Development of an Educational Strategy and Decision Support Tool to Enhance Appropriate Use of Stress Echocardiography at a Large Academic Medical Center: A Prospective, Pre- and Postintervention Analysis

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 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.