title: Improving appropriate use of echocardiography and single-photon emission computed tomographic myocardial perfusion imaging: a continuous quality improvement initiative.
abstract: BACKGROUND
  Appropriate use criteria for cardiovascular imaging have been published, but compliance in practice has been incomplete, with persistent high rates of inappropriate use. The aim of this study was to show the efficacy of a continuous quality improvement (CQI) initiative to favorably influence the appropriate use of outpatient transthoracic echocardiography and single-photon emission computed tomographic (SPECT) myocardial perfusion imaging (MPI) in a large cardiovascular practice.
  
  
  METHODS
  In this prospective study, a multiphase CQI initiative was implemented, and its impact on ordering patterns for outpatient transthoracic echocardiography and SPECT MPI was assessed. Between November and December 2010, a baseline analysis of the application of appropriate use criteria to indications for outpatient transthoracic echocardiographic studies (n = 203) and SPECT MPI studies (n = 205) was performed, with studies categorized as "appropriate," "inappropriate," "uncertain," or "unclassified." The CQI initiative was then begun, with (1) clinician education, including didactic lectures and case-based presentations with audience participation; (2) system changes in ordering processes, with redesigned image ordering forms; and (3) peer review and feedback. A follow-up analysis was then performed between June and August 2012, with categorization of indications for transthoracic echocardiographic studies (n = 206) and SPECT MPI studies (n = 206).
  
  
  RESULTS
  At baseline, 73.9% of echocardiographic studies were categorized as appropriate, 16.7% as inappropriate, 5.9% as uncertain, and 3.4% as unclassified. Similarly, for SPECT MPI studies 71.7% were categorized as appropriate, 18.5% as inappropriate, 7.8% as uncertain, and 1.9% as unclassified. Separate analysis of the two most important categories, appropriate and inappropriate, demonstrated a significant improvement after the CQI initiative, with a 63% reduction in inappropriate echocardiographic studies (18.5% vs 6.9%, P = .0010) and a 46% reduction in inappropriate SPECT MPI studies (20.5% vs 11.1%, P = .010).
  
  
  CONCLUSIONS
  This study demonstrates the effective and persistent positive impact of a CQI initiative to reduce inappropriate ordering of cardiovascular imaging.
authors.affiliation: Sanger Heart & Vascular Institute, Carolinas HealthCare System, Rock Hill, South Carolina. Electronic address: thomas.johnson@carolinashealthcare.org.
authors.forename: Thomas V
authors.initials: TV
authors.lastname: Johnson
authors.affiliation: Sanger Heart & Vascular Institute, Carolinas HealthCare System, Rock Hill, South Carolina.
authors.forename: Geoffrey A
authors.initials: GA
authors.lastname: Rose
authors.affiliation: Sanger Heart & Vascular Institute, Carolinas HealthCare System, Rock Hill, South Carolina.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Fenner
authors.affiliation: Dickson Advanced Analytics Carolinas HealthCare/Carolinas HealthCare System, Charlotte, North Carolina.
authors.forename: Nigel L
authors.initials: NL
authors.lastname: Rozario
mesh_terms: D000328:Adult; D000368:Aged; D002309:Cardiology / Q000379:methods*; D002318:Cardiovascular Diseases / Q000175:diagnosis*; D002983:Clinical Competence; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000379:methods / Q000706:statistics & numerical data*; D009657:North Carolina; D011446:Prospective Studies; D058996:Quality Improvement; D015899:Tomography, Emission-Computed, Single-Photon / Q000706:statistics & numerical data*
keywords: Appropriate use; Cardiac imaging; Continuous quality improvement