Specialty-Specific, Multimodality Education to De-Implement Rarely Appropriate Myocardial Imaging

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Specialty-Specific, Multimodality Education to De-Implement Rarely Appropriate Myocardial Imaging
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Open Heart 2017;4:e000589. doi:10.1136/ openhrt-2017-000589
Winchester, David
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Objective 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. Methods 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. Results 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. Conclusions 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.
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1 en-USABSTRACTen-USObjective Investigations of Appropriate Use Criteria en-US(AUC) education have shown a mixed effect on changing en-US provider behaviour. At our facility, rarely appropriate en-US myocardial perfusion imaging (MPI) differs by specialty; en-US awareness of AUC is low. Our objective is to investigate if en-US specialty-specic, multimodality education could reduce en-US rarely appropriate MPI.en-US Methods We designed education focused on the rarely en-USappropriate MPI ordered most often by each specialty. en-US We tracked appropriateness of MPI in three cohorts: pre, en-US post (immediately after) and late-post (4 months after) en-US intervention.en-US Results A total of 889 MPI were evalua ted (n=287 pre, n=313 post, n=289 la te-post), 95.3% were men. en-USChest pain was the most common symptom (n=530, en-US 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and en-USremained at 1.4% in the late-post cohort (p<0.0001). In en-US logistic regression, lack of symptoms (OR 31.3, 95% CI en-US 10.3 to 94.8, p.0001) and being in the post or late-post en-US cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were en-US associated with rarely appropriate MPI. Preoperative MPI en-US in patients with good exercise capacity was a common en-US rarely appropriate indication. Ischaemia was not observed en-US among patients with rarely appropriate indication for MPI.en-US Conclusions In certain clinical settings, education may en-USbe an effective approach for deimplementing rarely en-US appropriate MPI. The effect of education may be enhanced en-US when focused on improving patient care, delivered by a en-US peer, and needs assessment indicates low awareness en-US of guidelines. Lack of symptoms and preoperative MPI en-US continue to be the predominant rarely appropriate MPI en-US ordered.en-USINTRODUCTIONen-US The American College of Cardiology Founen-US -en-US dation (ACCF) and other cardiology specialty en-US societies first published Appropriate Use en-US Criteria (AUC) for nuclear myocardial en-US perfusion imaging (MPI) in 2005. Since en-US that time, a multitude of studies have evaluen-US -en-US ated the proportion of testing considered to en-US be inappropriate or rarely appropriate. en-US Meta-analyses of these studies have demonen-US -en-US strated no appreciable change in the en-US proportion of low-value tests over time.en-US1 2en-USA multitude of factors contribute to the   delay in   adoption of new practice recom en-US-en-US mendations by physicians and advanced en-US practice providers (APPs).en-US3en-US Among the many en-US strategies to encourage change, several have en-US been applied to AUC for cardiac testing. en-US Education is an attractive approach because en-US it requires few resources and physicians and en-US APPs are accustomed to participating in en-US didactics. Education can take many forms en-US and the evidence for effectiveness is mixed. en-US An early attempt to reduce low-value MPI en-US used lectures, meetings and a newsletter but en-US was not found to be effective.en-US4en-US Other attempts en-US which combined education with audit and en-US feedback were effective at reducing echocaren-US -en-US diograms and MPI.en-US5 6en-US A recent meta-analysis en-US of quality improvement (QI) projects for % enen-USAdditional material is en-US published online only. To view en-US please visit the journal online (http:// dx. doi. org/ 10. 1136/ openhrt 2017 000589) en-USTo cite: en-USWinchester DE, en-US Schmalfuss C, Helfrich CDen-US, en-US et alen-US. A specialty-specic, en-US multimodality educational en-US quality improvement initiative en-US to deimplement rarely en-US appropriate myocardial en-US perfusion imagingen-US. Open Hearten-US en-US 2017en-US;4en-US:e000589. doi:10.1136/en-US openhrt-2017-000589en-US Received 4 January 2017en-US Revised 6 April 2017en-US Accepted 11 April 2017 en-USFor numbered afliations see en-US end of article.en-US Correspondence to Dr David E Winchester; da vid. winchester@ va. gov en-USen-US en-US en-US   en-USDavid E Winchester,en-US1,en-US2en-US Carsten Schmalfuss,en-US1,en-US2en-US Christian D Helfrich,en-US3en-US en-US Rebecca J Beythen-US4,en-US5 Health care delivery, economics and global health care en-USKEY QUESTIONS en-USWhat is already known about this subject?en-USMedical tests are often ordered in clinical scenarios en-US where the patient is unlikely to benet. The evidence en-US on whether education can alter such patterns of care en-US delivery is mixed.en-USWhat does this study add?en-USWe showed that in certain circumstances, a well-en-US designed educational programme tailored to the needs en-US of the learners may effectively alter patterns of care en-US delivery in the short term.en-USHow might this impact on clinical practice?en-USEducation is a low-cost intervention which, if applied en-US properly, could help curtail the unnecessary use of en-US medical tests and procedures. on August 1, 2017 Published by Downloaded from


en-US2 AUC found that   education was less effective without audit en-USand feedback, whereas another systematic review looking en-US at education for changing behaviour on low-value care en-US overall found the majority of education-based projects to en-US be effective.en-US7 8en-USIn previous investigations at our facility, we observed en-US that patterns of rarely appropriate use varied by specialty en-US and that over one-third of providers have never heard of en-US AUC.en-US9 10en-US Based on this evidence, we hypothesised that en-US education would effectively reduce rarely appropriate en-US MPI. To test this, we designed and tracked effectiveness en-US of a specialty-specific, multimodality educational QI en-US initiative to deimplement rarely appropriate MPI at our en-US facility.en-US METHODSen-US We designed an educational initiative to encourage the en-US appropriate use of nuclear MPI. The initiative consisted en-US of two content delivery mechanisms, lectures and printed en-US posters. The lectures were given to groups of providers en-US based on their specialty: primary care, hospital medien-US -en-US cine and cardiology. Primary care lectures were given in   person at our two largest medical centres and one was en-USbroadcast via video link over the intranet to providers en-US throughout our clinical network. Each lecture audience en-US included both physician and APPs. The printed posters en-US were created in Microsoft PowerPoint (Redmond, WA, USA) and printed on 11 paper by the medical media en-USoffice (Supplementary figure). This size was chosen en-US because the primary care clinics have official notice en-US boards which accommodate this poster size. Posters were en-US distributed, two for each clinical site, with the request en-US that they be posted in the providers work areas for easy en-US reference.en-US Based on our prior investigation,en-US9en-US the content of the en-US lectures was tailored to each specialty and each lasted approximately 1 hour For example, the lecture for cardi en-US-en-US ology focused on topics such as (but not limited to) en-US arrhythmias and heart failure assessment, the lecture for en-US primary care focused on initial assessment and screening en-US for heart disease, and the lecture for hospital medicine en-US focused on evaluating acute chest pain and syncope. The en-US poster was geared towards the primary care audience en-US because they order the majority of MPI at our facility.en-US The tone of the lectures and poster was purposefully en-US one of collaboration. None of the materials focused en-US on shaming or punishing providers for ordering rarely en-US appropriate tests. We informed providers that the goal en-US of the initiative was to work together to achieve the best en-US for our patients. For example, when discussing screening en-US in asymptomatic patients (a common indication which is en-US rarely appropriate), we referred to studies that demonen-US -en-US strated no benefit of this practice and then showed the en-US providers how to apply the ACC Atherosclerotic Cardioen-US -en-US vascular Disease Risk Estimator as a more useful clinical en-US approach. A brief, anonymous posteducation email en-US survey was sent the day after the lecture to assess their en-US opinions of the content and its projected impact on their en-US future practice.en-US The primary outcome of our investigation was the en-US proportion of nuclear MPI performed at our facility that en-US was rated as rarely appropriate. Determinations of approen-US-en-US priateness were made using the 2013 Multimodality AUC en-US for stable ischaemic heart disease or the 2009 AUC for en-US cardiac radionuclide imaging, when needed (ie, for acute en-US chest pain indications).en-US11 12en-US Appropriateness rating was en-US performed on all MPI, sequentially, by a nurse at our affilen-US -en-US iated research foundation whose effort was supported by en-US grant funding and was not invested in the outcome of the en-US investigation. Our MPI are interpreted by an interdiscien-US -en-US plinary group of cardiologists, radiologists and nuclear en-US medicine physicians who generate perfusion sores and en-US study reports by combining the visual and computer-genen-US -en-US erated findings. In prior investigations at our facility, the en-US proportion of rarely appropriate MPI was 10% to 15%. en-US We estimated that we could detect a 50% relative reducen-US -en-US tion in rarely appropriate testing with alpha 0.05 and en-US 1-beta of 0.8 using a sample size of 801.en-US13en-US Our MPI volume en-US is approximately 150 studies a month. To achieve the en-US desired sample size, we planned to review the approprien-US -en-US ateness of 6 months of MPI studies creating three cohorts, each of 2 months duration: pre, post (immediately after) en-USand late-post (4 months after the intervention). Data en-US were collected between October 2014 and August 2015. en-US This design allowed us to measure the immediate effect en-US of the intervention as well as the durability of the effect.en-US For each patient we gathered the following data: age, en-US sex, symptoms (chest pain, dyspnoea or fatigue, other, en-US no symptoms) and medical history (prior myocardial en-US infarction (MI) or revascularisation, hypertension, en-US diabetes, current tobacco use). We also gathered inforen-US -en-US mation on the provider type (physician or other) and en-US provider specialty (cardiology, primary care, or other). en-US Secondary outcomes included the prevalence of ischen-US -en-US aemia and test conclusion (normal or abnormal). For the en-US MPI, we gathered data on the test conclusion, summed stress   scores, summed rest scores and summed   differ en-US-en-US ence scores (SDSs). Categorical and continuous variables en-US were compared by en-US en-US2en-US and Students t-test, respectively. We en-US constructed two logistic regression models to investigate en-US characteristics that were associated with the presence en-US of ischaemia and a test being rarely appropriate. Indeen-US -en-US pendent variables for the regression analyses included en-US the patient characteristics and symptoms; the regression en-US model for rarely appropriate testing also included varien-US-en-US ables on the ordering providers type (physician vs other) en-US and specialty (cardiology vs other) and cohort (post or en-US late-post vs pre). Results are reported as OR with 95% en-US CI. Analysis was performed on SPSS Statistics V.23 (IBM, Armonk, NY,   USA). en-USRESULTSen-US Our investigation included a total of 889 patients, 287 in en-US the pre cohort, 313 in the post cohort and 289 in the on August 1, 2017 Published by Downloaded from


Health care delivery, economics and global health care en-US3 en-USlate-post cohort ( table   1 en-US). A minority of the patients had en-US prior MI (n=127, 14.3%) or revascularisation (n=292, en-US 32.8%); the substantial majority had hypertension en-US (n=768, 86.4%). Most patients had chest pain (n=530, en-US 59.6%), whereas a minority (n=125, 14.1%) had no sympen-US -en-US toms. The majority of studies were classified using the en-US 2013 AUC for stable ischaemic heart disease (622, 70.0%) en-US while the remainder were classified using the indications en-US for acute presentations from the 2009 AUC for MPI. The en-US only patient characteristics that differed across the three en-US cohorts were symptom burden and age.en-US The proportion of appropriate testing increased from en-US 80.5% to 95.2% after our intervention; the effect persisted en-US and remained at 92.7% late after. Simultaneously, the en-US proportion of rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% (p<0.001, global en-USen-US2en-US) en-US ( figure   1 en-US). The posteducation survey was completed by en-US 18 providers; 78% of respondents agreed with the stateen-US -en-US ment I am likely to change my use of cardiac testing en-US based on this presentation. In our logistic regression en-US model testing, variables associated with rarely approen-US priate testing included lack of symptoms (OR   31.3, 95% CI 10.3   to   94.8, p en-USen-US0.0001) and being in the post or latepost cohorts (OR   0.27, 95% CI 0.11   to   0.68, p=0.006). en-USAmong patients with a rarely appropriate indication for testing, none had myocardial ischaemia (SDS   en-USen-US3). Table 1 en-USCharacteristics for n=889 patients Age(meanSD) Pre, n=287 Post, n=313 Late, n=289 pValue 64.8.1 66.3.6 67.1.9 0.007 n % n % n %en-US Maleen-US 270en-US 94.1en-US 299en-US 95.5en-US 278en-US 96.2en-US 0.47en-US Prior MIen-US 48en-US 16.7en-US 42en-US 13.4en-US 37en-US 12.8en-US 0.35en-US Prior revascularisationen-US 101en-US 35.2en-US 99en-US 31.6en-US 92en-US 31.8en-US 0.59en-US Hypertensionen-US 246en-US 85.7en-US 266en-US 85en-US 256en-US 88.6en-US 0.4en-US Diabetes mellitusen-US 124en-US 43.2en-US 135en-US 43.1en-US 122en-US 42.2en-US 0.96en-US Current tobacco useen-US 76en-US 26.5en-US 72en-US 23en-US 90en-US 32.1en-US 0.24en-US Symptoms Chest pain en-US168en-US 58.7en-US 187en-US 59.7en-US 175en-US 60.6en-US 0.91 Fatigue and/or dyspnoea en-US143en-US 49.8en-US 152en-US 48.6en-US 102en-US 35.7en-US 0.001 Other en-US72en-US 25.2en-US 104en-US 33.4en-US 143en-US 49.7en-US <0.0001 No symptoms en-US46en-US 16.1en-US 36en-US 11.5en-US 43en-US 14.9en-US 0.24en-US Provider characteristics Attending en-US183en-US 63.8en-US 186en-US 59.4en-US 165en-US 57.1en-US 0.2* Housestaff en-US44en-US 15.3en-US 63en-US 20.1en-US 48en-US 16.6 APP en-US60en-US 20.9en-US 64en-US 20.4en-US 76en-US 26.3 Inpatient test en-US78en-US 27.2en-US 106en-US 33.9en-US 95en-US 32.9en-US 0.17 Cardiology en-US101en-US 35.2en-US 115en-US 36.7en-US 119en-US 41.2en-US 0.02en-US Primary care en-US104en-US 36.2en-US 86en-US 27.5en-US 70en-US 24.2 Other en-US82en-US 28.6en-US 112en-US 35.8en-US 100en-US 34.6 en-US*Single comparison across attending, housestaff and APP.en-US Single comparison across cardiology, primary care and other.en-US APP, advanced practice provider; MI, myocardial infarction. Figure 1 en-USRate of rarely appropriate myocardial perfusion en-US imaging (MPI)for three patient cohorts.In this bar graph, en-US the rate of rarely appropriate MPI is displayed, signicantly en-US decreasing from 4.9% (n=14, pre cohort) to 1.3% (n=4, post en-US cohort) and persisting at 1.4% 4 months after (n=4, late-post en-US cohort) (p<0.0001 for trend). on August 1, 2017 Published by Downloaded from


4 en-US( table   2 en-US) The prevalence of ischaemia and abnormal en-US testing decreased from appropriate to maybe approen-US -en-US priate, to rarely appropriate test indications, although not significantly (p=0.09 for SDS   en-USen-US3; p=0.07 for abnormal en-US test). In our logistic regression model of ischaemia on MPI, the only predictive variable was prior MI (OR   2.47, 95% CI 1.34 to 4.55, p=0.004). en-USTen indications accounted for 74% of all the MPI en-US performed ( table   3 en-US). The most common indication en-US overall was 2013 indication #64, ischaemic equivalent in en-US a patient with prior revascularisation (n=163). Asympen-US -en-US tomatic patients who can exercise (2013 indication #8) en-US and preoperative assessment in patients with good exeren-US -en-US cise capacity (2013 indication #71) were among the most en-US common rarely appropriate indications for testing. We en-US evaluated the most common rarely appropriate indication for each of the three time cohorts (pre, post   and lateen-USpost); however, the sample sizes were too small to make en-US any conclusive observations about change in individual en-US indications for testing.en-US DISCUSSIONen-US We designed a specialty-specific, multimodality educaen-US -en-US tional intervention to test the hypothesis that education en-US could effectively deimplement rarely appropriate MPI en-US testing. Our results demonstrate that in immediate and en-US short-term follow-up at a facility such as ours, education en-US may be effective in this regard.en-US Education is perceived as being a weak intervention en-US with a mixed track record for changing the behaviour of en-US physicians and APPs ordering patterns. One of the first Table 2 en-USMyocardial perfusion imaging results Appropriate,n=780 Maybe appropriate,n=65 Rarely appropriate,n=22 pValue n % n % n %en-US SDSen-US 57en-US 7.3en-US 1en-US 1.5en-US 0en-US 0.0en-US 0.09en-US SDSen-US 19en-US 2.4en-US 1en-US 1.5en-US 0en-US 0.0en-US 0.69en-US Abnormalen-US 203en-US 25.6en-US 15en-US 22.7en-US 1en-US 4.5en-US 0.07 en-USFour tests which were not successfully rated were excluded.en-US SDS, summed difference score. Table 3 en-USMost common overall and rarely appropriate MPI indications Rank n AUC version Indication* Rating Descriptionen-US Most common test indications overallen-US 1en-US 163en-US 2013en-US 64en-US Aen-US Postrevascularisation with ischaemic equivalenten-US 2en-US 121en-US 2013en-US 3en-US Aen-US Symptomatic with intermediate pretest CAD risk and en-US able to exerciseen-US 3en-US 128en-US 2009en-US 9en-US Aen-US Acute chest pain, possible ACS, high TIMI risk, en-US negative troponinen-US 4en-US 76en-US 2009en-US 8en-US Aen-US Acute chest pain, possible ACS, low TIMI risk, en-US negative troponinen-US 5en-US 59en-US 2013en-US 4en-US Aen-US Symptomatic with intermediate pretest CAD risk and en-US unable to exerciseen-US 6en-US 45en-US 2013en-US 58en-US Aen-US Non-obstructive CAD on coronary angiographyen-US 7en-US 19en-US 2013en-US 24en-US Aen-US Abnormal ECG with intermediate/high CAD risken-US 8en-US 19en-US 2013en-US 25en-US Aen-US Abnormal exercise ECG testen-US 9en-US 15en-US 2013en-US 74en-US Men-US Poor/unknown functional capacity, intermediate risk surgery risk factor en-US10en-US 14en-US 2013en-US 76en-US Aen-US Poor/unknown functional capacity, kidney transplant en-US evaluationen-US Most common rarely appropriate indicationsen-USen-US1en-US 8en-US 2013en-US 8en-US Ren-US Asymptomatic with intermediate pretest CAD risk en-US and able to exerciseen-US 2en-US 3en-US 2013en-US 71en-US Ren-US Moderate or good functional capacity prior to any en-US surgeryen-US 3en-US 2en-US 2013en-US 67en-US R Asymptomatic and<5 years after coronar y bypass en-USsurgery en-US*Indication is the number assigned of the individual AUC clinical scenario described in the table.en-US The remainder of rarely appropriate tests were each ordered only once.en-US ACS, acute coronary syndrome; AUC, Appropriate Use Criteria; CAD, coronary artery disease; TIMI, thrombolysis in myocardial infarction. on August 1, 2017 Published by Downloaded from


Health care delivery, economics and global health care 5 en-USstudies of education to reduce rarely appropriate MPI en-US used the same basic methods as in our study: lectures en-US and printed materials.en-US4en-US In this study, education was not en-US effective, which set a negative tone for future application en-US of education-only strategies. Looking at education on a en-US broader sale, a recent systematic review on interventions en-US to change provider behaviour suggests that the majority en-US of studies on clinician education are actually effective.en-US8en-US en-US We believe there are a few reasons why our educational en-US intervention may have changed provider behaviour in en-US this particular setting. First, prior data demonstrated en-US that a substantial portion of providers at our facility were en-US unaware of AUC. This served as a needs assessment which en-US indicated that an underlying cause of overuse might en-US be lack of knowledge about appropriateness. Because en-US we observed a durable reduction in rarely appropriate en-US imaging, it may be reasonable to conclude that lack of en-US knowledge was a key driver more so than fixed practice en-US habits or false beliefs about the benefit of testing. Second, en-US prior data showed that the patterns of rarely appropriate en-US testing differed by specialty. Using education tailored en-US to the audience may have enhanced the effect. Third, en-US we adopted a collaborative tone focused on improving en-US patient care and used a peer to deliver a multimodality en-US approach. A collaborative tone, peer delivery, focus on en-US patient care and not on criticism are characteristics of en-US effective audit and feedback programmes.en-US14en-US Similar en-US observations have been made for educational intervenen-US -en-US tions geared towards training physicians in delivering en-US high value care.en-US15en-US This conclusion is indirectly supported en-US by the survey data from providers that indicated their en-US intent to change MPI ordering habits based on the educaen-US -en-US tion received.en-US Our data suggest that education may still be a en-US worthwhile endeavour, particularly in settings where en-US awareness of a best practice is low. In contrast, a en-US stronger intervention, such as audit and feedback, may en-US not be well suited for deimplementing rarely approen-USpriate MPI at our facility. Over a 6 month time frame, en-USonly 22 rarely appropriate MPI were observed. Given en-US that we have dozens of providers who can order MPI, en-US a periodic report for individual providers would not en-US likely give timely enough feedback to have an appreen-US -en-US ciable impact on ordering behaviour. An alternative en-US approach, immediate feedback with a point-of-care en-US decision support tool, is being considered at our en-US facility. We must also acknowledge that given the low en-US rate of rarely appropriate testing at baseline, further en-US efforts to reduce low-value tests may have detrimental en-US effects or be discouraging providers from ordering tests en-US that may benefit individual patients. While the AUC do en-US not include a target proportion for rarely appropriate en-US testing, the majority of providers at our facilities feel en-US that 0% to 5% is an acceptable proportion.en-US10en-USAn alternative explanation to our observations is that en-US providers did not change their ordering habits, but rather en-US just changed their documentation when ordering MPI en-US to meet the AUC. It is possible that MPI use was largely en-US appropriate all along and providers are now accurately en-US documenting the appropriate reasons for ordering MPIs. en-US We also cannot distinguish between a true education en-US effect of the intervention versus what might be termed a en-US Hawthorne effect that simply raised awareness about MPI en-US appropriateness. However, we did not make any public en-US declaration that the appropriateness of MPI was being en-US tracked at our facility, and furthermore, the persistently en-US low rate of rarely appropriate testing months after the education concluded suggests that   the effect is a true en-USone and due to a change in providers knowledge about en-US appropriate use of MPIs.en-US While not a primary focus of this investigation, these en-US data add to the body of literature on the low prevalence en-US of ischaemia among rarely appropriate tests. This obseren-US -en-US vation provides further confidence to the application of en-US AUC for cancelling or eliminating rarely appropriate en-US tests a priori. We have also duplicated the finding that en-US lack of symptoms continues to be a strong predictor of a en-US MPI test being rarely appropriate. While acknowledging en-US that women, diabetics, and post-transplant patients may en-US have a more subtle symptom profile, physicians and APPs en-US thinking of ordering a MPI for a patient without symptoms en-US should consult the AUC given the robust association with en-US rarely appropriate indications. In should also be acknowlen-US -en-US edged that MPI can be used for risk stratification, but also en-US for diagnosing CAD. In the latter, some additional leeway en-US for rarely appropriate testing may be in order. Lastly, we en-US observed the common use of MPI for preoperative risk en-US assessment in patients with good functional capacity. This en-US continues to be an area for improvement in the applicaen-US -en-US tion of AUC for MPI.en-US Our study is limited by the lack of a control group and en-US longer term follow-up. Assessment of appropriateness is a en-US time-consuming process when performed by a third party en-US after the test has been ordered and continual tracking en-US is not readily achievable. Our study is strengthened by en-US the fact that appropriateness ratings were performed by en-US someone with no vested interest in seeing the project en-US succeed. The sample size of our investigation was too en-US small to make conclusive statements about changes in en-US the individual rarely appropriate test indications. There en-US likely are also important characteristics of the VA study en-US setting that may limit generalisability, such as the lack of a en-US financial incentive either for the provider or for the instien-US -en-US tution to order MPIs. Future investigations should focus en-US on replicating our findings in other settings using more en-US a rigorous design with a control condition; assessing en-US whether the effects of the education intervention appear en-US to persist long term at the pilot site and ascertainment en-US of which educational elements were effective and which en-US could be omitted without diluting the effect.en-US CONCLUSIONen-US While education has a mixed track record of effectiveness, en-US it appears to be useful in selected circumstances. Future en-US studies of education for changing behaviour should pay on August 1, 2017 Published by Downloaded from


6 en-USclose attention to the environmental conditions that may en-US favour or oppose education as a change strategy.en-USAuthor afliationsen-US1en-USCardiology Section, Medical Service, Malcom Randall VA Medical Center, en-US Gainesville, Florida, USAen-US2en-USDivision of Cardiovascular Medicine, Department of Medicine, College of Medicine, en-US University of Florida, Gainesville, Florida, USAen-US3en-USVA Puget Sound Health Care System, Seattle, Washington, USAen-US4en-USGeriatric Research Education and Clinical Centers (GRECC), Malcom Randall VA en-US Medical Center, Gainesville, Florida, USAen-US5en-USDivision of General Internal Medicine, Department of Medicine, College of en-US Medicine, University of Florida, Gainesville, Florida, USA Contributors DEW: conception, design and drafting of the work. All authors: acquisition, analysis, interpretation of data for the work; revising it critically for important intellectual content; nal approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding en-USThis work was supported by Veterans Integrated Service Network-8 en-US Innovation Grant and with resources of the Malcom Randall VAMC. Additional funding en-US was provided by an unrestricted grant from the Florida Heart Research Institute en-US (Miami, FL). Competing interests None declared. Patient consent Not obtained because the study was performed under waiver of informed consent provided by the IRB. Ethics approval University of Florida Institutional Review Board. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Unpublished data are available from author DEW with an approved data sharing agreement between any requesting party and the US government. Open Access en-USThis is an Open Access article distributed in accordance with the en-US Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which en-US permits others to distribute, remix, adapt, build upon this work non-commercially, en-US and license their derivative works on different terms, provided the original work en-US is properly cited and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by nc/ 4. 0/ en-US Article author(s) (or their employer(s) unless otherwise stated in the text of the en-US article) 2017. All rights reserved. No commercial use is permitted unless otherwise en-US expressly granted.en-USREFERENCES 1. Elgendy IY Mahmoud A, Shuster JJ, et al. Outcomes after inappropriate nuclear myocardial perfusion imaging: a meta-analysis. J Nucl Cardiol 2016;23:680. 2. 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perfusion imaging deimplement rarely appropriate myocardial educational quality improvement initiative to A specialty-specific, multimodality Rebecca J Beyth David E Winchester, Carsten Schmalfuss, Christian D Helfrich and doi: 10.1136/openhrt-2017-0005892017 4: Open Heart Updated information and services can be found at: These include: References #BIBL This article cites 13 articles, 6 of which you can access for free at: Open Access non-commercial. See: provided the original work is properly cited and the use is non-commercially, and license their derivative works on different terms, permits others to distribute, remix, adapt, build upon this work Commons Attribution Non Commercial (CC BY-NC 4.0) license, which This is an Open Access article distributed in accordance with the Creative service Email alerting box at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in the Notes To request permissions go to: To order reprints go to: To subscribe to BMJ go to: on August 1, 2017 Published by Downloaded from