A Multi-centered Feedback and Education Intervention Designed to Reduce Inappropriate Transthoracic Echocardiograms
| Status: | Recruiting |
|---|---|
| Conditions: | Peripheral Vascular Disease |
| Therapuetic Areas: | Cardiology / Vascular Diseases |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 4/2/2016 |
| Start Date: | December 2014 |
| End Date: | May 2016 |
| Contact: | Sacha R Bhatia, MD |
| Email: | sacha.bhatia@wchospital.ca |
| Phone: | 4163237509 |
Feedback and Education Intervention to Reduce Inappropriate Transthoracic Echocardiograms (TTE)
This study is an international, prospective, multi-centred, investigator blinded, randomized
control trial of an educational and feedback-based intervention vs. usual care to study the
proportion of inappropriate TTEs ordered by clinicians in ambulatory care.
Increased inappropriate TTE utilization represents a burden to health budgets as costs rise
with increased utilization, and to patients themselves who are burdened with unnecessary
procedures that can adversely affect quality of care. Rising utilization in an environment
with limited supply also creates barriers to access and increased wait times for those
patients in the community who are awaiting necessary TTEs.
In a move to balance the concern regarding rising utilization while still ensuring physician
autonomy on access to ordering cardiac tests and procedures, the American College of
Cardiology collaborated with the American Society of Echocardiography to develop its
Appropriate Use Criteria (AUC) for Echocardiography in 2007, and were updated in 2011. AUC
were created by using the modified RAND appropriateness method. Studies applying AUC to TTE
orders at single centres in the US found inappropriate TTE rates in ambulatory (outpatient)
care ranging up to 35%.
We have successfully created an innovative education and feedback-based intervention that we
hypothesize will reduce the proportion of inappropriate TTEs ordered in clinical practice,
which will save healthcare dollars and improve quality of care and access to
echocardiography. Our objective is to prospectively study the following intervention in a
multicentre, randomized control trial format to determine if this intervention will reduce
inappropriate TTEs and the number of TTEs ordered in practice.
The study will take place at multiple hospitals in Canada the United States. Participants
include cardiologists and primary care providers (both general internal medicine and family
practice) who provide ambulatory care. Only providers who see patients in ambulatory care
clinics will be included. Pediatric cardiologists and physicians who specialize primarily in
adult congenital heart disease will be excluded from the study. Physicians who are
approached will be required to provide written consent prior to participation in the study.
Once cardiologists and primary care physicians are recruited for the study, they will be
randomized into one of two arms: 1) Intervention group, 2) Control group. Randomization will
occur at the same time for each site to ensure the study start date is consistent across all
sites.
Collection of TTE ordering information and TTE order classification:
A physician's TTE ordering information will be ascertained by review of the individual TTE
order and by review of the patient's medical record. This may be through review of the
Electronic Medical Record (EMR) or paper chart, depending on the individual site. Trained
research coordinators at each site will review the TTE order for indication and review the
patient record to ascertain clinical circumstances regarding the TTE order. The individual
research coordinator will review this information using the 2011 AUC and classify the TTE as
Appropriate (A), Inappropriate (I) or Uncertain (U), and assign the TTE order the most
appropriate indication number accordingly. TTE orders that do not have a corresponding
indication number will be designated as unclassifiable. Research Coordinators will be
blinded to which physicians are in the intervention or control group. This system of TTE
classification has been previously piloted and published by our group in two recently
published studies, and the rate of successful classification was greater than 98%11, 15, 16.
Dissemination of TTE monthly feedback reports:
Research Coordinators at each site will be responsible for individual physicians' TTE order
classifications but will be blinded to study group. Once monthly TTE orders are classified
and collated, this information will be transmitted to the central research laboratory, where
a research coordinator will collate all of the results and transmit monthly feedback reports
to individual physicians. This process ensures that local site coordinators and the study
investigators are blinded to the results to the study, while still enabling the creation and
dissemination of physician related feedback reports to the intervention group. The control
group will order TTEs as is their usual practice.
control trial of an educational and feedback-based intervention vs. usual care to study the
proportion of inappropriate TTEs ordered by clinicians in ambulatory care.
Increased inappropriate TTE utilization represents a burden to health budgets as costs rise
with increased utilization, and to patients themselves who are burdened with unnecessary
procedures that can adversely affect quality of care. Rising utilization in an environment
with limited supply also creates barriers to access and increased wait times for those
patients in the community who are awaiting necessary TTEs.
In a move to balance the concern regarding rising utilization while still ensuring physician
autonomy on access to ordering cardiac tests and procedures, the American College of
Cardiology collaborated with the American Society of Echocardiography to develop its
Appropriate Use Criteria (AUC) for Echocardiography in 2007, and were updated in 2011. AUC
were created by using the modified RAND appropriateness method. Studies applying AUC to TTE
orders at single centres in the US found inappropriate TTE rates in ambulatory (outpatient)
care ranging up to 35%.
We have successfully created an innovative education and feedback-based intervention that we
hypothesize will reduce the proportion of inappropriate TTEs ordered in clinical practice,
which will save healthcare dollars and improve quality of care and access to
echocardiography. Our objective is to prospectively study the following intervention in a
multicentre, randomized control trial format to determine if this intervention will reduce
inappropriate TTEs and the number of TTEs ordered in practice.
The study will take place at multiple hospitals in Canada the United States. Participants
include cardiologists and primary care providers (both general internal medicine and family
practice) who provide ambulatory care. Only providers who see patients in ambulatory care
clinics will be included. Pediatric cardiologists and physicians who specialize primarily in
adult congenital heart disease will be excluded from the study. Physicians who are
approached will be required to provide written consent prior to participation in the study.
Once cardiologists and primary care physicians are recruited for the study, they will be
randomized into one of two arms: 1) Intervention group, 2) Control group. Randomization will
occur at the same time for each site to ensure the study start date is consistent across all
sites.
Collection of TTE ordering information and TTE order classification:
A physician's TTE ordering information will be ascertained by review of the individual TTE
order and by review of the patient's medical record. This may be through review of the
Electronic Medical Record (EMR) or paper chart, depending on the individual site. Trained
research coordinators at each site will review the TTE order for indication and review the
patient record to ascertain clinical circumstances regarding the TTE order. The individual
research coordinator will review this information using the 2011 AUC and classify the TTE as
Appropriate (A), Inappropriate (I) or Uncertain (U), and assign the TTE order the most
appropriate indication number accordingly. TTE orders that do not have a corresponding
indication number will be designated as unclassifiable. Research Coordinators will be
blinded to which physicians are in the intervention or control group. This system of TTE
classification has been previously piloted and published by our group in two recently
published studies, and the rate of successful classification was greater than 98%11, 15, 16.
Dissemination of TTE monthly feedback reports:
Research Coordinators at each site will be responsible for individual physicians' TTE order
classifications but will be blinded to study group. Once monthly TTE orders are classified
and collated, this information will be transmitted to the central research laboratory, where
a research coordinator will collate all of the results and transmit monthly feedback reports
to individual physicians. This process ensures that local site coordinators and the study
investigators are blinded to the results to the study, while still enabling the creation and
dissemination of physician related feedback reports to the intervention group. The control
group will order TTEs as is their usual practice.
Inclusion Criteria:
- Cardiologist or physician practicing Primary Care in the Ambulatory care
Exclusion Criteria:
- . Pediatric cardiologists and physicians who specialize primarily in adult congenital
heart disease will be excluded from the study
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