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Healthcare expenditure on cardiovascular imaging, including echocardiography, has been growing rapidly; echocardiography growth rates have been in the range of 5–8% per year.1 ,2 In an effort to both understand the drivers of the growth of cardiovascular imaging and to help curb unnecessary use of these tests, the American College of Cardiology Foundation developed Appropriate Use Criteria (AUC),3 which now apply to all cardiac imaging modalities, including echocardiography. Despite the availability of such documents, the uptake and utilisation of AUC remains modest at best, and educational efforts alone have largely proven unsuccessful.4 ,5 Consequently, attempts have been made to implement AUC using a variety of active methods, including decision support tools.
The study by Boggan et al6 sought to improve the appropriateness of transthoracic echocardiogram (TTE) ordering at a tertiary care Veterans Affairs hospital in the USA by incorporating a decision support tool into an electronic ordering system, focused primarily on congestive heart failure and valvular heart disease, and interestingly including the ordering of a brain natriuretic peptide (BNP) test as part of this tool. However, over the study period, which consisted of a baseline period of 20 months and a post-intervention period of 12 months, the overall number of TTEs ordered did not change significantly. An initial decrease in orders occurred in the first 6 months, but this effect did not persist. The authors did not specifically look at the appropriateness of echo ordering to assess changes during the period of study but rather the total volume of studies performed. However, it is unlikely that the approximately unchanged total volume masks a decrease in inappropriate TTEs and a compensatory increase in appropriate ones.
The null study results highlight the challenges of quality improvement research in general and the difficulty in effecting real, appreciable change in inappropriate …