Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention.
BACKGROUND
We previously demonstrated that an Appropriate Use Criteria (AUC)-based educational intervention reduced inappropriate transthoracic echocardiograms (TTE) on an inpatient medical service. Whether improved TTE ordering is sustained after discontinuation of the intervention is unknown.


METHODS
We conducted a prospective, time series analysis of an educational intervention designed to reduce inappropriate TTE. Ordering patterns during the intervention were compared with a preintervention control period and a postintervention period. The goal of the present analysis was to determine the TTE ordering patterns after discontinuation of the educational intervention. The primary outcome was the proportion of inappropriate TTEs.


RESULTS
Using the 2011 AUC 99.2% of all TTEs were classifiable. Compared to the control, there was a 26% reduction in the number of TTEs ordered per day during the intervention (3.9 vs. 2.9 TTEs, P < 0.001), but no significant difference between the intervention and postintervention periods (2.9 vs. 3.1, P = 0.23). The intervention produced a decrease in the inappropriate TTE rate and an increase in the appropriate TTE rate. Compared to the intervention, in the postintervention period the rate of inappropriate TTEs increased (5% vs. 11%, P = 0.01) and appropriate TTEs decreased (93% vs. 86%, P = 0.008). The postintervention rate of inappropriate TTEs was similar to the preintervention control period (11% vs. 13%, P = 0.23).


CONCLUSIONS
Following completion of an AUC-based educational intervention the proportion of inappropriate TTEs increased to the preintervention level. The long-term success of an intervention designed to improve appropriate utilization of TTE requires a sustained effort of education and feedback.
Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts.
Rajan Sacha
RS
Bhatia
David M
DM
Dudzinski
Creagh E
CE
Milford
Michael H
MH
Picard
Rory B
RB
Weiner
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston / Q000453:epidemiology; D002309:Cardiology / Q000193:education / Q000592:standards; D002983:Clinical Competence / Q000592:standards / Q000706:statistics & numerical data; D004452:Echocardiography / Q000592:standards* / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006331:Heart Diseases / Q000000981:diagnostic imaging* / Q000453:epidemiology; D006801:Humans; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D015995:Prevalence; D011871:Radiology / Q000193:education* / Q000592:standards; D014481:United States; D019564:Unnecessary Procedures / Q000592:standards / Q000706:statistics & numerical data*
appropriate use criteria; feedback; resident education; transthoracic echocardiography