Transthoracic echocardiography (TTE) is a foundational tool in the diagnosis and management of numerous cardiac conditions. An aging population and increasing prevalence of cardiac disease have increased the demand for cardiac services, including TTE. Over the past few years, growth in TTE utilization has lead leading professional societies to develop appropriate use criteria (AUC) to help ensure high-quality and rational use of cardiac testing like TTE. AUC detail clinical scenarios in which testing may be considered and determine the appropriateness of doing a test in that scenario.

How to implement AUC in clinical practice has been a conundrum for clinicians, echocardiography lab directors, administrators, and health policy experts. Remembering the more than 100 AUC recommendations is difficult for any clinician. In addition, there was no prior published evidence on how to implement AUC in practice that would significantly reduce potentially unnecessary TTEs. Our research group recently sought to develop and test an evidence-based method to successfully reduce potentially unnecessary TTEs in clinical practice while still allowing physicians the autonomy to order needed TTEs on their patients.


Identifying “Rarely Appropriate” Use

The EchoWISELY (Will Inappropriate Scenarios for Echocardiography Lessen SignificantLY) study is an international, multi-centered, investigator-blinded, randomized control trial of a comprehensive educational intervention designed to reduce the proportion of “rarely appropriate” TTEs ordered in ambulatory care practices. This study, published in the Journal of the American College of Cardiology, builds upon previously published work our group has conducted on designing and testing this intervention among medical trainees and staff at Massachusetts General Hospital. The EchoWISELY study enrolled cardiologists and primary care physicians who practice in an ambulatory setting who were randomized into usual care or to receive a comprehensive intervention that included an introductory YouTube video describing AUC, the AUC mobile app created by the American Society of Echocardiography, and monthly confidential performance reports to each physician on his or her ordering appropriateness. Physicians in both groups ordered TTEs as per their usual practice, and no one but the individual physician receiving the report knew their performance.

From December 2014 to April 2016, 14,697 TTEs were classified by blinded, trained research coordinators. At the end of the study, physicians in the intervention group ordered 25% fewer rarely appropriate TTEs than the control group, (odds ratio, 0.75). Primary care physicians ordered fewer “rarely appropriate” TTEs than cardiologists. There were no differences in the effect of the intervention on Canadian versus US physicians, suggesting that the intervention appeared to work equally well in both countries. Finally, in addition to basic information provided to physicians through email, physicians could also log into a secure system to get more detailed feedback (Figure). Overall, 61% of physicians in the intervention group logged into the feedback system at least once, which is quite high for interventions of this type.


Unanswered Questions

The study does leave some unanswered questions that should be the focus of future studies. EchoWISELY was conducted at academic medical centers, making the generalizability to community hospitals and practices limited. Also, it is not known whether the effect of the intervention wears off when it is discontinued. We expect, as has been shown in previous work, that the intervention effect does end once the intervention ends. As a consequence, further work—perhaps using AI or another automated approach—could make collection of the data less cumbersome and the intervention more sustainable over time. Nevertheless, the intervention in the EchoWISELY study shows significant promise as an approach to responsibly use cardiac testing while maintaining physician autonomy.