title: Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency.
abstract: BACKGROUND
  Guidance for appropriate utilisation of transthoracic echocardiograms (TTEs) can be incorporated into ordering prompts, potentially affecting the number of requests.
  
  
  METHODS
  We incorporated data from the 2011 Appropriate Use Criteria for Echocardiography, the 2010 National Institute for Clinical Excellence Guideline on Chronic Heart Failure, and American College of Cardiology Choosing Wisely list on TTE use for dyspnoea, oedema and valvular disease into electronic ordering systems at Durham Veterans Affairs Medical Center. Our primary outcome was TTE orders per month. Secondary outcomes included rates of outpatient TTE ordering per 100 visits and frequency of brain natriuretic peptide (BNP) ordering prior to TTE. Outcomes were measured for 20 months before and 12 months after the intervention.
  
  
  RESULTS
  The number of TTEs ordered did not decrease (338±32 TTEs/month prior vs 320±33 afterwards, p=0.12). Rates of outpatient TTE ordering decreased minimally post intervention (2.28 per 100 primary care/cardiology visits prior vs 1.99 afterwards, p<0.01). Effects on TTE ordering and ordering rate significantly interacted with time from intervention (p<0.02 for both), as the small initial effects waned after 6 months. The percentage of TTE orders with preceding BNP increased (36.5% prior vs 42.2% after for inpatients, p=0.01; 10.8% prior vs 14.5% after for outpatients, p<0.01).
  
  
  CONCLUSIONS
  Ordering prompts for TTEs initially minimally reduced the number of TTEs ordered and increased BNP measurement at a single institution, but the effect on TTEs ordered was likely insignificant from a utilisation standpoint and decayed over time.
authors.affiliation: Department of Medicine, Durham VA Medical Center, Durham, North Carolina, USA Department of Medicine, Duke University Health System, Durham, North Carolina, USA.
authors.forename: Joel C
authors.initials: JC
authors.lastname: Boggan
authors.affiliation: Department of Medicine, Durham VA Medical Center, Durham, North Carolina, USA Department of Medicine, Duke University Health System, Durham, North Carolina, USA.
authors.forename: Ryan D
authors.initials: RD
authors.lastname: Schulteis
authors.affiliation: Department of Medicine, Durham VA Medical Center, Durham, North Carolina, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Donahue
authors.affiliation: Department of Medicine, Durham VA Medical Center, Durham, North Carolina, USA Department of Medicine, Duke University Health System, Durham, North Carolina, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Simel
mesh_terms: D003658:Decision Making, Computer-Assisted; D004452:Echocardiography / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D062606:Tertiary Care Centers / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*
chemical_list: D020097:Natriuretic Peptide, Brain
keywords: Control charts, run charts; Decision support, computerized; Quality improvement; Statistical process control