Cardiology Section, Medical Service, VA Palo Alto Health Care System, Palo Alto, CA (N.M.K.).
Division of Cardiovascular Medicine, Department of Medicine (N.M.K., E.L.), Stanford University School of Medicine, Stanford, CA.
Circ Cardiovasc Qual Outcomes. 2024 Nov;17(11):e010621. doi: 10.1161/CIRCOUTCOMES.123.010621. Epub 2024 Nov 19.
A limited transthoracic echocardiogram (TTE) can be an appropriate, lower-cost substitute for a full TTE. We assessed the impact of an electronic health record alternative alert promoting the adoption of limited TTEs on the ordering practices of cardiology clinicians and primary care providers and captured their perspectives on the initiative.
The alert was deployed in a cardiology clinic and 4 primary care clinics at an academic medical center. The alert provided clinical guidance on the appropriate use of limited TTEs when a clinician selected a full TTE order. We used logistic regression to estimate the change in the proportion of limited versus full TTEs ordered between the baseline and intervention periods in clinics with and without the alert. We also conducted interviews with 24 clinicians (5 cardiologists and 19 primary care providers) to identify implementation barriers and facilitators.
Cardiology clinicians ordered 10 654 and 3761 TTEs during the baseline and intervention periods, respectively, for 9100 patients. Primary care providers ordered 723 and 617 TTEs during the baseline and intervention periods for 1273 patients. The model estimated that the percentage of limited TTEs ordered increased by 16.1±2.3 percentage points (<0.0001) in the cardiology clinic with the alert and by 13.2±1.5 percentage points (<0.0001) in the primary care clinics with the alert from baseline to post-intervention. Ordering practices did not change in the cardiology (0.7±0.6 percentage points; =0.24) or primary care (0.7±1.0 percentage points; =0.52) clinics without the alert. Clinicians viewed the alert as acceptable. Cardiologists appreciated that the alert was concise, whereas primary care providers wanted more information from the alert.
An alternative alert providing clinical guidance on the use of limited TTEs at the point of care increased the selection of this lower-cost test in cardiology and primary care clinics. Perspectives on the alert differed between specialists and nonspecialists, highlighting the importance of tailoring intervention design to clinical expertise.
有限的经胸超声心动图（TTE）可以作为完整 TTE 的一种合适的低成本替代方法。我们评估了电子病历替代警报对心脏病学临床医生和初级保健提供者的订单实践的影响，并了解了他们对该倡议的看法。
该警报部署在学术医疗中心的一个心脏病诊所和 4 个初级保健诊所中。当临床医生选择完整 TTE 订单时，该警报为有限 TTE 的合理使用提供了临床指导。我们使用逻辑回归估计在有和没有警报的诊所中，基线期和干预期之间有限与完整 TTE 订单的比例变化。我们还对 24 名临床医生（5 名心脏病专家和 19 名初级保健提供者）进行了访谈，以确定实施障碍和促进因素。
心脏病学临床医生在基线期和干预期分别为 9100 名患者开了 10654 次和 3761 次 TTE，初级保健提供者在基线期和干预期分别为 1273 名患者开了 723 次和 617 次 TTE。模型估计，有警报的心脏病诊所中，有限 TTE 订单的百分比增加了 16.1±2.3 个百分点（<0.0001），有警报的初级保健诊所中增加了 13.2±1.5 个百分点（<0.0001）。从基线到干预后，没有警报的心脏病诊所（0.7±0.6 个百分点；=0.24）或初级保健诊所（0.7±1.0 个百分点；=0.52）的订单实践没有改变。临床医生认为该警报是可以接受的。心脏病专家认为该警报简洁明了，而初级保健提供者希望从警报中获得更多信息。
在护理点提供关于有限 TTE 使用的临床指导的替代警报增加了该低成本测试在心脏病学和初级保健诊所的选择。专家和非专家对警报的看法不同，这凸显了根据临床专业知识调整干预设计的重要性。
