table).1 These data provide important information on how testing is used in usual care, thereby creating the framework for designing quality improvement initiatives. Such initiatives require physicians to change their ordering practices—not an easy task. A broad variety of methods have been proposed to change behavior from passive education to active interventions, with the latter being more effective and harder to implement.2 In this issue of Circulation: Cardiovascular Quality and Outcomes, Chaudhuri et al3 provide a systematic review of studies using quality improvement initiatives to reduce the proportion of rarely appropriate cardiovascular imaging based on AUC.3 The meta-analysis used stringent criteria and included just 7 studies with 6 observational studies and 1 randomized control trial, assessing the use of noninvasive imaging. These studies varied significantly in terms of the number of patients, type of imaging modalities, target population for intervention, and the type and practice location of providers. Not surprisingly, the strategies used also varied, ranging from passive interventions, such as lectures, webinars, and pocket cards to more active ones, such as point-of-care decision support tools, daily monitoring of appropriateness of studies, and The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (R.S.); and Department of Medicine, Duke University, Durham, NC (P.S.D.). Correspondence to Pamela S. Douglas, MD, Duke University Medical Center, 7022 North Pavilion DUMC, Durham, NC 27715. E-mail pamela. [email protected] (Circ Cardiovasc Qual Outcomes. 2016;9:00-00. DOI: 10.1161/CIRCOUTCOMES.115.002510.) © 2016 American Heart Association, Inc. Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org DOI: 10.1161/CIRCOUTCOMES.115.002510
direct feedback to providers. Also not surprisingly, some projects reported encouraging results, whereas others did not. To better determine what interventions are most effective, Chaudhuri et al3 evaluated each component of each educational intervention. They found that a physician audit and feedback process was the most effective method. Interventions that included this component were associated with significantly lower odds of rarely appropriate testing, whereas those lacking this process had no significant effect (odds ratio for rarely appropriate testing versus control period: 0.36 versus 0.89, respectively). The use of decision support tools was also associated with significantly lower odds of rarely appropriate testing (odds ratio, 0.35). Such an analysis is important because 2 of the studies included in the meta-analysis reported no significant decrease in rarely appropriate tests, although overall, the quality improvement interventions were associated with significantly higher odds of appropriate testing and lower odds of rarely appropriate testing. Although effective, it is important to also recognize possible limitations even of interventions involving the audit and feedback mechanism. The studies using this method were conducted over a brief span of time, with perhaps significant time devoted by the investigators. The sustainability of such models, therefore, becomes questionable. Not all institutions may have the willingness or resources, including knowledgeable personnel, to dedicate to such processes. In addition, the Hawthorne effect may result in lower rates of rarely appropriate testing during the study simply because of awareness of the providers. To that effect, although the results of the randomized control trial by Bhatia et al4 were encouraging in terms of reduction in the rate of rarely appropriate test using the audit and feedback mechanism, it was disappointing that the proportion of rarely appropriate echocardiograms increased to the preintervention level after the intervention was stopped.5 With the nationwide implementation of electronic medical records, integration of AUC into such systems is an appealing idea. The only study in the current meta-analysis that used such a point-of-care decision support tool showed an impressive decline in the rate of rarely appropriate tests and a rise in the rate of appropriate tests.6 Importantly, this study was conducted in 3 cardiology practices (St. Louis, MO) and supported by a single, large private payer for nonMedicare individuals who exempted participating physicians from preauthorization irrespective of the level of appropriateness determined by the tool. The Formation of Optimal Cardiovascular Utilization Strategies is a larger scale initiative that has a self-directed tool consisting of a provider audit and feedback mechanism. This program has significantly
Downloaded from http://circoutcomes.ahajournals.org/1 at University of Pittsburgh--HSLS on January 7, 2016
2 Circ Cardiovasc Qual Outcomes January 2016 Table. Published Data on Appropriateness of Noninvasive Testing by Imaging Modality (After Fonseca et al1) Pooled Proportion of Tests (%)
Transthoracic echocardiography
Appropriate
Rarely Appropriate or Inappropriate
80–85
8–9
Transesophageal echocardiography
89–95
1–2
Stress echocardiography
52–53
18–27
Computed tomographic angiography
37–55
17–21
Single-photon emission computed tomography
68–72
11–21
reduced the rate of rarely appropriate testing (10%–5%) in the 55 participating centers using the radionuclide imaging performance improvement module.7 Perhaps similar modules could be made available for other imaging modalities. Some payers have started supporting such initiatives. In 2011, under court order, the Blue Cross Blue Shield of Delaware agreed to pay for Delaware physicians to participate in the Formation of Optimal Cardiovascular Utilization Strategies program instead of the existing preauthorization system.8 Offering such incentives for participating in quality improvement projects is easy to implement and effective and could have long-lasting effects on physician test ordering behavior. Because the AUC originated in response to reports of wide variation in the use of cardiac imaging, it is understandable that the primary focus of AUC-related research has been on reduction of rarely appropriate tests. But what about those patients who should be tested but do not get one (underutilization)? This is an area where AUC may have less effect as there are no must test recommendations, just clinical scenarios in which it is reasonable to test whether the provider thinks it would give useful information (defined as the benefit exceeding harm). It is also hard to identify a population that has been dismissed from care without testing. We need to remind ourselves that AUC are not meant to curb testing when indicated. A point-of-care decision support tool, if accessed at every patient encounter, may be helpful in assuring appropriate testing in all patients when indicated. Another important point in addition to appropriateness is the frequency of testing. A recent study using a decision support tool incorporating multiple guidelines on chronic heart failure reported that, after an initial small reduction in the frequency of ordering echocardiograms, the effects started waning after 6 months.9 One has to be cognizant of the fact that appropriateness could be artificially improved by changing documentation to reflect a disease severity that meets the appropriateness criteria for ordering the test (ie, gaming), but such a behavior will not result in reducing the frequency of tests or truly reflect improved use. Although appropriateness is one aspect of clinical practice and represents clinical processes, the more important question is outcomes: after nearly a decade of using various AUC in clinical practice, do they actually improve patient outcomes? Some such studies are starting to emerge. Matulevicius et al10 reported that although almost 90% of the echocardiograms in their study were appropriate, only one third resulted in
an active change in care. It is not clear whether this is a reasonable or desirable proportion. A study of linked National Cardiovascular Data Registry and Medicare data showed that patients cared for in institutions after a surveillance pattern of stress imaging within 1 year after percutaneous coronary intervention, a rarely appropriate indication, had a higher rate of repeat revascularization but no difference in all-cause death or myocardial infarction when compared with those cared for in hospitals with a symptom-driven testing pattern.11 The effect of AUC on important longer-term outcomes remains to be seen. So, what would it take to improve utilization of cardiac testing and to affect patient outcomes in a meaningful way? The meta-analysis by Chaudhuri et al3 provides valuable information about efforts to date, but are they sufficient? One has to first recognize some important barriers in accomplishing this task. Preauthorization may be one such barrier. The proprietary algorithms followed for such approvals are not directly accessible to the providers, may not be in line with the current literature, and may restrict access to care in addition to adding to the administrative overhead costs.12 Another barrier in appropriate utilization is current fee for service reimbursement models that reward physicians and hospitals when increasing the number of test and procedures. Instead, providing reimbursement incentives and exemption from preauthorization for participating in quality initiatives could provide a better model for improving the utilization of tests and ultimately improving patient outcomes. Promotion and funding of broader quality initiatives involving nationwide initiatives through professional societies or registries may also help in truly assessing the effect on patient care. Initiatives, such as the Choosing Wisely campaign, have raised awareness provider and public awareness on unnecessary or potentially harmful medical tests and procedures.13 The importance of quality measures in improving patient care needs to be equally appreciated by all stakeholders. The Protecting Access to Medicare Act of 2014 (H.R. 4302) was passed by the Congress in March 2014. Although implementation has recently been postponed, this act required ordering providers to consult with AUC for all Medicare patients receiving advanced imaging (nuclear, computed tomography, and magnetic resonance imaging) beginning in 2017.14 Importantly, this program will not adjudicate payments based on the appropriateness of the studies, a feature that recognizes the need for judgment rather than arbitrary rules in medicine. This is an important step toward realizing our national commitment to providing quality care to our patients. In conclusion, the meta-analysis presented here by Chaudhuri et al3 brings to light the varying effectiveness of active educational interventions in improving the appropriateness of testing and points a way forward for future efforts. Further work is needed to implement such interventions at a much larger scale and, more importantly, to assess their effect on improving patient outcomes and not just the appropriateness of testing. Provision of reimbursement incentives for participation in such efforts rather than punitive processes may be helpful. Furthermore, a unified front involving all stakeholders, including the providers, payers, and the patients
Downloaded from http://circoutcomes.ahajournals.org/ at University of Pittsburgh--HSLS on January 7, 2016
Sachdeva and Douglas AUC: Necessary But Not Sufficient 3 themselves in promoting these quality interventions will be an important key to the success of such efforts.
Disclosures None.
References 1. Fonseca R, Negishi K, Otahal P, Marwick TH. Temporal changes in appropriateness of cardiac imaging. J Am Coll Cardiol. 2015;65:763–773. doi: 10.1016/j.jacc.2014.11.057. 2. Mostofian F, Ruban C, Simunovic N, Bhandari M. Changing physician behavior: what works? Am J Manag Care. 2015;21:75–84. 3. Chaudhuri D, Montgomery A, Gulenchyn K, Mitchell M, Jospeh P. Effectiveness of quality improvement interventions at reducing inappropriate cardiac imaging: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2016;9:10–16. 4. Bhatia RS, Milford CE, Picard MH, Weiner RB. An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013;6:545–555. doi: 10.1016/j.jcmg.2013.01.010. 5. Bhatia RS, Dudzinski DM, Milford CE, Picard MH, Weiner RB. Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention. Echocardiography. 2014;31:916–923. doi: 10.1111/echo.12505. 6. Lin FY, Dunning AM, Narula J, Shaw LJ, Gransar H, Berman DS, Min JK. Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: a prospective multicenter study. J Am Coll Cardiol. 2013;62:308–316. doi: 10.1016/j.jacc.2013.04.059. 7. Saifi S, Taylor AJ, Allen J, Hendel R. The use of a learning community and online evaluation of utilization for SPECT myocardial perfusion
imaging. JACC Cardiovasc Imaging. 2013;6:823–829. doi: 10.1016/j. jcmg.2013.01.012. 8. Miller RR, Hird TJ, Tang P, Zlosnik JE. Whole-genome sequencing of three clonal clinical isolates of B. cenocepacia from a patient with cystic fibrosis. PLoS One. 2015;10:e0143472. doi: 10.1371/journal. pone.0143472. 9. Boggan JC, Baker AW, Lewis SS, Dicks KV, Durkin MJ, Moehring RW, Chen LF, Knelson LP, Hegland DD, Anderson DJ. An automated surveillance strategy to identify infectious complications after cardiac implantable electronic device procedures. Open Forum Infect Dis. 2015;2:ofv128. doi: 10.1093/ofid/ofv128. 10. Matulevicius SA, Rohatgi A, Das SR, Price AL, DeLuna A, Reimold SC. Appropriate use and clinical impact of transthoracic echocardiography. JAMA Intern Med. 2013;173:1600–1607. doi: 10.1001/ jamainternmed.2013.8972. 11. Shah BR, McCoy LA, Federspiel JJ, Mudrick D, Cowper PA, Masoudi FA, Lytle BL, Green CL, Douglas PS. Use of stress testing and diagnostic catheterization after coronary stenting: association of site-level patterns with patient characteristics and outcomes in 247,052 Medicare beneficiaries. J Am Coll Cardiol. 2013;62:439–446. doi: 10.1016/j.jacc.2013.02.093. 12. Sachdeva R, Samai C, Vincent RN. Pediatric appropriate use criteria for echocardiography: implications for clinical practice. Pediatrics. 2015;135:e1128–e1130. doi: 10.1542/peds.2014-3537. 13. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely Campaign. Acad Med. 2014;89:990–995. doi: 10.1097/ ACM.0000000000000270. 14. Dehmer GJ, Patel MR. Use of appropriate use criteria is increasing, but what are their effects on medical care? Circulation. 2015;132:4–6. doi: 10.1161/CIRCULATIONAHA.115.017243. Key Words: Editorials ◼ diagnostic imaging ◼ physicians ◼ quality improvement
Downloaded from http://circoutcomes.ahajournals.org/ at University of Pittsburgh--HSLS on January 7, 2016
Quality Improvement Interventions to Improve Appropriateness of Imaging Studies: Necessary, But Are They Sufficient? Ritu Sachdeva and Pamela S. Douglas Circ Cardiovasc Qual Outcomes. published online January 5, 2016; Circulation: Cardiovascular Quality and Outcomes is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2016 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-7705. Online ISSN: 1941-7713
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circoutcomes.ahajournals.org/content/early/2016/01/05/CIRCOUTCOMES.115.002510.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation: Cardiovascular Quality and Outcomes can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation: Cardiovascular Quality and Outcomes is online at: http://circoutcomes.ahajournals.org//subscriptions/
Downloaded from http://circoutcomes.ahajournals.org/ at University of Pittsburgh--HSLS on January 7, 2016
S
ince 2005, the American College of Cardiology Foundation, in conjunction with other societies, has released Appropriate Use Criteria (AUC) for various procedures and imaging modalities. The AUC are being increasingly recognized as an important link in the chain of quality improvement processes in cardiovascular patient care.
Article see p 10 Implementation studies evaluating AUC in usual clinical care have been instrumental in benchmarking the appropriateness and inappropriateness rates. A recent meta-analysis summarizing ≈60 published reports in >100 000 imaging tests found the rate of both appropriateness and rarely or inappropriate imaging test to vary widely by modality, as well as by iteration of the AUC document (Table).1 These data provide important information on how testing is used in usual care, thereby creating the framework for designing quality improvement initiatives. Such initiatives require physicians to change their ordering practices—not an easy task. A broad variety of methods have been proposed to change behavior from passive education to active interventions, with the latter being more effective and harder to implement.2 In this issue of Circulation: Cardiovascular Quality and Outcomes, Chaudhuri et al3 provide a systematic review of studies using quality improvement initiatives to reduce the proportion of rarely appropriate cardiovascular imaging based on AUC.3 The meta-analysis used stringent criteria and included just 7 studies with 6 observational studies and 1 randomized control trial, assessing the use of noninvasive imaging. These studies varied significantly in terms of the number of patients, type of imaging modalities, target population for intervention, and the type and practice location of providers. Not surprisingly, the strategies used also varied, ranging from passive interventions, such as lectures, webinars, and pocket cards to more active ones, such as point-of-care decision support tools, daily monitoring of appropriateness of studies, and The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (R.S.); and Department of Medicine, Duke University, Durham, NC (P.S.D.). Correspondence to Pamela S. Douglas, MD, Duke University Medical Center, 7022 North Pavilion DUMC, Durham, NC 27715. E-mail pamela. [email protected] (Circ Cardiovasc Qual Outcomes. 2016;9:00-00. DOI: 10.1161/CIRCOUTCOMES.115.002510.) © 2016 American Heart Association, Inc. Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org DOI: 10.1161/CIRCOUTCOMES.115.002510
direct feedback to providers. Also not surprisingly, some projects reported encouraging results, whereas others did not. To better determine what interventions are most effective, Chaudhuri et al3 evaluated each component of each educational intervention. They found that a physician audit and feedback process was the most effective method. Interventions that included this component were associated with significantly lower odds of rarely appropriate testing, whereas those lacking this process had no significant effect (odds ratio for rarely appropriate testing versus control period: 0.36 versus 0.89, respectively). The use of decision support tools was also associated with significantly lower odds of rarely appropriate testing (odds ratio, 0.35). Such an analysis is important because 2 of the studies included in the meta-analysis reported no significant decrease in rarely appropriate tests, although overall, the quality improvement interventions were associated with significantly higher odds of appropriate testing and lower odds of rarely appropriate testing. Although effective, it is important to also recognize possible limitations even of interventions involving the audit and feedback mechanism. The studies using this method were conducted over a brief span of time, with perhaps significant time devoted by the investigators. The sustainability of such models, therefore, becomes questionable. Not all institutions may have the willingness or resources, including knowledgeable personnel, to dedicate to such processes. In addition, the Hawthorne effect may result in lower rates of rarely appropriate testing during the study simply because of awareness of the providers. To that effect, although the results of the randomized control trial by Bhatia et al4 were encouraging in terms of reduction in the rate of rarely appropriate test using the audit and feedback mechanism, it was disappointing that the proportion of rarely appropriate echocardiograms increased to the preintervention level after the intervention was stopped.5 With the nationwide implementation of electronic medical records, integration of AUC into such systems is an appealing idea. The only study in the current meta-analysis that used such a point-of-care decision support tool showed an impressive decline in the rate of rarely appropriate tests and a rise in the rate of appropriate tests.6 Importantly, this study was conducted in 3 cardiology practices (St. Louis, MO) and supported by a single, large private payer for nonMedicare individuals who exempted participating physicians from preauthorization irrespective of the level of appropriateness determined by the tool. The Formation of Optimal Cardiovascular Utilization Strategies is a larger scale initiative that has a self-directed tool consisting of a provider audit and feedback mechanism. This program has significantly
Downloaded from http://circoutcomes.ahajournals.org/1 at University of Pittsburgh--HSLS on January 7, 2016
2 Circ Cardiovasc Qual Outcomes January 2016 Table. Published Data on Appropriateness of Noninvasive Testing by Imaging Modality (After Fonseca et al1) Pooled Proportion of Tests (%)
Transthoracic echocardiography
Appropriate
Rarely Appropriate or Inappropriate
80–85
8–9
Transesophageal echocardiography
89–95
1–2
Stress echocardiography
52–53
18–27
Computed tomographic angiography
37–55
17–21
Single-photon emission computed tomography
68–72
11–21
reduced the rate of rarely appropriate testing (10%–5%) in the 55 participating centers using the radionuclide imaging performance improvement module.7 Perhaps similar modules could be made available for other imaging modalities. Some payers have started supporting such initiatives. In 2011, under court order, the Blue Cross Blue Shield of Delaware agreed to pay for Delaware physicians to participate in the Formation of Optimal Cardiovascular Utilization Strategies program instead of the existing preauthorization system.8 Offering such incentives for participating in quality improvement projects is easy to implement and effective and could have long-lasting effects on physician test ordering behavior. Because the AUC originated in response to reports of wide variation in the use of cardiac imaging, it is understandable that the primary focus of AUC-related research has been on reduction of rarely appropriate tests. But what about those patients who should be tested but do not get one (underutilization)? This is an area where AUC may have less effect as there are no must test recommendations, just clinical scenarios in which it is reasonable to test whether the provider thinks it would give useful information (defined as the benefit exceeding harm). It is also hard to identify a population that has been dismissed from care without testing. We need to remind ourselves that AUC are not meant to curb testing when indicated. A point-of-care decision support tool, if accessed at every patient encounter, may be helpful in assuring appropriate testing in all patients when indicated. Another important point in addition to appropriateness is the frequency of testing. A recent study using a decision support tool incorporating multiple guidelines on chronic heart failure reported that, after an initial small reduction in the frequency of ordering echocardiograms, the effects started waning after 6 months.9 One has to be cognizant of the fact that appropriateness could be artificially improved by changing documentation to reflect a disease severity that meets the appropriateness criteria for ordering the test (ie, gaming), but such a behavior will not result in reducing the frequency of tests or truly reflect improved use. Although appropriateness is one aspect of clinical practice and represents clinical processes, the more important question is outcomes: after nearly a decade of using various AUC in clinical practice, do they actually improve patient outcomes? Some such studies are starting to emerge. Matulevicius et al10 reported that although almost 90% of the echocardiograms in their study were appropriate, only one third resulted in
an active change in care. It is not clear whether this is a reasonable or desirable proportion. A study of linked National Cardiovascular Data Registry and Medicare data showed that patients cared for in institutions after a surveillance pattern of stress imaging within 1 year after percutaneous coronary intervention, a rarely appropriate indication, had a higher rate of repeat revascularization but no difference in all-cause death or myocardial infarction when compared with those cared for in hospitals with a symptom-driven testing pattern.11 The effect of AUC on important longer-term outcomes remains to be seen. So, what would it take to improve utilization of cardiac testing and to affect patient outcomes in a meaningful way? The meta-analysis by Chaudhuri et al3 provides valuable information about efforts to date, but are they sufficient? One has to first recognize some important barriers in accomplishing this task. Preauthorization may be one such barrier. The proprietary algorithms followed for such approvals are not directly accessible to the providers, may not be in line with the current literature, and may restrict access to care in addition to adding to the administrative overhead costs.12 Another barrier in appropriate utilization is current fee for service reimbursement models that reward physicians and hospitals when increasing the number of test and procedures. Instead, providing reimbursement incentives and exemption from preauthorization for participating in quality initiatives could provide a better model for improving the utilization of tests and ultimately improving patient outcomes. Promotion and funding of broader quality initiatives involving nationwide initiatives through professional societies or registries may also help in truly assessing the effect on patient care. Initiatives, such as the Choosing Wisely campaign, have raised awareness provider and public awareness on unnecessary or potentially harmful medical tests and procedures.13 The importance of quality measures in improving patient care needs to be equally appreciated by all stakeholders. The Protecting Access to Medicare Act of 2014 (H.R. 4302) was passed by the Congress in March 2014. Although implementation has recently been postponed, this act required ordering providers to consult with AUC for all Medicare patients receiving advanced imaging (nuclear, computed tomography, and magnetic resonance imaging) beginning in 2017.14 Importantly, this program will not adjudicate payments based on the appropriateness of the studies, a feature that recognizes the need for judgment rather than arbitrary rules in medicine. This is an important step toward realizing our national commitment to providing quality care to our patients. In conclusion, the meta-analysis presented here by Chaudhuri et al3 brings to light the varying effectiveness of active educational interventions in improving the appropriateness of testing and points a way forward for future efforts. Further work is needed to implement such interventions at a much larger scale and, more importantly, to assess their effect on improving patient outcomes and not just the appropriateness of testing. Provision of reimbursement incentives for participation in such efforts rather than punitive processes may be helpful. Furthermore, a unified front involving all stakeholders, including the providers, payers, and the patients
Downloaded from http://circoutcomes.ahajournals.org/ at University of Pittsburgh--HSLS on January 7, 2016
Sachdeva and Douglas AUC: Necessary But Not Sufficient 3 themselves in promoting these quality interventions will be an important key to the success of such efforts.
Disclosures None.
References 1. Fonseca R, Negishi K, Otahal P, Marwick TH. Temporal changes in appropriateness of cardiac imaging. J Am Coll Cardiol. 2015;65:763–773. doi: 10.1016/j.jacc.2014.11.057. 2. Mostofian F, Ruban C, Simunovic N, Bhandari M. Changing physician behavior: what works? Am J Manag Care. 2015;21:75–84. 3. Chaudhuri D, Montgomery A, Gulenchyn K, Mitchell M, Jospeh P. Effectiveness of quality improvement interventions at reducing inappropriate cardiac imaging: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2016;9:10–16. 4. Bhatia RS, Milford CE, Picard MH, Weiner RB. An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013;6:545–555. doi: 10.1016/j.jcmg.2013.01.010. 5. Bhatia RS, Dudzinski DM, Milford CE, Picard MH, Weiner RB. Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention. Echocardiography. 2014;31:916–923. doi: 10.1111/echo.12505. 6. Lin FY, Dunning AM, Narula J, Shaw LJ, Gransar H, Berman DS, Min JK. Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: a prospective multicenter study. J Am Coll Cardiol. 2013;62:308–316. doi: 10.1016/j.jacc.2013.04.059. 7. Saifi S, Taylor AJ, Allen J, Hendel R. The use of a learning community and online evaluation of utilization for SPECT myocardial perfusion
imaging. JACC Cardiovasc Imaging. 2013;6:823–829. doi: 10.1016/j. jcmg.2013.01.012. 8. Miller RR, Hird TJ, Tang P, Zlosnik JE. Whole-genome sequencing of three clonal clinical isolates of B. cenocepacia from a patient with cystic fibrosis. PLoS One. 2015;10:e0143472. doi: 10.1371/journal. pone.0143472. 9. Boggan JC, Baker AW, Lewis SS, Dicks KV, Durkin MJ, Moehring RW, Chen LF, Knelson LP, Hegland DD, Anderson DJ. An automated surveillance strategy to identify infectious complications after cardiac implantable electronic device procedures. Open Forum Infect Dis. 2015;2:ofv128. doi: 10.1093/ofid/ofv128. 10. Matulevicius SA, Rohatgi A, Das SR, Price AL, DeLuna A, Reimold SC. Appropriate use and clinical impact of transthoracic echocardiography. JAMA Intern Med. 2013;173:1600–1607. doi: 10.1001/ jamainternmed.2013.8972. 11. Shah BR, McCoy LA, Federspiel JJ, Mudrick D, Cowper PA, Masoudi FA, Lytle BL, Green CL, Douglas PS. Use of stress testing and diagnostic catheterization after coronary stenting: association of site-level patterns with patient characteristics and outcomes in 247,052 Medicare beneficiaries. J Am Coll Cardiol. 2013;62:439–446. doi: 10.1016/j.jacc.2013.02.093. 12. Sachdeva R, Samai C, Vincent RN. Pediatric appropriate use criteria for echocardiography: implications for clinical practice. Pediatrics. 2015;135:e1128–e1130. doi: 10.1542/peds.2014-3537. 13. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely Campaign. Acad Med. 2014;89:990–995. doi: 10.1097/ ACM.0000000000000270. 14. Dehmer GJ, Patel MR. Use of appropriate use criteria is increasing, but what are their effects on medical care? Circulation. 2015;132:4–6. doi: 10.1161/CIRCULATIONAHA.115.017243. Key Words: Editorials ◼ diagnostic imaging ◼ physicians ◼ quality improvement
Downloaded from http://circoutcomes.ahajournals.org/ at University of Pittsburgh--HSLS on January 7, 2016
Quality Improvement Interventions to Improve Appropriateness of Imaging Studies: Necessary, But Are They Sufficient? Ritu Sachdeva and Pamela S. Douglas Circ Cardiovasc Qual Outcomes. published online January 5, 2016; Circulation: Cardiovascular Quality and Outcomes is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2016 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-7705. Online ISSN: 1941-7713
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circoutcomes.ahajournals.org/content/early/2016/01/05/CIRCOUTCOMES.115.002510.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation: Cardiovascular Quality and Outcomes can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation: Cardiovascular Quality and Outcomes is online at: http://circoutcomes.ahajournals.org//subscriptions/
Downloaded from http://circoutcomes.ahajournals.org/ at University of Pittsburgh--HSLS on January 7, 2016
