Educational Intervention to Reduce Outpatient Inappropriate Transthoracic Echocardiograms

Study Overview
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Brief Summary
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It is well documented that the proportion of inappropriate transthoracic echocardiograms (TTEs) is highest in the ambulatory environment, where it has been reported as high as 30%. Therefore, the potential to improve TTE utilization may be greatest in the outpatient setting. However, no study to date has evaluated whether an Appropriate Use Criteria (AUC)-based educational intervention can reduce inappropriate TTEs in this setting. The investigators therefore designed the first randomized control trial of an AUC-based educational and feedback intervention aimed at reducing inappropriate outpatient TTEs ordered by cardiology and internal medicine physicians in training.

Detailed Description
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The investigators designed a randomized, control trial of an AUC-based educational and feedback intervention designed to reduce the proportion of inappropriate TTEs in the cardiology and internal medicine outpatient practices at Massachusetts General Hospital. A random number generator divided 24 cardiology fellows and 88 internal medicine residents into control and intervention arms. During the study, physicians in the intervention arm receive the following multi-faceted educational intervention on TTE appropriateness: 1) a lecture at the beginning of the study period, which describes the AUC for echocardiography and highlights common clinical scenarios for which outpatient TTEs are ordered, 2) an electronic pocket card via email that provides tips on appropriate ordering of TTEs, and 3) an individualized monthly feedback report that categorizes TTEs ordered over the preceding month. The feedback reports contain the number of TTEs ordered during the month and how many are classified as appropriate, inappropriate, or uncertain based on the 2011 AUC. A description of all inappropriate TTEs and the rationale for the inappropriate classification is provided. The physicians in the control arm have their TTE orders tracked and classified, but do not receive any feedback on their ordering behavior. While study participants are not blinded to which arm of the study they are in, they were blinded to which arm of the study their colleagues are in. Prior to the start of the intervention, all study participants receive a knowledge assessment survey. The survey includes five case-based questions designed to assess knowledge of the AUC for TTE and also questions regarding attitudes toward diagnostic testing. Each participant also receives a post-study knowledge assessment survey. The primary outcome measures in this study are the rate of inappropriate and appropriate TTEs. Secondary outcome measures include the number of TTEs ordered, common appropriate and inappropriate TTE indications, and pre- and post-study knowledge assessment scores among the study physicians.

Official Title
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Reducing Outpatient Inappropriate Transthoracic Echocardiograms With An Educational Intervention: A Randomized Control Trial

Conditions
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Inappropriate Use of Echocardiography

Intervention / Treatment
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* Behavioral: Educational intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Cardiovascular Medicine fellows at Massachusetts General Hospital Internal Medicine residents at Massachusetts General Hospital Exclusion Criteria: Attending physicians
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Educational Intervention<br>Physicians in the intervention arm receive the following multi-faceted educational intervention on transthoracic echocardiogram appropriateness: 1) a lecture at the beginning of the study period, which describes the Appropriate Use Criteria (AUC) for echocardiography and highlights common clinical scenarios for which outpatient TTEs are ordered, 2) an electronic pocket card via email that provides tips on appropriate ordering of TTEs, and 3) an individualized monthly feedback report that categorized TTEs ordered over the preceding month. The feedback reports contains the number of TTEs ordered during the month and how many are classified as appropriate, inappropriate, or uncertain based on the 2011 AUC. | Behavioral: Educational intervention<br>* Educational and feedback intervention, as described in the Arm Description.<br>|
| No Intervention: Control group<br>Physicians in the control arm have their TTE orders tracked and classified, but do not receive any feedback on their ordering behavior. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of Inappropriate transthoracic echocardiograms | Rate of inappropriate echocardiograms determined from a review of the electronic medical record. | 9 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of Appropriate Transthoracic Echocardiograms | Rate of appropriate transthoracic echocardiograms determined from a review of the electronic medical record. | 9 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Echocardiography, Appropriate Use Criteria, Educational Intervention