Mayo Foundation, 200 First Street SW, Rochester, MN 55905, USA.
Circulation. 2011 Feb 8;123(5):499-503. doi: 10.1161/CIRCULATIONAHA.110.975995. Epub 2011 Jan 24.
We previously reported the application of the 2005 American College of Cardiology Foundation appropriate use criteria for stress single-photon emission computed tomography (SPECT) imaging to patients at Mayo Clinic (Rochester, MN) in 2005 and 2006. A subsequent internal quality improvement project focused on physician education in an attempt to reduce the rate of inappropriate SPECT studies.
Our 2008 physician education effort, focused on 4 specific indications that accounted for 88% of the inappropriate SPECT studies, included a presentation at medical grand rounds, a publication in the staff newsletter, meetings with physician administrators, and focused presentations to departments/divisions with many ordering physicians. We then remeasured the appropriateness of SPECT studies using previously published methods. The general categories of study indications, eg, after revascularization, were similar in 273 SPECT patients in 2008 and in our 2005 (n=284) and 2006 (n=284) cohorts. There was a trend suggesting a change in the overall classification of appropriateness over time (P=0.08) and a significant change in the rate of inappropriate studies over time (P=0.018). Inappropriate studies decreased from 14.4% in 2005 to 7.0% in 2006 before initiation of the quality improvement project. After completion of the quality improvement project, inappropriate studies increased to 11.7% (P=0.06). The 95% confidence limits for the 4.7% increase in inappropriate studies after the quality improvement project included a decrease of 0.2% and an increase of 9.6%.
This quality improvement project, focused on feedback, physician education, and remeasurement, did not reduce the rate of inappropriate stress SPECT studies in a single academic medical center. Similar limited interventions focused on physician education alone may have limited benefit. More extensive intervention may be necessary to improve the quality of care with appropriateness criteria.
我们曾报道过，2005 年美国心脏病学院基金会适当应用标准在梅奥诊所（明尼苏达州罗彻斯特）应用于压力单光子发射计算机断层（SPECT）成像，对象是 2005 年和 2006 年的患者。随后的内部质量改进项目专注于医生教育，旨在降低不适当的 SPECT 研究率。
我们在 2008 年的医生教育工作中，重点关注了占不适当 SPECT 研究 88%的 4 种特定适应证，包括在医疗大查房时的演讲、在员工通讯中发表文章、与医生管理人员开会，以及向有许多开单医生的科室/部门进行重点介绍。然后，我们使用之前发表的方法重新评估了 SPECT 研究的适宜性。2008 年 273 例 SPECT 患者的研究适应证一般类别，如再血管化后，与我们 2005 年（n=284）和 2006 年（n=284）的队列相似。随着时间的推移，整体适宜性分类有变化的趋势（P=0.08），而且不适当研究的比例随着时间的推移也有显著变化（P=0.018）。在质量改进项目开始之前，不适当的研究从 2005 年的 14.4%下降到 2006 年的 7.0%。在质量改进项目完成后，不适当的研究增加到 11.7%（P=0.06）。质量改进项目后，不适当研究增加了 4.7%，95%置信区间包括减少 0.2%和增加 9.6%。
这项以反馈、医生教育和重新测量为重点的质量改进项目，并没有降低一家学术医疗中心不适当压力 SPECT 研究的比例。类似的、仅以医生教育为重点的有限干预措施可能收效有限。可能需要更广泛的干预措施，才能通过适宜性标准提高医疗质量。
