title: Development of an Educational Strategy and Decision Support Tool to Enhance Appropriate Use of Stress Echocardiography at a Large Academic Medical Center: A Prospective, Pre- and Postintervention Analysis.
abstract: BACKGROUND
  Despite previous studies demonstrating suboptimal appropriate use of stress echocardiography (SE), few interventions have been demonstrated to improve its appropriate use. The aim of this study was to develop a novel mechanism to improve the appropriateness of SE by implementing a point-of-care decision support tool and ordering requisition coupled with an educational strategy.
  
  
  METHODS
  A prospective pre- and postintervention analysis was conducted. The intervention included education and the development and implementation of novel ordering requisition coupled with a decision support tool that integrated appropriate use criteria (AUC) for SE.
  
  
  RESULTS
  In the baseline period, 256 consecutive stress echocardiographic studies were evaluated, and 97% were classifiable by the 2011 AUC. During the intervention period, 159 studies were evaluated (98% classifiable). The intervention resulted in an increase in the appropriate proportion from 65% to 76% and a reduction in the rarely appropriate proportion from 31% to 19% (P = .017). After adjustment for physician specialty, the postintervention period had lower odds of rarely appropriate testing (0.54; 95% CI, 0.3-0.95; P = .04). Cardiology had significant lower odds of rarely appropriate testing (0.23; 95% CI, 0.11-0.50; P < .001) compared with family practice (the reference standard). Vascular surgery had the highest odds (5.76; 95% CI, 2.18-21.52; P = .002) of rarely appropriate testing.
  
  
  CONCLUSIONS
  AUC have not previously been applied to SE in a single-payer, publicly funded health system. The development of an educational intervention involving a new requisition and decision support tool that integrated AUC resulted in a significantly reduced proportion of rarely appropriate SE. Cardiologists ordered the highest proportion of appropriate SE. Further study is needed to determine the generalizability of the results.
authors.affiliation: Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
authors.forename: Kevin
authors.initials: K
authors.lastname: Levitt
authors.affiliation: St. Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Edwards
authors.affiliation: St. Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
authors.forename: Chi-Ming
authors.initials: CM
authors.lastname: Chow
authors.affiliation: Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre of the University Health Network, Toronto General Hospital, Toronto, Ontario, Canada. Electronic address: sacha.r.bhatia@wchospital.ca.
authors.forename: R Sacha
authors.initials: RS
authors.lastname: Bhatia
mesh_terms: D000046:Academic Medical Centers; D002309:Cardiology / Q000193:education; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000628:therapy; D003661:Decision Support Techniques; D025401:Echocardiography, Stress / Q000592:standards*; D004502:Education, Medical, Continuing / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D017408:Guidelines as Topic / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods*; D019095:Point-of-Care Systems; D011446:Prospective Studies; D014481:United States
keywords: Appropriate use; Decision support tool; Stress echocardiography