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  • Feedback On TEE Ordering Cuts Inappropriate Use Education and monthly check-ins worked in randomized trial

    Personal feedback on one’s rate of ordering inappropriate transthoracic echocardiography (TTE) — along with a lecture on which scenarios are rarely appropriate — improved utilization, a single-center trial suggested.

    Rory B. Weiner, MD, of Boston’s Massachusetts General Hospital, and colleagues subjected some of their staff cardiologists to an educational intervention: a lecture accompanied by an electronic information card, plus monthly feedback via email that revealed a count of “rarely appropriate” TTEs ordered and an explanation of why they were classified as such according to the 2011 American College of Cardiology appropriate use criteria.

    This group showed a reduction in inappropriate outpatient TTEs ordered compared with attending cardiologists who received the lecture but not monthly feedback (10.5% versus 16.5%, OR 0.59, 95% CI 0.39 to 0.88) and a nonsignificant trend towards a higher rate of appropriate TTEs (77.6% versus 72.0%, OR 1.38, 95% CI 0.93 to 2.05), Weiner’s group reported online in JAMA Cardiology.

    The intervention and the control groups showed similar rates of ordering TTEs that “may be appropriate” as per the appropriate use criteria (11.9% versus 11.5%, OR 0.99, 95% CI 0.59 to 1.67).

    “Results from our study indicate that attending academic cardiologists can amend their ordering of outpatient TTEs in response to education and feedback,” they wrote.

    Moreover, it appeared that experience did not affect the trend, as stratification by academic rank did not produce any outlying groups.

    The most common reasons for inappropriate TTE were:

    • Routine imaging within 3 years of prosthetic valve insertion (17.1% of cases)
    • Routine screening for valvular stenosis less than a year apart between TTEs (15.0%)
    • Routine surveillance of cardiomyopathy (10.5%) or ventricular function (8.4%)

    Cases involving atrial fibrillation were the most common source of unclassifiable TTEs (3.3%), which appropriate use criteria guidelines did not designate as “appropriate,” “may be appropriate,” or “rarely appropriate.” Other unclassifiable scenarios involved serial follow-up on cardiac resynchronization therapy without worsening heart failure or device dysfunction and left ventricular function assessment after revascularization.

    “It is possible that the need for practice improvement in these domains is greater than believed, since the appropriate use criteria do not readily capture clinical practice in these particular settings,” Weiner and colleagues suggested.

    Their prospective, randomized trial included a staff of 66 attending cardiologists (one of whom retired during the course of the study and was excluded from the analysis) who saw patients from November 2013 to June 2014 .

    “There are several limitations of this study,” the investigators acknowledged.

    “First, the trial was aimed at attending academic cardiologists, and the effect of performing this type of intervention on attending physicians from other disciplines (ie, general internists) is unknown. Noncardiologists (e.g., primary care, family practice, surgeons, neurologists) ordered up to half of the TTEs in a large Medicare database; therefore, any systemic efforts will need to include physicians other than cardiologists,” they wrote, adding that future studies should include nurse practitioners who order TTEs.

    “Second, this study was performed at an academic center, where several specialized referral cardiac programs (e.g., interventional valvular disease, thoracic aortic disease, and adult congenital heart disease) exist; therefore, our findings may not be generalizable to other practice environments.”

    They commented that it was impossible to blind their study participants and that “perhaps knowing that they were to receive individual feedback stimulated a change in ordering from the outset in the intervention group.” Another caveat to their findings was the possibility that patterns in documentation changed in response to that monthly email, not actual practice.

    Finally, “the sustainability of the impact of this type of intervention needs further study since there are discrepant data on the long-lasting effects of these types of interventions,” the authors added.

    To address some of the study’s limitations, Weiner’s group pointed to an ongoing, multi-center study on appropriate use criteria-based interventions in TTE ordering.



    Weiner disclosed no relevant relationships with industry.


    JAMA Cardiology

    Dudzinski DM, et al “Effect of educational intervention on the rate of rarely appropriate outpatient echocardiograms ordered by attending academic cardiologists: A randomized clinical trial” JAMA Cardiol 2016; DOI: 10.1001/jamacardio.2016.2232.


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