Winchester David E, Schmalfuss Carsten, Helfrich Christian D, Beyth Rebecca J
Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida, USA.
Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA.
Open Heart. 2017 May 16;4(1):e000589. doi: 10.1136/openhrt-2017-000589. eCollection 2017.
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.
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.
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.
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.
适当使用标准（AUC）教育的研究表明，其对改变医疗服务提供者行为的效果不一。在我们的机构中，很少有适当的心肌灌注成像（MPI）因专业而异；对AUC的知晓率较低。我们的目的是调查针对特定专业的多模式教育是否可以减少很少适当的MPI。
我们设计了针对每个专业最常开出的很少适当的MPI的教育。我们在三个队列中跟踪MPI的适当性：干预前、干预后（干预后立即）和干预后期（干预后4个月）。
共评估了889例MPI（干预前n = 287，干预后n = 313，干预后期n = 289），95.3%为男性。胸痛是最常见的症状（n = 530，59.6%），而14.1%（n = 125）无症状。很少适当的检查从4.9%降至1.3%，在干预后期队列中保持在1.4%（p < 0.0001）。在逻辑回归中，无症状（比值比31.3，95%可信区间10.3至94.8，p≤0.0001）以及处于干预后或干预后期队列（比值比0.27，95%可信区间0.11至0.68，p = 0.006）与很少适当的MPI相关。运动能力良好的患者术前MPI是常见的很少适当的指征。在很少有适当MPI指征的患者中未观察到缺血。
在某些临床环境中，教育可能是减少很少适当的MPI的有效方法。当专注于改善患者护理、由同行提供且需求评估表明对指南知晓率较低时，教育效果可能会增强。无症状和术前MPI仍然是开出的主要很少适当的MPI。
