title: Quality Improvement Implementation: Improving Reproducibility in the Echocardiography Laboratory.
abstract: BACKGROUND
  Interpretative variability can adversely affect echocardiographic reliability, but there is no widely accepted method to minimize variability and improve reproducibility.
  
  
  METHODS
  A continuous quality improvement process was devised that involves testing reproducibility by assessment of measurement differences followed by robust review, retraining, and retesting. Reproducibility was deemed acceptable if ≥80% of all interreader comparisons were within a prespecified acceptable difference. Readers not meeting this standard underwent retraining and retesting until acceptable reproducibility was achieved for the following parameters: left ventricular end-diastolic volume, biplane ejection fraction, mitral and aortic regurgitation, left ventricular outflow tract diameter, peak and mean aortic valve gradients, and aortic valve area. Eight hundred interreader comparisons for evaluation of reproducibility were generated from five readers interpreting 10 echocardiograms per testing cycle. The applicability and efficacy of this method were then evaluated by testing a second larger group of 10 readers and reevaluating reproducibility 1 year later.
  
  
  RESULTS
  All readers demonstrated acceptable reproducibility for biplane ejection fraction, mitral regurgitation, and peak and mean aortic valve gradients. Acceptable reproducibility for left ventricular end-diastolic volume, aortic regurgitation, and aortic valve area was achieved by four of five readers. No readers attained acceptable reproducibility on initial evaluation of left ventricular outflow tract diameter. After review and retraining, all readers demonstrated acceptable reproducibility, which was maintained on subsequent testing 1 year later. A second larger group of 10 readers was also evaluated and yielded similar results.
  
  
  CONCLUSIONS
  A continuous quality improvement process was devised that successfully reduced interpretative variability in echocardiography and improved reproducibility that was sustained over time.
authors: Department of Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina. Electronic address: melissa.daubert@dm.duke.edu.
authors: Melissa A
authors: MA
authors: Daubert
authors: Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors: Eric
authors: E
authors: Yow
authors: Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors: Huiman X
authors: HX
authors: Barnhart
authors: Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors: Dawn
authors: D
authors: Rabineau
authors: Department of Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors: Anna Lisa
authors: AL
authors: Crowley
authors: Department of Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors: Pamela S
authors: PS
authors: Douglas
mesh_terms: D002983:Clinical Competence / Q000592:standards / Q000706:statistics & numerical data*; D004452:Echocardiography / Q000592:standards / Q000706:statistics & numerical data*; D006331:Heart Diseases / Q000000981:diagnostic imaging* / Q000453:epidemiology; D006801:Humans; D009657:North Carolina / Q000453:epidemiology; D015588:Observer Variation; D058996:Quality Improvement / Q000592:standards / Q000706:statistics & numerical data*; D011871:Radiology / Q000193:education* / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity
keywords: Coverage probability; Echocardiography; Quality improvement; Reliability; Reproducibility