Educational intervention to reduce outpatient inappropriate echocardiograms: a randomized control trial

Objectives: This study sought to prospectively study the impact of an appropriate use criteria (AUC)-based educational intervention on outpatient transthoracic echocardiography (TTE) ordering by physicians-in-training.

Background: AUC were developed in response to concerns about inappropriate utilization. It is unknown whether an educational intervention can reduce inappropriate outpatient TTE.

Methods: We conducted a randomized control trial in which physicians-in-training were randomized to an AUC-based educational intervention or a control group at an academic medical center in Boston, Massachusetts. The primary endpoints were the rates of inappropriate and appropriate TTE.

Results: For the cardiology physicians-in-training, the proportion of inappropriate TTE was significantly lower in the intervention than in the control group (13% vs. 34%, p < 0.001). As a corollary, the proportion of appropriate TTE ordered by the intervention group was significantly higher than that of the control group (81% vs. 58%, p < 0.001). The odds of ordering an appropriate TTE in the cardiology intervention group was 2.7 (95% confidence interval [CI]: 1.5 to 5.1, p = 0.002) relative to the control group. The internal medicine physicians-in-training ordered a small number of TTE overall, and there was a trend toward significant odds of ordering an appropriate TTE in the intervention group relative to the control group (odds ratio [OR]: 8.1, 95% CI: 0.95 to 69.0, p = 0.055). Six clinical scenarios accounted for 75% of all inappropriate TTE, with the 3 most common inappropriate indications being routine surveillance (<1 year) of known cardiomyopathy without a change in clinical status, routine surveillance of known small pericardial effusion, and routine surveillance of ventricular function with known coronary artery disease and no change in clinical status.

Conclusions: In cardiology fellows with a high rate of ordering inappropriate TTE, an AUC-based educational and feedback intervention reduced the proportion of inappropriate outpatient TTE and increased the proportion of appropriate outpatient TTE. (Educational Intervention to Reduce Outpatient Inappropriate Transthoracic Echocardiograms; NCT01944202).