Implementation of a Computerized Order Entry Tool to Reduce the Inappropriate and Unnecessary Use of Cardiac Stress Tests With Imaging in Hospitalized Patients

Gertz, Zachary M.; O’Donnell, William T.; Raina, Amresh; Balderston, Jessica R.; Litwack, Andrew J.; Goldberg, Lee R.

doi:10.1016/j.amjcard.2016.07.021

Cited by 7 publications

(10 citation statements)

References 18 publications

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“…Among the 77 studies that reported improvements following the intervention [ 37 – 45 , 47 – 49 , 52 , 53 , 56 , 57 , 59 , 60 , 62 – 64 , 67 , 69 , 71 – 81 , 83 , 85 – 90 , 92 – 106 , 108 – 117 , 120 – 123 , 125 , 128 – 131 ], decreases in low-value imaging varied largely from < 1 to 62%. Of the remaining studies, three studies reported mixed results, where only some of the targeted low-value imaging examinations were reduced [ 46 , 54 , 68 ], and 16 studies showed a non-significant change or increase in the use of low-value imaging post-intervention [ 50 , 51 , 55 , 58 , 61 , 65 , 66 , 70 , 82 , 84 , 91 , 107 , 118 , 119 , 124 , 127 ].…”

Section: Resultsmentioning

confidence: 99%

Interventions to reduce low-value imaging – a systematic review of interventions and outcomes

Kjelle

Andersen

Soril

et al. 2021

BMC Health Serv Res

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Background It is estimated that 20–50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. Methods An electronic database search was completed in Medline – Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. Results The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. Conclusions Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.

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Section: Resultsmentioning

confidence: 99%

Interventions to reduce low-value imaging – a systematic review of interventions and outcomes

Kjelle

Andersen

Soril

et al. 2021

BMC Health Serv Res

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“…Fourteen of the 28 studies had a moderate risk of bias 22,24,25,27–29,31–34,36,41,43,49 . Nine had a low risk of bias, 30,38–40,42,44–47 and five had a high risk of bias (Table 1; Supporting Information: Tables ) 23,26,35,37,48 …”

Section: Resultsmentioning

confidence: 99%

“…Our review included several studies testing interventions designed to reduce low‐value preoperative cardiac testing, 23,29,31,35,36,39 and all but one 31 successfully reduced testing. The one intervention that was not successful was aimed at reducing stress tests with imaging and not specifically preoperative stress tests, although it did provide results separately for preoperative stress testing.…”

Section: Discussionmentioning

confidence: 99%

Patient, provider, and system‐level factors associated with preoperative cardiac testing: A systematic review

Ellenbogen,

Drmanovic,

Segal

et al. 2023

Journal of Hospital Medicine

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BackgroundOveruse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system‐level factors associated with variation in testing have not been systematically studied.ObjectiveTo conduct a systematic review to better delineate the patient, provider, and system‐level factors associated with variation in preoperative cardiac testing.MethodsWe included studies of an adult US population evaluating a patient, provider, or system‐level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle–Ottawa Scale and Evidence Project Risk of Bias tool.ResultsTwenty‐eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher‐intensity testing. The evidence for provider and system‐level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low‐value testing can be successful.ConclusionsThere is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well‐defined. Further work should aim to better understand these factors.

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“…For example, rarely appropriate stress tests were reduced by 16% after implementation of an EDS tool among several hospitals in a single metropolitan area, but a similar tool tested in another study had no impact on rates of rarely appropriate testing. 61,62 As the use of EDS tools increases, they should be continually reviewed and revised to ensure that they are based on up-to-date evidence and simple to use within the clinical workflow. Some tools increase complexity without measurable increases in health care value or may even be harmful.…”

Section: Intervention Types and Evidence Basementioning

confidence: 99%

“…57,58 Clinical Decision Support Providing feedback to ordering clinicians about their low-value care practices, whether in personalized periodic reports or at the point of ordering through electronic decision support (EDS), has shown mixed results in changing clinician practice patterns. [59][60][61][62] EDS tools generally involve interactive electronic forms or reminders that require the ordering clinician to justify the selection of tests or treatments. The variable impact of EDS tools is likely attributable to differences among the specific test or treatment studied, the characteristics of the EDS tool itself, and factors related to local practice patterns, among others.…”

Section: Clinician Educationmentioning

confidence: 99%

Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association

Kini¹,

Breathett²,

Groeneveld³

et al. 2022

Circ: Cardiovascular Quality and Outcomes

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Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system–, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.

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Implementation of a Computerized Order Entry Tool to Reduce the Inappropriate and Unnecessary Use of Cardiac Stress Tests With Imaging in Hospitalized Patients

Cited by 7 publications

References 18 publications

Interventions to reduce low-value imaging – a systematic review of interventions and outcomes

Interventions to reduce low-value imaging – a systematic review of interventions and outcomes

Patient, provider, and system‐level factors associated with preoperative cardiac testing: A systematic review

Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association

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