title: Implementing a Continuous Quality Improvement Program in a High-Volume Clinical Echocardiography Laboratory: Improving Care for Patients With Aortic Stenosis.
abstract: BACKGROUND
  The management of aortic stenosis rests on accurate echocardiographic diagnosis. Hence, it was chosen as a test case to examine the utility of continuous quality improvement (CQI) approaches to increase echocardiographic data accuracy and reliability. A novel, multistep CQI program was designed and prospectively used to investigate whether it could minimize the difference in aortic valve mean gradients reported by echocardiography when compared with cardiac catheterization.
  
  
  RESULTS
  The Duke Echo Laboratory compiled a multidisciplinary CQI team including 4 senior sonographers and MD faculty to develop a mapped CQI process that incorporated Intersocietal Accreditation Commission standards. Quarterly, the CQI team reviewed all moderate- or greater-severity aortic stenosis echocardiography studies with concomitant catheterization data, and deidentified individual and group results were shared at meetings attended by cardiologists and sonographers. After review of 2011 data, the CQI team proposed specific amendments implemented over 2012: the use of nontraditional imaging and Doppler windows as well as evaluation of aortic gradients by a second sonographer. The primary outcome measure was agreement between catheterization- and echocardiography-derived mean gradients calculated by using the coverage probability index with a prespecified acceptable echocardiography-catheterization difference of <10 mm Hg in mean gradient. Between January 2011 and January 2014, 2093 echocardiograms reported moderate or greater aortic stenosis. Among cases with available catheterization data pre- and post-CQI, the coverage probability index increased from 54% to 70% (P=0.03; 98 cases, year 2011; 70 cases, year 2013). The proportion of patients referred for invasive valve hemodynamics decreased from 47% pre-CQI to 19% post-CQI (P<0.001).
  
  
  CONCLUSIONS
  A laboratory practice pattern that was amenable to reform was identified, and a multistep modification was designed and implemented that produced clinically valuable performance improvements. The new protocol improved aortic stenosis mean gradient agreement between echocardiography and catheterization and was associated with a measurable decrease in referrals of patients for invasive studies.
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC. zainab.samad@duke.edu.
authors.forename: Zainab
authors.initials: Z
authors.lastname: Samad
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Minter
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Alicia
authors.initials: A
authors.lastname: Armour
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Amanda
authors.initials: A
authors.lastname: Tinnemore
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Sivak
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Brenda
authors.initials: B
authors.lastname: Sedberry
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Karen
authors.initials: K
authors.lastname: Strub
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Seanna M
authors.initials: SM
authors.lastname: Horan
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: J Kevin
authors.initials: JK
authors.lastname: Harrison
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Joseph
authors.initials: J
authors.lastname: Kisslo
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
authors.affiliation: From the Division of Cardiology, Department of Medicine (Z.S., J.A.S., J.K.H., J.K., P.S.D., E.J.V.), Cardiac Diagnostic Unit (Z.S., S.M., A.A., A.T., B.S., K.S., S.M.H., P.S.D., E.J.V.), and Duke Clinical Research Institute (Z.S., S.M.H., P.S.D., E.J.V.), Duke University Medical Center, Durham, NC.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
mesh_terms: D001021:Aortic Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy; D006328:Cardiac Catheterization / Q000592:standards*; D019091:Critical Pathways / Q000592:standards; D015150:Echocardiography, Doppler / Q000592:standards*; D005240:Feasibility Studies; D006439:Hemodynamics; D061847:Hospitals, High-Volume / Q000592:standards*; D006801:Humans; D015588:Observer Variation; D010348:Patient Care Team / Q000592:standards; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011237:Predictive Value of Tests; D015397:Program Evaluation; D011446:Prospective Studies; D058996:Quality Improvement / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D057188:Workflow
keywords: aortic valve stenosis; catheterization; echocardiography; image acquisition; image quality; quality improvement