Effects of an Electronic Medical Record Intervention on Appropriateness of Transthoracic Echocardiograms: A Prospective Study.

BACKGROUND: Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders. METHODS: This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography. RESULTS: Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z = 0.00018) but decreased to 90.0% at late intervention (z = 0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30 days prior (odds ratio = 2.85; 95% CI, 1.18-6.31; P = .005). CONCLUSIONS: The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns.

Specialty-Based Variability in Diagnosing and Managing Heart Failure With Preserved Ejection Fraction.

OBJECTIVE: To quantify differences in the diagnosis and treatment of heart failure with preserved ejection fraction (HFpEF) between cardiologists and noncardiologists, who often diagnose and manage HFpEF. METHODS: Cardiologists and noncardiologists (internal medicine, medicine/pediatrics, family medicine, geriatrics) were anonymously surveyed between January 16, 2018, and March 2, 2018, regarding practices related to diagnosing and managing HFpEF at the University of Michigan and Weill Cornell Medical Center. Response data were compared using χ2 analysis. RESULTS: Of 1010 physicians surveyed, 211 completed a significant portion of the survey: 32 cardiologists and 179 noncardiologists. Most noncardiologists were unaware of HFpEF diagnostic guidelines and commonly used left ventricular diastolic dysfunction and natriuretic peptides to diagnose HFpEF. Noncardiologists (32.3%, n=52) were less likely than cardiologists (64.5%, n= 20) to prescribe an aldosterone antagonist for HFpEF (P=.001). Both groups reported similar use of ß-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and exercise programs. Noncardiologists were more likely to refer patients with HFrEF to cardiology (63.1%, n=111) compared with patients with HFpEF (33.5%, n=59; P<.001). Noncardiologists were more likely to discuss prognosis and goals of care with patients with HFrEF (84.4%, n=151) than with patients with HFpEF (65.9%, n=118; P<.001). CONCLUSION: Cardiologists and noncardiologists vary significantly in their HFpEF diagnosis and treatment practices. As diagnostic criteria continue to be evaluated for HFpEF, dissemination of these guidelines to noncardiologists, with an emphasis on the morbidity and mortality associated with HFpEF, is imperative.