Curbing Overuse of Cardiac Imaging Requires Audits and Feedback, Analysis Shows

Quality improvement efforts to reduce excess use of cardiac imaging seem to work best when they specifically involve physician audit and feedback, according to a recent meta-analysis.

Admittedly that finding is “somewhat expected,” Philip Joseph, MD, of Hamilton General Hospital in Canada told TCTMD. That being said, “hopefully this will help direct what sort of further strategies are used for quality improvement initiatives,” he added.

For physicians, the power of audit and feedback could relate to having the “opportunity from a clinical standpoint to know your practice patterns and where you may be potentially not in accordance with guidelines,” Joseph explained. “You may consider adjusting your practice based on getting information you just didn’t know about before…. I think also the constant feedback is an important component of it.”

Published online January 5, 2016, in Circulation Cardiovascular Quality and Outcomes, the meta-analysis included 6 observational studies and 1 randomized controlled trial looking at initiatives meant to reduce cardiac imaging considered inappropriate (ie, rarely effective in directing management or having an unclear benefit/risk advantage). Definitions varied depending on which appropriate use criteria (AUC) were used in each study.

All were conducted in the United States. Among them, 6 included physician education and 5 had a mechanism for audit and feedback. “All studies had potential sources of bias that could have affected the observed estimates,” the paper stresses.

In general, the quality improvement programs were linked to lower use of inappropriate testing, though there was much heterogeneity. This variation in effectiveness appeared most related to the audit/feedback component. Interventions that had this aspect reduced the odds of inappropriate testing by two-thirds, whereas those lacking audit and feedback had no effect (P < .001).

Whether the programs included an element of education mattered less, Joseph said. This may be because, in contrast to ongoing evaluation that keeps physicians more aware of their behavior, a one-time educational component can more easily be forgotten.

The specific type of audit and feedback varied among the studies. One had a computer-based decision support tool that provided immediate information to physicians making choices, whereas other initiatives provided reports on a daily, biweekly, or monthly basis.

Sustainability Key

While acknowledging the effectiveness of programs involving audit and feedback, Rita Sachdeva, MBBS, of Emory University School of Medicine (Atlanta, GA), and Pamela S. Douglas, MD, of Duke University Medical Center (Durham, NC), point out that they may be too rigorous to maintain.

“The studies using this method were conducted over a brief span of time, with perhaps significant time devoted by the investigators,” they note in an accompanying editorial. “The sustainability of such models, therefore, becomes questionable. Not all institutions may have the willingness or resources, including knowledgeable personnel to dedicate to such processes.”

Another complicating factor is the potential for a Hawthorne effect, in which awareness of being observed can lead to temporary changes in behavior.

More to It Than Just the Physician

Still, the current study “points a way forward for future efforts,” Sachdeva and Douglas comment. “Further work is needed to implement such interventions at a much larger scale and, more importantly, to assess their effect on improving patient outcomes and not just the appropriateness of testing.” Reimbursement incentives rather than punitive measures might prove helpful, as might widespread recognition among providers, payers, and patients that quality improvement efforts deserve attention, they say.

The fact that clinicians do not practice in a vacuum must be kept in mind, Joseph noted. “During this time period, people were becoming more aware of AUC in general,” he explained, and this may be why the effect seen here was more dramatic than what had been observed previously for initiatives directed at other types of health services.

Both Joseph and the editorialists point to the American College of Cardiology’s Formation of Optimal Cardiovascular Utilization Strategies program, known as FOCUS, which allows physicians to use a self-directed web-based tool. “In 2011, under court order, the Blue Cross Blue Shield of Delaware agreed to pay for Delaware physicians to participate in [FOCUS] instead of the existing preauthorization program,” Sachdeva and Douglas report. “Offering such incentives for participating in quality improvement projects is easy to implement and effective and could have long-lasting effects on physician test ordering behavior.”

Sources: 
1. Chaudhuri D, Montgomery A, Gulenchyn K, et al. Effectiveness of quality improvement interventions at reducing inappropriate cardiac imaging: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.
2. Sachdeva R, Douglas PS. Quality improvement interventions to improve appropriateness of imaging studies: necessary, but are they sufficient [editorial]? Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.

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