This study addresses CHF QUERI's goal of improving the appropriateness of testing for left ventricular ejection fraction. Inappropriate use of left ventriculography is both a quality and cost issue for the VA. The quality issues include the unnecessary use of contrast (potential adverse effect on kidney function), radiation (possible long term risk of cancer), and other procedural complications including air embolism, ventricular tachycardia, and vascular injury. Costs of the procedure include the additional laboratory and provider time, catheters, contrast dye, and treatment of any complication.
This procedure, usually performed during a coronary angiogram, provides a measure of the left ventricular ejection fraction which in turn is used to determine eligibility for life prolonging heart failure treatments. However, left ventriculography requires use of contrast dye (potentially worsening kidney function), radiation, and has a less expensive non-invasive alternative (e.g. echocardiography). Furthermore, the investigators have demonstrated wide variation in the use of left ventriculography in the VA with some catheterization laboratories performing the procedure in < 1% of their coronary angiogram cases while other facilities are using it in over 95% of their cases. This marked variation is not explained by differences in patient case mix and indicates that the VA is inappropriately using the technology at some facilities.
The Aims of the proposed Rapid Response Project are the following:
Aim 1) To determine views of VA invasive cardiologists regarding the value of left ventriculography. Hypothesis Aim 1. Providers' views on the value of left ventriculography will explain much of the variation in use across facilities after adjustment for patient and facility characteristics.
Aim 2) To have VA cardiologists define a list of inappropriate uses of left ventriculography.
Aim 3) To determine the variation in inappropriate use of left ventriculography across the VA system. Hypothesis Aim 3. There will be substantial variation in inappropriate use across VA facilities, and inappropriate use will correlate with overall use of left ventriculography.
Aim 4) To develop an audit and feedback intervention for appropriateness of left ventriculography in the VA system.
Aim 1) To determine views of VA invasive cardiologists regarding the value of left ventriculography.
Survey Population: With the assistance of CART-CL staff we identified invasive cardiologists performing coronary angiography in the VA Health Care System in 2011. We identified approximately 200 invasive cardiologists. The e-mail survey request was sent jointly from CART-CL / Office of Patient Care Services, CHF QUERI and Ischemic Heart Disease QUERI.
Email Survey. We worked with qualitative and survey researcher, Dr. Zickmund to guide the design of the e-mail based survey of invasive cardiologists. A draft of the questions is shown in Appendix 1. The goal of the survey was to determine general views of invasive cardiologists regarding left ventriculography. We determined provider characteristics that may be associated with use of left ventriculography such as years since training, and use of left ventriculography during training. We asked providers if they believe their facility provides more or less left ventriculography than the typical VA facility. In addition we examined providers' views on potential benefits (education of trainees) and harms (radiation, extra contrast dye).
Aim 2). To have VA invasive cardiologists define a list of inappropriate uses of left ventriculography.
Creation of Indications for Appropriateness Ratings. Using experts in coronary angiography and ischemic heart disease at the Palo Alto and Eastern Colorado VA Health Care Systems we created a list of clinical indications using left ventriculography for appropriateness rating. These indications (clinical scenarios) are designed to cover at least 85% of clinical situations faced by invasive cardiologists when deciding to perform left ventriculography. In particular they are designed to identify the clinical scenarios where proceeding with a left ventriculogram is inappropriate. The scenarios/indications were created such that all the clinical characteristics described map to data fields within CART-CL wherever possible. This allows the CART-CL database to be used to determine appropriateness without requiring additional data from chart review.
Ratings of Appropriateness. Using a modified RAND/UCLA method described we first identified a panel of invasive cardiologists to rate the appropriateness of left ventriculography. We included invasive cardiologists (n=9) as they are the main providers who order, perform and interpret the images. We also included other cardiology providers (n=3) who are not invasive cardiologists but who often order, perform, and interpret other imaging tests that provide similar information to left ventriculography (e.g. echocardiography). During our survey of invasive cardiologists for Specific Aim 1 we asked for volunteers to serve as appropriateness raters. We identified non-invasive cardiologist volunteers from our VA Heart Failure Network, a network of 800+ providers with an interest in heart failure, with over 200 cardiologist providers. The panel was asked to rate indications from 1 to 9 where a 9 rating is clearly appropriate and a 1 rating is clearly inappropriate as described above.
Aim 3). To determine the variation in inappropriate use of left ventriculography across the VA system. We documented absolute use variation as noted above, using administrative and CART-CL data.
Aim 4) To develop an audit and feedback intervention for appropriateness of left ventriculography in the VA system. We developed written feedback of the use of left ventriculography by facility to each invasive cardiologist at the facility.
This feedback intervention is designed with characteristics likely to be effective based on the meta-analyses of Kluger (8) and Hysong. (9) The feedback is designed to be non-public in that only the providers at the local facility will know where their facility lies in the overall distribution of overall use and appropriateness.
The Quality Enhancement Research Initiative of the VA Health Care system established and evaluated Appropriate Use Criteria (AUC) for the use of left ventriculography during cardiac catheterization and coronary angiography.
The writing group identified 32 indications for left ventriculography that were based on common clinical scenarios. These included 23 scenarios for stable patients 9 for those with acute coronary syndromes. A separate and independent rating panel composed of 9 invasive and 9 non-invasive VA cardiologists (total 18) scored each scenario on a 1-9 scale where 9 is highly appropriate and 1 is highly inappropriate. Each scenario was grouped according to the mean score into appropriate (mean score > 6.5), uncertain appropriateness (3.5-6.5) and inappropriate < 3.5. Six scenarios were rated as appropriate, 14 as uncertain and 12 as inappropriate. Examples of inappropriate indications for left ventriculography included patients with a recent measure of left ventricular function, and those with poor kidney function.
These AUC will be a useful guide to clinicians and trainees in the future care of patients. They will serve as a mechanism for quality improvement as well as a method to improve the efficiency of use of medical resources.
Initial evaluation of 4 inappropriate scenarios for the 80+ VA cath labs found a large variation in use.
To determine why providers may still be doing inappropriate studies we surveyed 33 laboratory directors. 53% strongly or very strongly agreed that left ventriculography was important to do for teaching purposes. 24% strongly or very strongly agreed that the increased dye used for the procedure was not a clinical concern compared to 58% that disagreed or strongly disagreed. 21% agreed or strongly agreed that left ventriculography was superior to non-invasive methods of determining left ventricular ejection fraction compared to 73% who disagreed or strongly disagreed. These findings indicate that there are strongly held beliefs by those that perform the procedure that may make it difficult to change behavior.
The CART-CL group has conducted an evaulation ("audit") of VA cath labs regarding inappropriate use. An intervention is now developed in collaboration with Patient Care Services to provide targetetd feedback to VA cath labs regarding their use.
None at this time.
Treatment - Observational