Quality Improvement Interventions to Improve Appropriateness of Imaging Studies: Necessary, But Are They Sufficient?

Abstract

Since 2005, the American College of Cardiology Foundation, in conjunction with other societies, has released Appropriate Use Criteria (AUC) for various procedures and imaging modalities. The AUC are being increasingly recognized as an important link in the chain of quality improvement processes in cardiovascular patient care. Article see p 7 Implementation studies evaluating AUC in usual clinical care have been instrumental in benchmarking the appropriateness and inappropriateness rates. A recent meta-analysis summarizing ≈60 published reports in >100 000 imaging tests found the rate of both appropriateness and rarely or inappropriate imaging test to vary widely by modality, as well as by iteration of the AUC document (Table).1 These data provide important information on how testing is used in usual care, thereby creating the framework for designing quality improvement initiatives. Such initiatives require physicians to change their ordering practices—not an easy task. A broad variety of methods have been proposed to change behavior from passive education to active interventions, with the latter being more effective and harder to implement.2 View this table: Table. Published Data on Appropriateness of Noninvasive Testing by Imaging Modality (After Fonseca et al1) In this issue of Circulation: Cardiovascular Quality and Outcomes , Chaudhuri et al3 provide a systematic review of studies using quality improvement initiatives to reduce the proportion of rarely appropriate cardiovascular imaging based on AUC.3 The meta-analysis used stringent criteria and included just 7 studies with 6 observational studies and 1 randomized control trial, assessing the use of noninvasive imaging. These studies varied significantly in terms of the number of patients, type of imaging modalities, target population for intervention, and the type and practice location of providers. Not surprisingly, the strategies used also varied, ranging from passive interventions, such as lectures, webinars, and pocket cards to more active ones, such as …