R Sacha Bhatia

University of Toronto, Toronto, Ontario, Canada

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Publications (27)203.3 Total impact

  • Kevin Levitt · Kaveh G Shojania · R Sacha Bhatia
    BMJ quality & safety 10/2015; DOI:10.1136/bmjqs-2015-004785 · 3.99 Impact Factor
  • Kevin Levitt · Jeremy Edwards · Chi-Ming Chow · R Sacha Bhatia
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    ABSTRACT: Background: Despite previous studies demonstrating suboptimal appropriate use of stress echocardiography (SE), few interventions have been demonstrated to improve its appropriate use. The aim of this study was to develop a novel mechanism to improve the appropriateness of SE by implementing a point-of-care decision support tool and ordering requisition coupled with an educational strategy. Methods: A prospective pre- and postintervention analysis was conducted. The intervention included education and the development and implementation of novel ordering requisition coupled with a decision support tool that integrated appropriate use criteria (AUC) for SE. Results: In the baseline period, 256 consecutive stress echocardiographic studies were evaluated, and 97% were classifiable by the 2011 AUC. During the intervention period, 159 studies were evaluated (98% classifiable). The intervention resulted in an increase in the appropriate proportion from 65% to 76% and a reduction in the rarely appropriate proportion from 31% to 19% (P = .017). After adjustment for physician specialty, the postintervention period had lower odds of rarely appropriate testing (0.54; 95% CI, 0.3-0.95; P = .04). Cardiology had significant lower odds of rarely appropriate testing (0.23; 95% CI, 0.11-0.50; P < .001) compared with family practice (the reference standard). Vascular surgery had the highest odds (5.76; 95% CI, 2.18-21.52; P = .002) of rarely appropriate testing. Conclusion: AUC have not previously been applied to SE in a single-payer, publicly funded health system. The development of an educational intervention involving a new requisition and decision support tool that integrated AUC resulted in a significantly reduced proportion of rarely appropriate SE. Cardiologists ordered the highest proportion of appropriate SE. Further study is needed to determine the generalizability of the results.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 09/2015; DOI:10.1016/j.echo.2015.08.003 · 4.06 Impact Factor
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    ABSTRACT: The Choosing Wisely campaign began in the USA in 2012 to encourage physicians and patients to discuss inappropriate and potentially harmful tests, treatments and procedures. Since its inception, the campaign has grown substantially and has been adopted by 12 countries around the world. Of great interest to countries implementing the campaign, is the effectiveness of Choosing Wisely to reduce overutilisation. This article presents an integrated measurement framework that may be used to assess the impact of a Choosing Wisely campaign on physician and provider awareness and attitudes on low-value care, provider practice behaviour and overuse of low-value services. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    BMJ quality & safety 06/2015; 24(8). DOI:10.1136/bmjqs-2015-004070 · 3.99 Impact Factor
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    ABSTRACT: There is concern about increasing utilization of low-value health care services, including preoperative testing for lowrisk surgical procedures. We investigated temporal trends, explanatory factors, and institutional and regional variation in the utilization of testing before low-risk procedures. For this retrospective cohort study, we accessed linked population-based administrative databases from Ontario, Canada. A cohort of 1 546 223 patients 18 years or older underwent a total of 2 224 070 low-risk procedures, including endoscopy and ophthalmologic surgery, from Apr. 1, 2008, to Mar. 31, 2013, at 137 institutions in 14 health regions. We used hierarchical logistic regression models to assess patient- and institution-level factors associated with electrocardiography (ECG), transthoracic echocardiography, cardiac stress test or chest radiography within 60 days before the procedure. Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. ECG and chest radiography were conducted before 31.0% (95% confidence interval [CI] 30.9%-31.1%) and 10.8% (95% CI 10.8%-10.8%) of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% (95% CI 2.9%-2.9%) and 2.1% (95% CI 2.1%-2.1%), respectively. Significant variation was present across institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. Receipt of preoperative ECG and radiography were associated with older age (among patients 66-75 years of age, for ECG, adjusted odds ratio [OR] 18.3, 95% CI 17.6-19.0; for radiography, adjusted OR 2.9, 95% CI 2.8-3.0), preoperative anesthesia consultation (for ECG, adjusted OR 8.7, 95% CI 8.5-8.8; for radiography, adjusted OR 2.2, 95% CI 2.1-2.2) and preoperative medical consultation (for ECG, adjusted OR 6.8, 95% CI 6.7-6.9; for radiography, adjusted OR 3.6, 95% CI 3.5-3.6). The median ORs for receipt of preoperative ECG and radiography were 2.3 and 1.6, respectively. Despite guideline recommendations to limit testing before low-risk surgical procedures, preoperative ECG and chest radiography were performed frequently. Significant variation across institutions remained after adjustment for patient- and institution-level factors. © 8872147 Canada Inc.
    Canadian Medical Association Journal 06/2015; 187(11). DOI:10.1503/cmaj.150174 · 5.96 Impact Factor
  • R Sacha Bhatia · Ciara Pendrith · Heather Ross
    Canadian Medical Association Journal 05/2015; 187(10). DOI:10.1503/cmaj.141479 · 5.96 Impact Factor
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    ABSTRACT: Appropriate use criteria (AUC) for transthoracic echocardiography (TTE) were developed to address concerns regarding inappropriate use of TTE. A previous pilot study suggests that an educational and feedback intervention can reduce inappropriate TTEs ordered by physicians in training. It is unknown if this type of intervention will be effective when targeted at attending level physicians in a variety of clinical settings. The aim of this international, multicenter study is to evaluate the hypothesis that an AUC-based educational and feedback intervention will reduce the proportion of inappropriate echocardiograms ordered by attending physicians in the ambulatory environment. In an ongoing multicentered, investigator-blinded, randomized controlled trial across Canada and the United States, cardiologists and primary care physicians practicing in the ambulatory setting will be enrolled. The intervention arm will receive (1) a lecture outlining the AUC and most recent available evidence highlighting appropriate use of TTE, (2) access to the American Society of Echocardiography mobile phone app, and (3) individualized feedback reports e-mailed monthly summarizing TTE ordering behavior including information on inappropriate TTEs and brief explanations of the inappropriate designation. The control group will receive no education on TTE appropriate use and order TTEs as usual practice. The Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly in an education RCT) study is the first multicenter randomized trial of an AUC-based educational intervention. The study will examine whether an education and feedback intervention will reduce the rate of outpatient inappropriate TTEs ordered by attending level cardiologists and primary care physicians (www.clinicaltrials.gov identifier NCT02038101). Copyright © 2015 Elsevier Inc. All rights reserved.
    American Heart Journal 05/2015; 170(2). DOI:10.1016/j.ahj.2015.04.022 · 4.46 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A1324. DOI:10.1016/S0735-1097(15)61324-9 · 16.50 Impact Factor
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    ABSTRACT: The CArdiovascular HEalth in Ambulatory care Research Team (CANHEART) is conducting a unique, population-based observational research initiative aimed at measuring and improving cardiovascular health and the quality of ambulatory cardiovascular care provided in Ontario, Canada. A particular focus will be on identifying opportunities to improve the primary and secondary prevention of cardiovascular events in Ontario's diverse multiethnic population. A population-based cohort comprising 9.8 million Ontario adults ≥20 years in 2008 was assembled by linking multiple electronic survey, health administrative, clinical, laboratory, drug, and electronic medical record databases using encoded personal identifiers. The cohort includes ≈9.4 million primary prevention patients and ≈400 000 secondary prevention patients. Follow-up on clinical events is achieved through record linkage to comprehensive hospitalization, emergency department, and vital statistics administrative databases. Profiles of cardiovascular health and preventive care will be developed at the health region level, and the cohort will be used to study the causes of regional variation in the incidence of major cardiovascular events and other important research questions. Linkage of multiple databases will enable the CANHEART study cohort to serve as a powerful big data resource for scientific research aimed at improving cardiovascular health and health services delivery. Study findings will be shared with clinicians, policy makers, and the public to facilitate population health interventions and quality improvement initiatives. © 2015 American Heart Association, Inc.
    Circulation Cardiovascular Quality and Outcomes 02/2015; 8(2). DOI:10.1161/CIRCOUTCOMES.114.001416 · 5.66 Impact Factor
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    ABSTRACT: Much attention has been paid to the inappropriate underuse of tests and treatments but until recently little attention has focused on the overuse that does not add value for patients and may even cause harm. Choosing Wisely is a campaign to engage physicians and patients in conversations about unnecessary tests, treatments and procedures. The campaign began in the United States in 2012, in Canada in 2014 and now many countries around the world are adapting the campaign and implementing it. This article describes the present status of Choosing Wisely programs in 12 countries. It articulates key elements, a set of five principles, and describes the challenges countries face in the early phases of Choosing Wisely. These countries plan to continue collaboration including developing metrics to measure overuse. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    BMJ quality & safety 12/2014; 24(2). DOI:10.1136/bmjqs-2014-003821 · 3.99 Impact Factor
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    ABSTRACT: Background: Little is known about variations in the quality of ambulatory care between urban and rural communities for patients with stable ischemic heart disease. The objectives of this study were to understand the effect of rurality on variations of ambulatory processes of care and outcomes for patients with stable ischemic heart disease. Methods and results: A population-based cohort study was conducted, which included all Ontario patients with stable ischemic heart disease confirmed on cardiac catheterization between October 1, 2008, and September 30, 2011. Patients were categorized as rural or urban based on the Rurality Index for Ontario score. Ambulatory processes of care of interest were diagnostic testing, medication usage, and access to general/speciality physicians over a 1-year time-horizon. Primary outcome was 1-year mortality. Secondary outcomes included 1-year myocardial infarction, repeat cardiac/all-cause hospitalization, and emergency department visits. The cohort consisted of 38 804 patients, of whom 34 949 (90%) were urban and 3855 (10%) were rural patients. After risk-adjustment, rural patients had lower rates of cholesterol assessment (odds ratios 0.41; 95% confidence interval [CI], 0.38-0.44; P<0.001), hemoglobin A1C assessment (odds ratios 0.41; 95% CI, 0.38-0.44; P<0.001), and statin use (odds ratios 0.67; 95% CI, 0.57-0.79; P<0.001) compared with urban patients. Rural patients had fewer total ambulatory physician visits (rate ratio 0.76; 95% CI, 0.75-0.78; P<0.001)), primary care (0.76; 95% CI, 0.74-0.78; P<0.001), and cardiology visits (0.71; 95% CI, 0.68-0.74; P<0.001) over 1 year. Emergency department utilization was higher among rural patients (odds ratios 1.82; 95% CI, 1.70-1.96; P<0.001), but myocardial infarction, hospitalization, and mortality rates were similar. Conclusions: Despite variation in ambulatory processes of care between urban and rural patients with stable ischemic heart disease, there were no outcome differences.
    Circulation Cardiovascular Quality and Outcomes 10/2014; 7(6). DOI:10.1161/CIRCOUTCOMES.114.001076 · 5.66 Impact Factor
  • R Sacha Bhatia · Wendy Levinson · Douglas S Lee
    BMJ quality & safety 10/2014; 24(2). DOI:10.1136/bmjqs-2014-003605 · 3.99 Impact Factor
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    ABSTRACT: This study sought to prospectively study the impact of an appropriate use criteria (AUC)-based educational intervention on outpatient transthoracic echocardiography (TTE) ordering by physicians-in-training.
    JACC Cardiovascular Imaging 08/2014; 7(9). DOI:10.1016/j.jcmg.2014.04.014 · 7.19 Impact Factor
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    ABSTRACT: Study objectives Hospital admission rates for patients with heart failure (HF) presenting for emergency department (ED) care vary, and the implications of direct discharge home from the ED are unknown. We examined whether patients treated in hospitals with low admission rates exhibit higher rates of repeat ED visits, hospital readmissions and death. Methods We divided EDs into low-, medium- and high-admission-rate tertiles by their standardised HF admission rate in Ontario, Canada. Among adults (≥18 years) with HF discharged from an ED between April 2004 and March 2010, we evaluated the primary outcomes of repeat ED visits or hospitalisations for HF, and secondary outcomes, which included death, within 30 days stratified by HF admission-rate tertile. Results 89 878 patients with HF presented to low- (n=29 929), medium- (n=30 900) or high- (n=29 049) admission-rate institutions, with hospitalisation rates of <67%, 67–75% and >75%, respectively. Among 28 175 ED-discharged patients, the multivariable-adjusted HR for repeat ED visit or hospitalisation for HF at low-admission-rate institutions was 1.18 (95% CI 1.07 to 1.29, p<0.001) compared with high-admission institutions. Similarly, the HR for repeat ED visits for HF was 1.28 (95% CI 1.14 to 1.44, p<0.001) at low-admission hospitals. Compared with discharged patients in the high-admission-rate tertile, adjusted HR for 30-day mortality was 1.19 (95% CI 0.95 to 1.47) at low-admission-rate hospitals. The HRs for all of the above outcomes were not significantly increased at medium-admission-rate hospitals. Discussion Patients seeking care at institutions with lower rates of HF admission showed higher rates of repeat ED visits or hospitalisations after previous ED discharge.
    BMJ quality & safety 07/2014; 23(12). DOI:10.1136/bmjqs-2014-002816 · 3.99 Impact Factor
  • David M Dudzinski · R Sacha Bhatia · Rory B Weiner
    JAMA Internal Medicine 07/2014; 174(7):1195-1196. DOI:10.1001/jamainternmed.2014.1440 · 13.12 Impact Factor
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    Journal of the American College of Cardiology 04/2014; 63(12):A1233. DOI:10.1016/S0735-1097(14)61233-X · 16.50 Impact Factor
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    ABSTRACT: We previously demonstrated that an Appropriate Use Criteria (AUC)-based educational intervention reduced inappropriate transthoracic echocardiograms (TTE) on an inpatient medical service. Whether improved TTE ordering is sustained after discontinuation of the intervention is unknown. We conducted a prospective, time series analysis of an educational intervention designed to reduce inappropriate TTE. Ordering patterns during the intervention were compared with a preintervention control period and a postintervention period. The goal of the present analysis was to determine the TTE ordering patterns after discontinuation of the educational intervention. The primary outcome was the proportion of inappropriate TTEs. Using the 2011 AUC 99.2% of all TTEs were classifiable. Compared to the control, there was a 26% reduction in the number of TTEs ordered per day during the intervention (3.9 vs. 2.9 TTEs, P < 0.001), but no significant difference between the intervention and postintervention periods (2.9 vs. 3.1, P = 0.23). The intervention produced a decrease in the inappropriate TTE rate and an increase in the appropriate TTE rate. Compared to the intervention, in the postintervention period the rate of inappropriate TTEs increased (5% vs. 11%, P = 0.01) and appropriate TTEs decreased (93% vs. 86%, P = 0.008). The postintervention rate of inappropriate TTEs was similar to the preintervention control period (11% vs. 13%, P = 0.23). Following completion of an AUC-based educational intervention the proportion of inappropriate TTEs increased to the preintervention level. The long-term success of an intervention designed to improve appropriate utilization of TTE requires a sustained effort of education and feedback.
    Echocardiography 01/2014; 31(8). DOI:10.1111/echo.12505 · 1.25 Impact Factor
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    ABSTRACT: After identifying that significant care gaps exist within the management of atrial fibrillation (AF), a patient-focused tool was developed to help patients better assess and manage their AF. This tool aims to provide education and awareness regarding the management of symptoms and stroke risk associated with AF, while engaging patients to identify if their condition is optimally managed and to become involved in their own care. An interdisciplinary group of health care providers and designers worked together in a participatory design approach to develop the tool with input from patients. Usability testing was completed with 22 patients of varying demographics to represent the characteristics of the patient population. The findings from usability testing interviews were used to further improve and develop the tool to improve ease of use. A physician-facing tool was also developed to help to explain the tool and provide a brief summary of the 2012 Canadian Cardiovascular Society atrial fibrillation guidelines. By incorporating patient input and human-centered design with the knowledge, experience, and medical expertise of health care providers, we have used an approach in developing the tool that tries to more effectively meet patients' needs.
    Patient Preference and Adherence 11/2013; 7:1139-46. DOI:10.2147/PPA.S51285 · 1.68 Impact Factor
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    Rajan Sacha Bhatia · Creagh E Milford · Michael H Picard · Rory B Weiner
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    ABSTRACT: OBJECTIVES: This study sought to prospectively study the impact of an appropriate use criteria (AUC)-based educational intervention on transthoracic echocardiography (TTE) ordering among house staff on the inpatient general internal medicine service at an academic medical center. BACKGROUND: AUC for TTE were developed in response to concerns about inappropriate use of TTE. To date, educational interventions based on the AUC to reduce inappropriate use of TTE have not been prospectively studied. METHODS: A prospective, time series analysis of an educational intervention was conducted and then compared with TTE ordering on the same medical service during a control period. The intervention consisted of: 1) a lecture to house staff on the 2011 AUC for TTE; 2) a pocket card that applied the AUC to common clinical scenarios; and 3) biweekly e-mail feedback regarding ordering behavior. TTE ordering was tracked over the intervention period on a daily basis and feedback reports were e-mailed at 2-week intervals. The primary outcome was the proportion of inappropriate and appropriate TTE ordered during the intervention period. RESULTS: Of all TTEs ordered in the control and study periods, 99% and 98%, respectively, were classifiable using the 2011 AUC. During the study period, there was a 26% reduction in the number of TTE ordered per day compared with the number ordered during the control period (2.9 vs. 3.9 TTE, p < 0.001). During the study period, the proportion of inappropriate TTE was significantly lower (5% vs. 13%, p < 0.001) and the proportion of appropriate TTE was significantly higher (93% vs. 84%, p < 0.001). CONCLUSIONS: A simple educational intervention produced a significant reduction in the proportion of inappropriate TTE and increased the proportion of appropriate TTE ordered on an inpatient academic medical service. This study provides a practical approach for using the AUC to reduce the number of inappropriate TTE. Further study in other practice environments is warranted.
    JACC. Cardiovascular imaging 04/2013; 6(5). DOI:10.1016/j.jcmg.2013.01.010 · 7.19 Impact Factor
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    ABSTRACT: The purpose of this study was to examine utilization and growth in echocardiography among the general population of Ontario between 2001 and 2009. The age- and sex-adjusted rates of echocardiography grew from 39.1 per 1,000 persons in 2001 to 59.9 per 1,000 persons in 2009, for an annual rate of increase of 5.5%. Repeat echocardiograms increased at a rate of 10.6% per year and accounted for 25.3% of all procedures in 2009 as compared to 18.5% in 2002. While significant increases in echocardiography utilization were observed, opportunities may exist to improve the clinical utility of the echocardiograms performed in Ontario.
    JACC. Cardiovascular imaging 04/2013; 6(4):515-22. DOI:10.1016/j.jcmg.2012.10.026 · 7.19 Impact Factor
  • R Sacha Bhatia · Vishesh Kumar · Michael H Picard · Rory B Weiner
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    ABSTRACT: Background: The 2008 appropriate use criteria (AUC) for stress echocardiographic (SE) examinations were revised in 2011 to cover a wider range of scenarios of use. Data comparing the 2008 and 2011 AUC for SE are limited. Methods: A retrospective chart review of SE studies performed at an academic medical center was conducted, and ordering of SE studies was assessed using the 2008 and 2011 AUC. Results: A total of 252 consecutive SE studies performed in 2011 were reviewed. The 2008 AUC classified 126 SE studies (50%), and the 2011 AUC classified 221 SE studies (88%) (P < .001). Of all SE studies, 106 (42%) were performed as part of evaluations for noncardiac solid-organ transplantation. The majority of these studies (79%) were classified as inappropriate using the 2011 AUC and were not classifiable using the 2008 AUC. Of the 146 SE studies performed for other reasons, 69% were appropriate and 22% were inappropriate using the 2011 AUC. Inappropriate SE studies for both the general nontransplant and noncardiac solid-organ transplantation populations were nearly exclusively ordered for perioperative assessment with normal functional capacity. The SE studies that remained unclassified by the 2011 AUC were related to the assessment of specialized cardiac conditions, including hypertrophic cardiomyopathy and follow-up after heart transplantation. Conclusions: The 2011 AUC classify a significantly greater proportion of SE studies compared with the 2008 AUC. Most of the reclassified SE studies using the 2011 AUC were inappropriate and were ordered for perioperative assessments in patients with normal functional capacity.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 01/2013; 26(4). DOI:10.1016/j.echo.2012.12.001 · 4.06 Impact Factor

Publication Stats

977 Citations
203.30 Total Impact Points


  • 2006–2015
    • University of Toronto
      • • Department of Medicine
      • • Sunnybrook Health Sciences Centre
      Toronto, Ontario, Canada
  • 2014
    • Women's College Hospital
      Toronto, Ontario, Canada
  • 2013–2014
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
  • 2012–2013
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 2011–2013
    • Harvard University
      Cambridge, Massachusetts, United States