A specialty-specific, multimodality educational quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging.

Winchester DE, Schmalfuss C, Helfrich CD, Beyth RJ. A specialty-specific, multimodality educational quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging. Open heart. 2017 May 16; 4(1):e000589.

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Abstract:

OBJECTIVE: Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI. METHODS: We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention. RESULTS: A total of 889 MPI were evaluated (n = 287?pre, n = 313?post, n = 289?late-post), 95.3% were men. Chest pain was the most common symptom (n = 530, 59.6%), while 14.1% (n = 125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3%?and remained at 1.4% in the late-post cohort (p < 0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p = 0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p = 0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI. CONCLUSIONS: In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered.