title: Effectiveness of Quality Improvement Interventions at Reducing Inappropriate Cardiac Imaging: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Between 5% and 25% of cardiac imaging tests are performed for inappropriate indications. Studies have examined the impact of appropriate use criteria-based quality improvement initiatives on inappropriate testing, but they have not been systematically evaluated.
  
  
  RESULTS
  We performed a systematic review of studies evaluating quality improvement initiatives aimed at reducing inappropriate cardiac imaging. The primary outcome was the proportion of inappropriate tests based on appropriate use criteria. Studies were analyzed using a random effects meta-analysis model, and heterogeneity was examined using subgroup analyses. We identified 6 observational studies and 1 randomized control trial. Most interventions (n=6) had a formal education component, and 5 included a mechanism for physician audit and feedback. Although these interventions were associated with lower odds of inappropriate testing (odds ratio, 0.44 [95% confidence interval, 0.32-0.61]; P<0.001), significant heterogeneity was observed (I(2)=70%), which was best explained by the utilization of physician audit and feedback. Interventions that employed physician audit and feedback were associated with significantly lower odds of inappropriate testing (odds ratio, 0.36 [95% confidence interval, 0.31-0.41]; P<0.001; I(2)=0%), whereas those that did not had no effect (odds ratio, 0.89 [95% confidence interval, 0.61-1.29]; P=0.51; I(2)=0%; P value for difference <0.001). All studies had potential sources of bias that could have affected the observed estimates.
  
  
  CONCLUSIONS
  Interventions using physician audit and feedback are associated with lower odds of inappropriate cardiac testing. Further research is needed to evaluate a greater diversity of intervention types, with improved study designs.
authors.affiliation: Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada.
authors.forename: Dipayan
authors.initials: D
authors.lastname: Chaudhuri
authors.affiliation: Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada.
authors.forename: Alison
authors.initials: A
authors.lastname: Montgomery
authors.affiliation: Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Gulenchyn
authors.affiliation: Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada.
authors.forename: Morgan
authors.initials: M
authors.lastname: Mitchell
authors.affiliation: Michael G. DeGroote School of Medicine (D.C.), Departments of Medicine (A.M., K.G., P.J.), Radiology (A.M., K.G., P.J.), Faculty of Science (M.M.), and Population Health Research Institute (P.J.), McMaster University, Hamilton, Ontario, Canada. philip.joseph@phri.ca.
authors.forename: Philip
authors.initials: P
authors.lastname: Joseph
mesh_terms: D057791:Cardiac Imaging Techniques; D054869:Clinical Audit; D003661:Decision Support Techniques; D004502:Education, Medical, Continuing; D005246:Feedback; D006801:Humans; D058996:Quality Improvement; D012052:Reimbursement, Incentive; D019564:Unnecessary Procedures
keywords: cardiac imaging; meta-analysis; quality improvement; research