We previously reported the application of the 2005 American College of Cardiology Foundation appropriate use criteria for stress single-photon emission computed tomography (SPECT) imaging to patients at Mayo Clinic (Rochester, MN) in 2005 and 2006. A subsequent internal quality improvement project focused on physician education in an attempt to reduce the rate of inappropriate SPECT studies.
Our 2008 physician education effort, focused on 4 specific indications that accounted for 88% of the inappropriate SPECT studies, included a presentation at medical grand rounds, a publication in the staff newsletter, meetings with physician administrators, and focused presentations to departments/divisions with many ordering physicians. We then remeasured the appropriateness of SPECT studies using previously published methods. The general categories of study indications, eg, after revascularization, were similar in 273 SPECT patients in 2008 and in our 2005 (n=284) and 2006 (n=284) cohorts. There was a trend suggesting a change in the overall classification of appropriateness over time (P=0.08) and a significant change in the rate of inappropriate studies over time (P=0.018). Inappropriate studies decreased from 14.4% in 2005 to 7.0% in 2006 before initiation of the quality improvement project. After completion of the quality improvement project, inappropriate studies increased to 11.7% (P=0.06). The 95% confidence limits for the 4.7% increase in inappropriate studies after the quality improvement project included a decrease of 0.2% and an increase of 9.6%.
This quality improvement project, focused on feedback, physician education, and remeasurement, did not reduce the rate of inappropriate stress SPECT studies in a single academic medical center. Similar limited interventions focused on physician education alone may have limited benefit. More extensive intervention may be necessary to improve the quality of care with appropriateness criteria.
"This large community-based study indicates that practitioner expertise does not explain the wide gap in adherence to AUC between cardiologists and non-cardiologists; the reported differences are likely due to disparity in patient populations. Therefore, educating physicians about AUC is unlikely, by itself, to sustainably reduce inappropriate MPI use . Future efforts to minimize inappropriate MPI use should include, in addition to physician education, " hard-wired " decision-making support tools embedded in the test ordering process at the point of care in addition to incorporating AUC in test reimbursement rules and laboratory accreditation. "
[Show abstract][Hide abstract] ABSTRACT: Appropriate use criteria (AUC) were developed to guide the use of myocardial perfusion imaging (MPI). While MPI use has grown exponentially, women remain under tested. Given this bias in testing, we sought to determine if gender disparity exists in tests categorized by appropriateness and the role of referral bias.
The AUC were applied to 314 consecutive MPI. Analysis of variance and chi-squared tests were used for analysis. Gender disparity was assessed using correlation matrices comparing baseline to gender reversed data.
Of the 314 studies, 263 were appropriate, 34 inappropriate, and 17 uncertain. Women had 68% of inappropriate studies, and 82% of uncertain studies (P < .01). Cardiologists ordered more appropriate studies than primary care physicians (PCPs) in women (86% vs 71%, P = .04). Among studies ordered by cardiologists and PCPs, a higher percentage of studies were appropriate in men vs women (96% vs 86%, P = 0.05 and 88% vs 71% P = .003), respectively. Gender reversal demonstrates disparity in the AUC tool with 46 (15%) not correlating (P < .00001).
Comparing patient gender and ordering physician, the majority of inappropriate and uncertain studies were ordered in women by PCPs, indicating a continuing need for education among PCPs, particularly as the AUC apply to women.
Beatriz Vaquerizo, Marco Spaziano, Juwairia Alali, Darren Mylote, Pascal Theriault-Lauzier, Rashed Alfagih, Giuseppe Martucci, Jean Buithieu, Nicolo Piazza
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