The impact of a High Value Care curriculum on rate of repeat of trans-thoracic echocardiogram ordering among medical residents
There is little data to confirm the impact of a High Value Care curriculum on echocardiogram ordering practices in a residency training program. We sought to evaluate the rate of performance of repeat transthoracic echocardiograms (TTE) before and after implementation of a High Vale Care curriculum.
A High Value Care curriculum was developed for the medical residents at Griffin Hospital, a community hospital, in 2015. The curriculum included a series of lectures aimed at promoting cost-conscious care while maintaining high quality. It also involved house staff in different quality improvement (QI) projects aimed at promoting high value care.
A group of residents decided to work on an initiative to reduce repeat echocardiograms. Repeat echocardiograms were defined as those performed within 6 months of a previous echocardiogram on the same patient. Only results in our EHR reflecting in-patient echocardiograms were utilized.
We retrospectively examined the rates of repeat echocardiograms performed in a 6 month period in 2014 before the High Vale Care curriculum was initiated. We assessed data from a 5 month period in 2016 to determine the rate of repeat electrocardiograms ordered at our institution.
A total of 1,709 echocardiograms were reviewed in both time periods. Of these, 275 were considered repeat. At baseline, or before the implementation of a High Value Care curriculum, we examined 908 echocardiograms that were ordered, of which 21% were repeats.
After the implementation of a High Vale Care curriculum, 801 echocardiograms were ordered. Only 11% of these were repeats. This corresponds to a 52% reduction in the rate of repeated ordering of echocardiograms.
The significant improvement in the rate of repeat echocardiograms was noted without any initiative directed specifically at echocardiogram ordering practices. During the planning phases of the proposed QI initiative to reduce repeat echocardiograms, house staff noted that their colleagues were already being more selective in their echocardiogram ordering practices because of the impact of the-cost conscious care lectures they had attended, as well as hospital-wide attention on the first resident-driven QI initiative that was aimed at reducing repetitive daily labs.
As part of the reducing repetitive labs QI, house staff had to provide clear rationale for why they were ordering daily labs. The received regular updates about their lab ordering practices and direct feedback if they consistently did not provide clear rationale for ordering daily labs.
We believe the impact of the lectures and the initial QI project molded resident behavior in echocardiogram ordering. They noted that the night team deferred echocardiogram orders to the day team to allow for conversations with the cardiology service regarding the need for an echocardiogram. They also reported that there was more effort to determine if the patient had a previous echocardiogram done as an out-patient, which was not immediately available.
Our study clearly showed a greater than 50% reduction in the ordering of repeat echocardiograms because of a High Value Care curriculum in our residency training program.
The improvement was brought on by increased awareness by house staff regarding provision of high quality care while being cognizant of the costs involved. The reduction in repeat echocardiograms resulted in more efficient use of a limited hospital resource.
Dr. Arole is chief of hospital medicine at Griffin Hospital, Derby, Conn. Dr. Zyed is in the department of internal medicine at Griffin Hospital. Dr. Njike is with the Yale University Prevention Research Center at Griffin Hospital.