Electronic Feedback to Cardiologists Reduces Number of ‘Rarely Appropriate’ TTEs

Cardiologists are more likely to follow guideline recommendations for outpatient ordering of transthoracic echocardiograms (TTEs) when they receive targeted education and personalized real-time feedback on their ordering practices, a small study suggests.

“We think it might be a way to engage physicians and preserve their autonomy while letting them know how they stack up,” said the study’s senior author, Rory B. Weiner, MD (Massachusetts General Hospital, Boston, MA), in an interview with TCTMD.

For the study, conducted between November 2013 and June 2014, 66 attending cardiologists at Weiner’s institution received a lecture on appropriate use criteria (AUC) concepts along with a review of common clinical scenarios in which TTE is considered “appropriate,” “may be appropriate,” and “rarely appropriate.” The classifications are consistent with the change introduced by the American College of Cardiology in 2013, which replaced “appropriate,” “uncertain,” and “inappropriate.”


Routine Surveillance Tops List

Cardiologists randomized to the intervention group received individualized email feedback documenting the TTEs they ordered and whether they were classified as appropriate, may be appropriate, or rarely appropriate according to AUC. Those randomized to the control group had their TTE ordering tracked and classified, but they received no feedback on how it corresponded with AUC. A total of 3,193 TTEs were ordered during the study period.

The results, published online August 10, 2016, in JAMA Cardiology, show that the rate of rarely appropriate TTEs was lower in the intervention group than in the control group (10.5% vs. 16.5%; P = 0.01), while the proportion of appropriate TTEs was higher but did not reach significance (77.6% vs. 72.0%; P = 0.11).

For the group as a whole, the overall percentage of rarely appropriate TTEs decreased over time, but the reduction was most pronounced in the intervention group. The most common indications for TTEs classified as rarely appropriate were related to routine surveillance:


  • Within 3 years after implantation of a prosthetic valve
  • Within 1 year for moderate or severe valve stenosis
  • Within 1 year for known cardiomyopathy despite no change in clinical status or exam
  • Of ventricular function with no symptoms or signs of CV disease


Weiner said cutting back on routine surveillance testing that is rarely appropriate may represent “the low-hanging fruit” in terms of improving utilization of TTE and other types of cardiac imaging.

Staying Power of Feedback Unclear

A prior study by the same researchers looking at cardiology fellows had shown similar results in terms of behavioral changes in response to tracking and feedback, but whether this approach would work with established cardiologists was uncertain and was an impetus for the current study, Weiner explained. Reassuringly, he added, when they looked at the impact of the intervention across a spectrum of academic rank, there were no differences.

Despite the small size and single-center nature of the educational initiative, Weiner said it may provide support for broadening this type of feedback-oriented concept in regard to ordering of other imaging techniques such as coronary CT, nuclear stress testing, and cardiac MRI.

“We think this concept could also be expanded to providers beyond cardiologists,” Weiner said. “Cardiologists order a lot of echos but so do internal and family medicine docs and neurologists.” In a separate ongoing trial, his group is looking at this question among a variety of different providers in the US and Canada.

But a looming question is what happens after the active intervention is over. Will physicians continue on their own to assess their TTE ordering or will they regress?

“It’s a viable question,” Weiner noted. “We think it’s going to depend a lot on automation. Could there be automated prompts when a doctor is ordering a study that cross-references AUC, and automated ways to generate feedback? Because the reality is our study was very labor-intensive in terms of manually tracking echos and sending out emails. There is some research out there that suggests we can find ways to automate all of that.”





  • Dudzinski DM, Bhatia RS, Mi MY, et al. Effect of educational intervention on the rate of rarely appropriate outpatient echocardiograms ordered by attending academic cardiologists: a randomized clinical trial. JAMA Cardiol. 2016;Epub ahead of print.




  • Weiner reports no relevant conflicts of interest.


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